2026 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 86

 

Benefit Description

Hospice Care (cont.)

Inpatient Hospice Care
  • Inpatient services are necessary to provide an interval of relief (respite) to the caregiver

Note: Benefits are provided for up to 30 consecutive days in a facility licensed as an inpatient hospice facility. 


Standard Option - You Pay
Preferred facilities: Nothing (no deductible)

Member facilities: $450 per admission copayment, plus 35% of the Plan allowance (no deductible)

Non-member facilities: $450 per admission copayment, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment

Basic Option - You Pay
Preferred facilities: Nothing

Member/Non-member facilities: You pay all charges

 

Benefit Description

Not covered:
 
  • Advanced care planning, except when provided as part of a covered hospice care treatment plan
     
  • Homemaker services
     
 
Standard Option - You Pay
All charges

Basic Option - You Pay
All charges

 

Benefit Description

Ambulance
Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and:
 
  • Associated with covered hospital inpatient care
     
  • Related to medical emergency
     
  • Associated with covered hospice care

Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.


Standard Option - You Pay
$100 copayment per day for ground ambulance transport services (no deductible)

$150 copayment per day for air or sea ambulance transport services

Basic Option - You Pay
$250 copayment per day for ground ambulance transport services

$75 copayment per day for air or sea ambulance transport services

 

Benefit Description

Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and when related to accidental injury

Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.

Note: Prior approval is required for all non-emergent air ambulance transport.


Standard Option - You Pay
Nothing (no deductible)

Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, see above.

Basic Option - You Pay
$250 copayment per day for ground ambulance transport services

$75 copayment per day for air or sea ambulance transport services

 

Benefit Description

Medically necessary emergency ground, air and sea ambulance transport services to the nearest hospital equipped to adequately treat your condition if you travel outside the United States, Puerto Rico and the U.S. Virgin Islands

Note: If you are traveling overseas and need assistance with emergency evacuation services to the nearest facility equipped to adequately treat your condition, please contact the Overseas Assistance Center (provided by GeoBlue) by calling 804-673-1678.


Standard Option - You Pay
$100 copayment per day for ground ambulance transport services (no deductible)

$150 copayment per day for air or sea ambulance transport services

Basic Option - You Pay
$250 copayment per day for ground ambulance transport services

$75 copayment per day for air or sea ambulance transport services

 

Ambulance - continued on next page