What You Need to Know About Your Benefits
We understand how important health care services are to our members. To ensure you receive the best and most appropriate care, we offer a multitude of programs and services to help keep you healthy, while trying to make managing your benefits as simple as possible.
How to get care from out-of-network providers
In most cases, care you receive from an out-of-network provider will be covered at the same cost share as in-network services. Listed below are two exceptions:
- The plan covers medical services covered by Original Medicare and more. However, there are some exceptions to what Medicare will cover. If the service is not covered by Medicare, you may be responsible for the cost of the service. For more information about this, and to see the Evidence of Coverage.
- If you receive a service from a provider that is not participating with Medicare, you may be responsible for the cost of the service. Providers that are non-contracted Medicare are required to let you know their participation status, however, in some cases they may not make you aware. You can always contact Customer Service to determine if a provider is non-participating with our plan.
Toll Free 800.779.6962 (TTY: 711)
Monday – Friday
Extended hours October 1 through February 14
8:00 am – 8:00 pm
Your Rights and Responsibilities
Disenrollment is the process by which your membership in our Plan ends. This may be done voluntarily by you, or you may be involuntarily disenrolled for certain reasons.
- If you qualify for special enrollment periods. Call Medicare at 1.800.MEDICARE (800.633.4227), 24 hours a day, 7 days a week. TTY: 711.
If you leave our Plan, it may take time before your membership ends and your new Medicare coverage goes into effect. During that time, you must continue to get your medical care and prescription drugs through our Plan.
We may end your coverage for any of the following reasons:
- If you do not stay continuously enrolled in Medicare Part A and Part B.
- If you move out of our service area for more than six months or at any time when you confirm a permanent out-of-area address.
- If you intentionally give us incorrect information when you are enrolling in our Plan and that information affects your eligibility for our Plan; We cannot make you leave our Plan for this reason unless we get permission from Medicare first.
- If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care to you and other Members in our Plan. We cannot make you leave our Plan for this reason unless we get permission from Medicare first.
- If you let someone else use your membership card to get medical care; We cannot make you leave our Plan for this reason unless we get permission from Medicare first.
- If you do not pay the Plan premiums for two calendar months.
Quality Improvement Organization
You should contact the Quality Improvement Organization if you have a complaint about the quality of care you have received. For example, you can contact the Quality Improvement Organization if you were given the wrong medication or if you were given medications that interact in a negative way.
Livanta (Pennsylvania’s Quality Improvement Organization)
Visit the Livanta website.
Write by mail:
Livanta BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701
For information and questions regarding your current plan contact us at 800.779.6962.
PSERS Health Options Program Representative
Talk to a Representative Call 1.800.773.7725
Speak with a representative about billing, ID cards, benefits, claims and more. Call 800.779.6962 to get started. Representatives are available 8 am to 8 pm, seven days per week from October 1 – March 31.
From April 1 to September 30, representatives are available 8 am to 8 pm. There is a secure messaging system on Saturdays, Sundays, and federal holidays. Leave your name, phone number and the time you call. A representative will contact you no more than one business day after you leave your message.
2500 Elmerton Avenue
Harrisburg, PA 17177-9799
1221 W. Hamilton Street
Allentown, PA 18102-4304
The information provided here is general in nature and may be offered by or available through Capital BlueCross. Your benefits could be different. The actual terms and conditions of your coverage are set forth in the contract between the PSERS and Capital BlueCross and Capital Advantage Insurance Company, which legally governs the administration of the program. If there is a difference between this material and the contract, the terms and conditions of the contract should control. If you require answers to specific questions, please contact member services listed on your identification card.