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This document is a rider that modifies the terms of a subscriber's health insurance plan related to diagnostic tests. It changes the cost sharing amounts for outpatient lab tests, x-rays, and other tests to have no charge deductible for in-network services and 20% coinsurance after deductible for out-of-network services. It also changes the cost sharing for advanced imaging tests to a $100 copayment per category of test for in-network services and 20% coinsurance after deductible for out-of-network services. All other plan provisions remain the same.

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Erick Álvarez-Sarabia
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55 views

Group Project Topics

This document is a rider that modifies the terms of a subscriber's health insurance plan related to diagnostic tests. It changes the cost sharing amounts for outpatient lab tests, x-rays, and other tests to have no charge deductible for in-network services and 20% coinsurance after deductible for out-of-network services. It also changes the cost sharing for advanced imaging tests to a $100 copayment per category of test for in-network services and 20% coinsurance after deductible for out-of-network services. All other plan provisions remain the same.

Uploaded by

Erick Álvarez-Sarabia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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attached to and made part of

Blue Cross and Blue Shield of Massachusetts, Inc.


Blue Care Elect Preferred Provider Plan Subscriber Certificate

Rider
Diagnostic Tests

This rider modifies the terms of your health plan. Please keep this rider with your Subscriber Certificate
for easy reference.

The cost share amount you pay for outpatient lab tests, x-rays, and other tests as shown in your Schedule
of Benefits has been changed as follows:

 Outpatient Lab Tests and X-Rays


Your cost share amount for outpatient diagnostic lab tests and outpatient diagnostic x-rays and other
imaging tests (other than advanced imaging tests as described below) is changed to: no charge
(deductible does not apply) for in-network covered services; or, for out-of-network covered services,
20% coinsurance after deductible (if a deductible applies for your health plan).

This cost share amount also applies to other covered outpatient tests and preoperative tests.

 Outpatient Advanced Imaging Tests


Your cost share amount for those advanced imaging tests listed in your Schedule of Benefits is
changed to: a $100 copayment per category of test per service date (deductible does not apply) for
in-network covered services; or, for out-of-network covered services, 20% coinsurance after
deductible (if a deductible applies for your health plan).

All other provisions remain as described in your Subscriber Certificate.

R04-4000 (2015) to be attached to BCBS-PPO

Page 1 406262097.doc

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