PSHB Standard and Basic Options
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 89
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 89
Benefit Description
Hospice Care (cont.)
Traditional Home Hospice Care
Periodic visits to the member’s home for the management of the terminal medical condition and to provide limited patient care in the home.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member/Non-member facilities: $450 copayment per episode (no deductible)
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: You pay all charges
Hospice Care (cont.)
Traditional Home Hospice Care
Periodic visits to the member’s home for the management of the terminal medical condition and to provide limited patient care in the home.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member/Non-member facilities: $450 copayment per episode (no deductible)
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: You pay all charges
Benefit Description
Continuous Home Hospice Care
Services provided in the home during a period of crisis, such as frequent medication adjustments to control symptoms or to manage a significant change in the member’s condition, requiring a minimum of 8 hours of care during each 24-hour period by a registered nurse (R.N.) or licensed practical nurse (L.P.N.).
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member facilities: $450 per episode copayment (no deductible)
Non-member facilities: $450 per episode 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
Continuous Home Hospice Care
Services provided in the home during a period of crisis, such as frequent medication adjustments to control symptoms or to manage a significant change in the member’s condition, requiring a minimum of 8 hours of care during each 24-hour period by a registered nurse (R.N.) or licensed practical nurse (L.P.N.).
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member facilities: $450 per episode copayment (no deductible)
Non-member facilities: $450 per episode 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
Inpatient Hospice Care
Benefits are available for inpatient hospice care when provided by a facility that is licensed as an inpatient hospice facility and when:
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
Inpatient Hospice Care
Benefits are available for inpatient hospice care when provided by a facility that is licensed as an inpatient hospice facility and when:
- Inpatient services are necessary to control pain and/or manage the member’s symptoms;
- Death is imminent; or
- 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:
Basic Option - You Pay
All charges
Not covered:
- Advanced care planning, except when provided as part of a covered hospice care treatment plan
- Homemaker services
Standard Option - You Pay
All chargesBasic Option - You Pay
All charges
Benefit Description
$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
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Ambulance
Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and:
Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.
Standard Option - You PayProfessional 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.
$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
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services