Schedule of Benefits

Transcription

1 H5F, 09/10 Schedule of Benefits Services listed are covered when Medically Necessary. Please see your Benefit Handbook for details. Your Plan offers two levels of coverage: and. Coverage coverage applies when you use a Participating Provider for covered services. Coverage coverage applies when you use a Non-Participating Provider for covered services. Please refer to your Benefit Handbook for further information about how your and coverage works. Members are required to share the cost of the benefits provided under the Plan. The following is a summary of the cost sharing amounts under your Plan. Your Plan has Copayments that are listed in the table below. Your Plan has an Deductible of $2,000 per Member or $6,000 per family, per calendar year, applied to the eligible expense. Your Plan has an Deductible of $3,000 per Member or $9,000 per family, per calendar year, applied to the eligible expense. Your Plan has an Durable Medical and Prosthetic Equipment Deductible of $100 per calendar year. Your Plan has Coinsurance of 20% of Covered Charges after the Deductible is met until the Out-of- Pocket Maximum is reached. Your Plan has Coinsurance of 40% of Covered Charges after the Deductible is met until the Out-of-Pocket Maximum is reached. Your Plan has an Out-of-Pocket Maximum of $6,000 per Member or $18,000 per family per calendar year, including Deductible, Copayments and Coinsurance, (excluding prescription drugs). Any charges in excess of the Usual, Customary, and Reasonable Charge do not apply to the Outof-Pocket Maximum. Any Deductible amount incurred for services rendered during the last three months of a calendar year will be applied to the Deductible requirement for the next year. You have an Lifetime Benefit Maximum of $1,000,000 in payments by HPIC per Member. 1

2 Inpatient Acute Hospital Services Coronary care Hospital services Intensive care Semi-private room and board Physicians and surgeons services, including consultations Day Surgery Hospital services Physicians' and surgeons' services including consultations Skilled Nursing Facility Care and Inpatient Rehabilitation Services 20% Coinsurance after 20% Coinsurance after 40% Coinsurance after 40% Coinsurance after Limited to a combined maximum of 100 days per calendar year Hospital Outpatient Department Services Anesthesia services Chemotherapy Endoscopic procedures Laboratory tests and x-rays Physicians' and surgeons' services Radiation therapy CT Scans and MRI 20% Coinsurance after the Deductible has been 20% Coinsurance after the Deductible has been 40% Coinsurance after 40% Coinsurance after 40% Coinsurance after 2

3 Physician Services Administration of injections Allergy tests and treatments Changes and removals of casts, dressings, or sutures Chemotherapy Diabetes self-management, including education and training Diagnostic screening and tests (see below for CT Scans and MRI), including blood tests, lead screenings and screenings mandated by state law Family planning services Health education, including nutritional counseling Medical treatment of temporomandibular joint dysfunction (TMD) Preventive care, including routine physical examinations, immunizations, annual eye examinations, school, camp, sports and premarital examinations Sick and well office visits, including medication management Vision and hearing screenings Administration of allergy injections CT Scans and MRI Emergency Room Care Services Hospital emergency room treatment (Please note: there is no charge for diagnostic tests, x- rays, and immunizations if billed without an office visit and no other services are provided.) $5 Copayment per 20% Coinsurance after the Deductible has been $100 Copayment per (This Copayment is waived if you are admitted directly to the hospital from the emergency room.) $100 Copayment per (This Copayment is waived if you are admitted directly to the hospital from the emergency room.) 3

4 Emergency Admission Services Inpatient services which are required immediately following the rendering of emergency room treatment Urgent Care Services 20% Coinsurance after the Deductible has been 20% Coinsurance after the Urgent care center treatment Maternity Services 50% of your Emergency Room Care Copayment. 50% of your Emergency Room Care Copayment. Prenatal and postpartum care All hospital services for mother, including inpatient physician services Routine nursery charges for newborn 20% Coinsurance after the Deductible has been Mental Health and Drug and Alcohol Rehabilitation Services Inpatient Services Mental health services Drug and alcohol rehabilitation services Detoxification services Partial Hospitalization Services Partial hospitalization services 20% Coinsurance. 40% Coinsurance. 20% Coinsurance. 40% Coinsurance. Outpatient Services Mental health services Individual therapy Group therapy $10 Copayment per 40% Coinsurance. 4

5 Mental Health and Drug and Alcohol Rehabilitation Services (Continued) Drug and alcohol rehabilitation services Individual therapy Group therapy Detoxification services Medication management Psychological testing Dental Services Initial emergency treatment (as described in your Benefit Handbook) Home Health Care Services Home care services Intermittent skilled nursing care No cost sharing or benefit limits apply to durable medical equipment, physical therapy, occupational therapy or speech therapy received as part of authorized home health care. $10 Copayment per If inpatient services are required, please see "Inpatient Acute Hospital Services" for cost sharing. 40% Coinsurance. 40% Coinsurance 40% Coinsurance 20% Coinsurance after If inpatient services are required, please see "Inpatient Acute Hospital Services" for cost sharing. 40% Coinsurance after 5

6 Durable Medical and Prosthetic Equipment Durable medical and prosthetic equipment (other than prosthetic arms and legs) limited to $3,500 per calendar year for all covered equipment. Coverage includes, but is not limited to: Durable medical equipment Prosthetic devices Breast prostheses, including replacements and mastectomy bras (no benefit limit applies) Ostomy supplies Wigs, (as described in your Benefit Handbook) Oxygen and respiratory equipment 20% Copayment after the $100 Durable Medical Equipment Deductible has been The coverage limit of $3,500 is calculated by combining the amount paid by HPIC and the Member Copayment and the Durable Medical and Prosthetic Equipment Deductible. No benefit limit applies. deductible has been No benefit limit applies. Prosthetic Arms and Legs Prosthetic arms and legs 20% Copayment after the $100 Durable Medical Equipment Deductible has been No benefit limit applies. No benefit limit applies. 6

7 Diabetes Equipment and Supplies Therapeutic molded shoes and inserts, dosage gauges, injectors, lancet devices, voice synthesizers and visual magnifying aids Blood glucose monitors, insulin pumps and supplies and infusion devices Insulin, insulin syringes, insulin pens with insulin, lancets, oral agents for controlling blood sugar, blood test strips, and glucose, ketone and urine test strips Subject to the applicable cost sharing, if any, under the durable medical and prosthetic equipment benefit. Subject to the applicable prescription drug Copayment listed on your ID card, if your Employer Group has selected prescription drug coverage. If prescription drug coverage is not available, then you will pay a $5 Copayment for Tier 1 items, $10 Copayment for Tier 2 items and a $25 Copayment for Tier 3 items. Subject to the applicable cost sharing, if any, under the durable medical and prosthetic equipment benefit. Subject to the applicable prescription drug Copayment listed on your ID card, if your Employer Group has selected prescription drug coverage. If prescription drug coverage is not available, then you will pay a $5 Copayment for Tier 1 items, $10 Copayment for Tier 2 items and a $25 Copayment for Tier 3 items. 7

8 Other Health Services Cardiac rehabilitation Chiropractic care limited to12 visits per calendar year Dialysis Early intervention services $3,200 per calendar year, up to $9,600 per lifetime Second opinion Physical and Occupational therapies combined up to 25 visits per condition Speech therapy limited to 25 visits per condition House calls Emergency ambulance services Ambulance services Low protein foods ($1,800 per calendar year) Special formulas (as described in your Benefit Handbook) Hospice services Infertility services limited to consultation and evaluation Vision hardware for special conditions (as described in your Benefit Handbook) 20% Coinsurance after the Deductible has been 20% Coinsurance after the Deductible has been If inpatient services are required, please see Inpatient Acute Hospital Services for cost sharing. 20% Coinsurance after the Deductible has been If inpatient services are required, please see Inpatient Acute Hospital Services for cost sharing. 8

9 Other Health Services (Continued) Telemedicine Your Member cost sharing will depend upon the types of services provided, as listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician Services. For inpatient hospital care, see Inpatient Acute Hospital Services. Your Member cost sharing will depend upon the types of services provided, as listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician Services. For inpatient hospital care, see Inpatient Acute Hospital Services. 9

10 Special Enrollment Rights If an employee declines enrollment for the employee and his or her Dependents (including his or her spouse) because of other health insurance coverage, the employee may be able to enroll himself or herself, along with his or her Dependents in this Plan if the employee or his or her Dependents lose eligibility for that other coverage (or if the employer stops contributing toward the employee s or Dependents other coverage). However, enrollment must be requested within 30 days after the other coverage ends (or after the employer stops contributing toward the employee s or Dependents other coverage). In addition, if an employee has a new Dependent as a result of marriage, birth, adoption or placement for adoption, the employee may be able to enroll himself or herself and his or her Dependents. However, enrollment must be requested within 30 days after the marriage, birth, adoption or placement for adoption. Special enrollment rights may also apply to persons who lose coverage under Medicaid or the Children s Health Insurance Program (CHIP) or become eligible for state premium assistance under Medicaid or CHIP. An employee or Dependent who loses coverage under Medicaid or CHIP as a result of the loss of Medicaid or CHIP eligibility may be able to enroll in this Plan, if enrollment is requested within 60 days after Medicaid or CHIP coverage ends. An employee or Dependent who becomes eligible for group health plan premium assistance under Medicaid or CHIP may be able to enroll in this Plan if enrollment is requested within 60 days after the employee or Dependent is determined to be eligible for such premium assistance. Copayments As a Member of the Plan, you are responsible for a portion of the cost of certain benefits through Copayments. These Copayments are payable to the provider at the time of service. Your identification card indicates the Copayment amounts for the Plan s most frequently used services. Deductible A Deductible is a specific dollar amount that is payable by the Member for covered services each calendar year before benefits subject to the Deductible are available under the Plan. Deductible amounts are incurred as of the date of service. Your Plan has separate Deductibles that apply to your and benefits. Any eligible expenses you incur toward the Deductible in a calendar year apply to both the and the Deductibles. Once you meet the Deductible, which is usually the lower of the two, you may begin to receive coverage for services. If you later meet the Deductible you may also receive coverage for services. Each Member is responsible for the per Member Deductible for covered services each calendar year, unless a family Deductible applies. If a family Deductible applies, it is met when any combination of Members in a covered family incur expenses for services to which the Deductible applies in a calendar year. In such event, the Member Deductible is Deductible Carryover Your Plan has a Deductible carryover which allows you to apply any Deductible amount paid for covered services during the last three (3) months of a calendar year toward the Deductible for the next year. In order for a Deductible carryover to apply, the Member (or family) must have had continuous coverage under the Plan through the same Employer Group at the time the charges for the prior year were incurred. 10

11 Coinsurance Coinsurance is a specific percentage amount that is payable by the Member for certain covered services. Coinsurance amounts are in addition to the Deductible and any applicable Copayment amounts. Out-of-Pocket Maximum The total maximum Copayment, Deductible, and Coinsurance amounts you will be required to pay for all services, excluding prescription drugs, per calendar year. HPIC will notify you if you have reached these limits. If you feel you have reached these limits but have not been notified, please contact HPIC. Required Approvals and Penalties Hospital Admissions Members are responsible for obtaining approval from HPIC before any hospital admission occurs when either the doctor or facility is a Non-Participating Provider (this includes Day Surgery and day hospitalization for psychiatric or drug and alcohol rehabilitation services). If you do not get Prior Approval you are responsible for the first $500 of the eligible expense. The $500 penalty payment does not count toward the Deductible or the Out-of-Pocket Maximum. Call for Prior Approval. Specialized Services When using Non-Participating Providers for the specialized services listed below, it is the Member s responsibility to obtain approval from HPIC before any costs are incurred. If you do not get Prior Approval you are responsible for the first $500 of the eligible expense. The $500 penalty payment does not count toward the Deductible or the Out-of-Pocket Maximum. Call for Prior Approval of the following services: All inpatient services Physical, speech, and occupational therapies Advanced reproductive technologies All services provided in the Member s home Human organ transplants 48 Hour Emergency Notification In cases of an emergency hospital admission to a Non-Participating Provider, you must notify HPIC within 48 hours of the admission, unless notification is not possible because of your condition. If you do not notify HPIC of the admission, you will be responsible for the first $500 of the eligible expenses. The $500 penalty payment does not count toward your Deductible or the Out-of-Pocket Maximum. Call for Prior Approval. Maternity Care If you use a Participating Provider, he or she will obtain Prior Approval for you. If you use a Non-Participating Provider, you are responsible for obtaining Prior Approval. The Prior Approval process is initiated by calling

12 Benefit Exclusions The Plan does not provide coverage for: Cosmetic procedures, except as described in your Benefit Handbook Treatment with crystals Sensory integrative praxis tests Commercial diet plans or weight loss programs and any services in connection with such programs Transsexual surgery, including related drugs or procedures Services that are not Medically Necessary Any products or services, including, but not limited to, drugs, devices, treatments, procedures, and diagnostic tests, which are Experimental,Unproven, or Investigational Dental services, (except the specific services listed in your Benefit Handbook and this Schedule of Benefits), including restorative, periodontal, orthodontic, endodontic, prosthodontic and dental services for temporomandibular joint dysfunction (TMD), removal of impacted teeth to prepare for or support orthodontic, prosthodontic or periodontal procedures and dental fillings, crowns, gum care, including gum surgery, braces, root canals, bridges, bonding and dentures are not covered. Eyeglasses, contact lenses and fittings, except as listed in your Benefit Handbook and this Schedule of Benefits Refractive eye surgery, including laser surgery and orthokeratology, for correction of myopia, hyperopia and astigmatism Transportation other than by ambulance Cost for any services for which you are entitled to treatment at government expense, including military service connected disabilities Costs for any services covered by workers compensation, third party liability, other insurance coverage or an employer under state or federal law Hair removal or restoration, including, but not limited to, electrolysis, laser treatment, transplantation or drug therapy Routine foot care, biofeedback, pain management programs, myotherapy, and sports medicine clinics Testing for central auditory processing Physical examinations for insurance, licensing or employment purposes Rest or custodial care Personal comfort or convenience items (including telephone and television charges) Exercise equipment Repair or replacement of durable medical equipment or prosthetic devices as a result of loss, negligence, willful damage or theft Non-durable medical equipment, unless used as part of the treatment at a medical facility or as part of approved home health care services Reversal of voluntary sterilization (including any services for infertility related to voluntary sterilization and its reversal) Any form of surrogacy Infertility treatment for Members who are not medically infertile Devices or special equipment needed for sports or occupational purposes Services for which no charge would be made in the absence of insurance Services after termination of membership Services for non-members Services or supplies given to you by: (1) anyone related to you by blood, marriage or adoption or (2) anyone who ordinarily lives with you Services for which no coverage is provided in your Benefit Handbook, this Schedule of Benefits or Prescription Drug Brochure (if your Employer Group has selected this coverage) Any home adaptations, including, but not limited to, home improvements and home adaptation equipment Vocational rehabilitation or vocational evaluations on job adaptability, job placement or therapy to restore function for a specific occupation 12

13 Benefit Exclusions The Plan does not provide coverage for: Charges for any products or services, including, but not limited to, professional fees, medical equipment, drugs and hospital or other facility charges that are related to any care that is not a covered service under your Benefit Handbook Charges for missed appointments Acupuncture, aromatherapy and alternative medicine All charges over the semi-private room rate, except when a private room is Medically Necessary Hospital charges after the date of discharge Preventive dental care Extraction of teeth impacted in bone Care by a chiropractor outside the scope of standard chiropractic practice, including, but not limited to, surgery, prescription or dispensing of drugs or medications, internal examinations, obstetrical practice or treatment of infections and diagnostic testing for chiropractic care other than an initial x-ray Hearing aids Foot orthotics, except for the treatment of severe diabetic foot disease Birth control injections, implants and devices, unless your Employer Group provides prescription drug coverage A provider's charge to file a claim or to transcribe or copy your medical records Any service or supply furnished along with a non-covered service Taxes or assessments on services or supplies Wigs, except as described in your Benefit Handbook Advanced reproductive technologies, including, but not limited to, in vitro fertilization, gamete intrafallopian transfer, zygote intrafallopian transfer, intra-cytoplasmic sperm injection, and donor egg procedures, including related egg and inseminated egg procurement, processing and banking Methadone maintenance Private duty nursing Massage therapy when performed by anyone other than a licensed physical therapist, physical therapy assistant, occupational therapist, or certified occupational therapy assistant Myotherapy Health resorts, recreational programs, camps, wilderness programs, outdoor skills programs, relaxation or lifestyle programs, including any services provided in conjunction with, or as part of, such types of programs Therapeutic donor insemination, including related sperm procurement and banking Telemonitoring, telemedicine services involving , fax, or audio-only telephone, telemedicine services involving stored images forwarded for future consultation, i.e. store and forward telecommunication Services for any condition with only a V Code designation in the Diagnostic and Statistical Manual of Mental Disorders, which means that the condition is not attributable to a mental disorder Unless otherwise specified in this Benefit Handbook or the Schedule of Benefits (and required by law), the Plan does not cover food or nutritional supplements, including FDA-approved medical foods obtained by prescription Educational services or testing. No benefits are provided: (1) for educational services intended to enhance educational achievement; (2) to resolve problems of school performance; or (3) to treat learning disabilities 13