Annual member notices

Annual state and federally mandated healthcare notices and plan information for our members

Your health

Easy ways to manage your health

As a valued Capital Blue Cross member, you have access to many programs, services, and educational tools to help you live your healthiest life — all from the convenience of your computer, smartphone, or tablet.

Register for your Capital Blue Cross secure account

Log in or register to access your secure account. From your secure account, you can manage your plan, find in-network providers, and view your Explanation of Benefits (EOBs) or ID card. You can also update your contact information and communication preferences as well as view your member rights and responsibilities.

Access your benefit plan documents

You may be able to access your coverage documents online by simply logging in to your secure account. If you are unable to access your coverage documents online, you can get a copy by calling Member Services at the number on the back of your member ID card. Your coverage documents include information about:
  • Benefit restrictions that apply to services obtained outside our system or service area.
  • Language assistance.
  • How to submit a claim for covered services, if applicable.
  • How to use the MyCare Finder tool to find providers and compare treatment costs.
  • Providers with whom we contract to offer you member rates on healthcare services.
  • Primary care services, including points of access and specialty care, behavioral health services, and hospital services.
  • How to obtain care after normal business hours.
  • How to obtain emergency care, including our policy on when to directly access emergency care or use 911 services.
  • How to obtain care and coverage when you are out of our service area.
  • How to submit a complaint or appeal a decision that adversely affects coverage, benefits, or your relationship with us.
  • How we evaluate new technology to include as a covered benefit for you.
In addition, other important plan information includes:
  • Pharmacy management procedures, including online management of your prescription benefits.
  • Copayments and your financial responsibilities.
  • How to find information about doctors or other network providers.
  • How to obtain a new member ID card.
  • Information about our quality improvement program.
  • How to transition from pediatric to adult primary care.
  • Care management programs and eligibility.
  • An affirmative statement about financial incentives.
  • The availability of an independent, external review of a final, internal, medical necessity determination.

Manage your prescription drug benefits

If your plan includes prescription drug benefits, your secure account is your one-stop shop to:

  • Check drug coverage and cost.
  • Determine a drug’s common side effects.
  • Find generic substitutes.
  • Download home delivery and claim forms.
  • Find a pharmacy.
  • Order a refill for an unexpired home delivery prescription.
  • Review your prescription history.
  • View the formulary (approved drug list).

For the most up-to-date prescription drug information and updates to the list of covered drugs, view the drug lists online. If you would like paper copies of the materials available, call Member Services at the number on the back of your member ID card.

Note: We may limit communication of updates to “negative” formulary changes, such as changes that result in restrictions or replacements, and may limit such communications to affected members and their providers.

Importance of obtaining preauthorization

Preauthorization is the process in which certain medications, tests, procedures, medical devices, or other medical services are reviewed for medical necessity and appropriateness before you receive certain healthcare services. Preauthorization ensures that services are medically appropriate. In-network providers (including BlueCard® facilities that provide inpatient services outside Capital Blue Cross’ 21-county service area) are responsible for obtaining preauthorization. If you receive services from an out-of-network provider or outpatient services from a BlueCard provider outside our service area, you are responsible for obtaining preauthorization, if required. If you do not obtain preauthorization, your claim may be reviewed for medical necessity and you may be responsible for paying the cost of the service. Search for participating providers, hospital, and labs, and learn more about preauthorization requirements.

Women’s Health

We provide benefits for mastectomy-related services in accordance with the Women’s Health and Cancer Rights Act of 1998. These benefits include:

  • All stages of reconstruction and surgery to achieve symmetry between breasts.
  • Prostheses.
  • Complications resulting from a mastectomy, including lymphedema. If you have questions about these benefits, call Member Services at the number on your ID card.

Newborns’ and mothers’ health protection act

Under federal law, group health plans and health insurers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section. However, the plan or insurer may pay for a shorter stay if the attending provider (e.g., provider, nurse midwife, or physician assistant) after consultation with the mother, discharges the mother or newborn earlier. Also under federal law, plans and insurers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under federal law, require that a provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain preauthorization.

Coverage for newborn children

Pennsylvania Act 81 automatically provides health insurance coverage under a subscriber’s plan to newborns for the first 31 days following birth. Any costs for benefits provided to the newborn child will be applied to the subscriber’s cost-sharing amounts. Separate cost-sharing amounts will not apply to the newborn child unless and until the child is separately enrolled as a dependent in accordance with the terms of the subscriber's Certificate of Coverage. Some self-funded groups do not have this coverage. Please check your benefits booklet or call Member Services at the number on your member ID card to confirm your benefits.

Transition to adult primary care

As children transition into young adults, it is important they receive the right healthcare services. Usually by the time young adults finish school, they should move their care from a pediatrician to a Primary Care Physician (PCP). To help with the transition to adult care, visit MyCare Finder, our online tool to view the most up-to-date listings of providers in your area. You can also compare treatment costs and learn more about providers that are accepting new patients, their specialties, hours, and hospital affiliations.

Log in or register to access your secure account to access MyCare Finder. If you need support using MyCare Finder or finding a new provider, contact Member Services at the number on the back of your member ID card.

Your pediatrician’s office may be able to recommend an in-network PCP for adults. Also remember to speak with them about sending your child’s medical records to the new provider.

2022 new and updated programs

For 2022, we have made additions and updates to some of our plans. To determine if the following changes apply to you, check your Benefits Booklet (Certificate of Coverage), which you can access through your secure account, or call Member Services for more information.

Update: Blood unit deductible

Starting on your plan’s next renewal date on or after January 1, 2022, there will no longer be a three-unit blood-pint deductible per benefit period. The blood deductible is the number of units of blood you are responsible for paying prior to receiving benefit coverage. Currently, the standard benefit allows blood billed by a provider when medically necessary to be subject to a blood deductible and cost share (if applicable) prior to providing benefit coverage. This benefit update does not apply to Capital Blue Cross CHIP members or members of certain self-funded groups. Please check your benefits booklet or call Member Services at the number on your member ID card to confirm your benefits.

Update: Colorectal Cancer Screenings

The U.S. Preventive Services Task Force updated their recommendation for adults to start colorectal cancer screenings at age 45 instead of 50. Effective August 1, 2021, we have updated our Patient Protection and Affordable Care Act preventive coverage guidance to include colorectal cancer screenings beginning at age 45 for early detection of colorectal cancer. These screenings include colonoscopies, flexible sigmoidoscopies, computed tomography (CT) colonography, fecal occult blood tests, and fecal immunochemical (FIT)-DNA tests. Talk with your doctor to find out the best screening for you. To determine if your preventive screening is covered with no cost share, please check your Benefits Booklet (Certificate of Coverage) or call Member Services.

New: No Surprises Act protects members from unexpected medical bills

Beginning in January 2022, a new law protects members from unexpected bills for out-of-network emergency services and for services provided by specialists at in-network facilities (such as anesthesia or radiology services providers). Under the new law, those providers will not be able to bill the member directly unless you consent. Member deductibles and coinsurance will also be limited to in-network amounts in those circumstances.

New: ID cards

Most members will receive a new ID card when your coverage renews in 2022. The new cards will include more details about the coverage, including the in-network and out-of-network deductibles and maximum out-of-pocket limits for your plan. Capital Blue Cross CHIP members and most members with only dental and/or vision coverage will not receive new ID cards.

Your privacy

Your privacy is important to us

At Capital Blue Cross, we are committed to providing you with the highest quality healthcare products and services. An important part of this commitment is our pledge to do everything we can to protect your nonpublic, personal financial information.

Our privacy pledge

Capital Blue Cross does not sell member information. We do not disclose your nonpublic, personal financial information, except as permitted by law. We do not disclose this information, even when our member relationships end, except as permitted by law.

Information we collect

We collect nonpublic, personal financial information about you from the following sources:

  • Applications and other forms provided to us.
  • Transactions (such as claims submissions and payments) with us, our affiliates, or others.
  • Outside sources, such as healthcare providers, other insurance companies, and federal and state agencies.

How we protect member information

Our policies restrict access of your information to employees who need this information to provide our products and services to you as permitted by law. We maintain physical, electronic, and procedural safeguards that comply with legal requirements to protect your nonpublic, personal financial information. We also maintain a Notice of Privacy Practices. If you have any questions about our privacy policy or want to receive a printed copy of the Notice of Privacy Practices, call the Member Services number on the back of your member ID card.

Help fight healthcare fraud, waste, and abuse

You can help fight the rising costs of healthcare fraud by monitoring claims processed under your plan. When you receive an Explanation of Benefits (EOB) or view it from your secure account, look for discrepancies such as the date(s) of service, the provider’s information, or the procedure performed. Protect yourself against medical identity theft by guarding your member ID card as you do your credit card.

If you suspect fraud, or believe you are a victim of medical identity theft, report it immediately in any of the following ways:

We're here to help

Let our Utilization Management and Member Services staff help you with questions about preauthorization or your health coverage. Call Member Services at the number on the back of your member ID card or for Utilization Management, call 800.962.2242 (TTY: 711). You may also contact us online with any questions. Emailed questions are reviewed Monday through Friday, 8:00 AM - 6:00 PM. Member Services will make every effort to respond within 24 hours or one business day of receiving your inquiry.

Commercial member rights and responsibilities

As a member of the Capital Blue Cross family of companies, you have certain rights and responsibilities. The success of your treatment and your satisfaction depends, in part, on you taking responsibility as a patient. Acquainting yourself with your rights and responsibilities will help you take a more active role in your healthcare.

CHIP member rights and responsibilities

Keystone Health Plan® Central, and its network of doctors and other providers of services, do not discriminate against members based on race, sex, religion, national origin, disability, age, sexual orientation, gender identity, or any other basis prohibited by law. As a member of the Children’s Health Insurance Program (CHIP) of Pennsylvania, you have certain rights and responsibilities.

Other information

Medical necessity review

Clinical medical necessity determinations are based only on the appropriateness of care and service and the existence of coverage. We do not reward, reimburse, or provide a bonus to individuals on the basis of utilization, issuance of denials of coverage, or provision of financial incentives of any kind to encourage decisions that may result in underutilization or that could negatively influence the provision of healthcare services.

We do not use incentives to encourage barriers to care and service, nor do we make decisions about hiring, promoting, or terminating providers or other staff based on the likelihood, or the perceived likelihood, that the provider or staff member supports, or tends to support, denial of benefits.

If you disagree with our adverse benefit determination, you may seek internal review of that determination by submitting a written appeal. An internal, expedited review may be requested if the situation is considered life-threatening or the member's health is in jeopardy. This expedited review may be requested by contacting Member Services using the telephone number provided on the determination letter or mailing the request to the address provided on the determination letter. If the requested appeal meets the expedited criteria, we will respond with an internal appeal review determination as soon as possible, but no later than 72 hours after receiving the appeal request. You also may request an external appeal through an independent review organization of a final, internal, adverse benefit determination pertaining to medical necessity. Please refer to your benefit plan documents for specific guidelines on your right to appeal. For more information on the appeal process, call the Member Services number on your member ID card.

Claims filing reminder

In-network providers automatically send your hospital and medical claims to us for processing. However, you may be responsible for submitting claims directly to us if you visit an out-of-network provider. Make sure you ask your out-of-network provider if they will be submitting a claim on your behalf, or if you will need to submit the claim yourself. Also, you may need to provide information related to your eligibility for coverage from time to time. For example, you may need to respond to requests from us about other insurance coverage to coordinate benefits or resolve other-party liability issues (payments due from other organizations). We may withhold payment of a claim if you do not provide the requested information in a timely manner. You may print claim forms or you may contact us to request they be mailed to you.

Quality measures

We have quality initiative procedures in place to help us evaluate how we are doing as a health plan. Our annual quality improvement program is available for you to review. For a paper copy, call the Member Services number on the back of your member ID card.

Nondiscrimination and foreign language assistance notice

We comply with applicable federal civil rights laws and do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex. Review our Nondiscrimination and Foreign Language Assistance Notice.

Help for people with disabilities and English as a second language

We provide free aids and services to people with disabilities or whose primary language is not English, such as:
  • Qualified sign language interpreters.
  • Written information in other formats (large print, audio, accessible electronic format).
  • Qualified interpreters for other languages.
  • Written information in other languages.

If you need these services, call 800.962.2242 (TTY: 711).  If you believe we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our civil rights coordinator. You can file a grievance in person or by mail, fax, or email at:

Capital Blue Cross
PO Box 779880, Harrisburg, PA 17177-9880
800.417.7842 (TTY: 711), fax: 855.990.9001
CRC@capbluecross.com

If you need help filing a grievance, our civil rights coordinator is available to help you. You can also file a civil rights complaint electronically with the U.S. Department of Health and Human Services, Office for Civil Rights through the Office for Civil Rights Complaint portal, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW., Room 509F, HHH Building
Washington, D.C. 20201
Toll-free: 800.368.1019, (TTY: 800.537.7697)
Complaint forms are available.

The information provided is not intended to replace the advice of your healthcare provider. Please consult your healthcare provider if you have any questions or concerns about the information provided, as your healthcare provider is familiar with your personal medical history.

Benefits vary by type of product and benefit design; therefore, not all programs or issues addressed may be available, covered, or applicable to your specific coverage. Please refer to your benefit documents (also known as "Certificate of Coverage") or contact Member Services at the number on the back of your plan member ID card.