Adventist Health System Schedule of Benefits for Adventist Health System Effective January 1, 2018

Transcription

1 Adventist Health System Schedule of Benefits for Adventist Health System Effective January 1, 2018 High Health Plan with Health Savings Account (Health Savings Plan) TIER 1 TIER 2 TIER 3 CALENDAR YEAR DEDUCTIBLE* Individual * $1,500 $3,000 $6,000 Family * $3,000 $6,000 $12,000 *Unless otherwise indicated, any applicable must be met before benefits are paid. Plan Maximum Out-of-Pocket Limit includes Plan and Copayments. Individual Maximum Out-of-Pocket Limit: For Tier 1 expenses: $4,000. For Tier 2 expenses: $6,000. For Out-of-Network expenses: No limit. Family Maximum Out-of-Pocket Limit: For Tier 1 expenses: $6,850. For Tier 2 expenses: $6,850. For Out-of-Network expenses: No limit. PLAN FEATURES TIER 1 TIER 2 TIER 3 Lifetime Maximum Benefit per person Unlimited Unlimited Unlimited Payment Percentage listed in the Schedule below reflects the Plan Payment Percentage. This is the amount the Plan pays. You are responsible to pay any s and the remaining Payment Percentage (Coinsurance). You are responsible for full payment of any non-covered expenses you incur. All Covered Expenses are subject to the unless otherwise noted in the Schedule below. Maximums for specific covered expenses, including visit, day and dollar Maximums are combined Maximums between Network and Out-of-Network, unless specifically stated otherwise. 1

2 PREVENTIVE CARE BENEFITS ROUTINE PHYSICAL EXAMS OFFICE VISITS 40% per exam after No Copay or No Copay or applies Covered Persons through age 21: Maximum age & visit limits Subject to any age and visit limits provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Subject to any age and visit limits provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Subject to any age and visit limits provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Covered Persons ages 22 but less than 65: Maximum visits per year* 1 visit 1 visit 1 visit Covered Persons age 65 and over: Maximum visits per year* 1 visit 1 visit 1 visit *Please call your Administrator to determine if the Maximum is determined by or by visits over 12 consecutive months. PREVENTIVE CARE IMMUNIZATIONS Performed in a Facility or Physician s office No Copay or No Copay or SCREENING & COUNSELING SERVICES- OBESITY, MISUSE OF ALCOHOL AND/OR DRUGS & USE OF TOBACCO PRODUCTS No Copay or No Copay or 2

3 OBESITY Maximum visits per year* (This Maximum applies only to Covered Persons ages 22 & older.) 26 visits (however, of these only 10 visits will be allowed under the Plan for healthy diet counseling provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and dietrelated chronic disease)**. 26 visits (however, of these only 10 visits will be allowed under the Plan for healthy diet counseling provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and dietrelated chronic disease)** 26 visits (however, of these only 10 visits will be allowed under the Plan for healthy diet counseling provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and dietrelated chronic disease)** *Please call your Administrator to determine if the Maximum is determined by or by visits over 12 consecutive months. **Note: In figuring the Maximum visits, each session of up to 60 minutes is equal to one visit. MISUSE OF ALCOHOL AND/OR DRUGS Maximum visits per year* 5 visits** 5 visits** 5 visits** *Please call your Administrator to determine if the Maximum is determined by or by visits over 12 consecutive months. **Note: In figuring the Maximum visits, each session of up to 60 minutes is equal to one visit. USE OF TOBACCO PRODUCTS Maximum visits per year* 8 visits** 8 visits** 8 visits** *Please call your Administrator to determine if the Maximum is determined by or by visits over 12 consecutive months. **Note: In figuring the Maximum visits, each session of up to 60 minutes is equal to one visit. WELL WOMAN PREVENTIVE VISITS Office Visits 40% per exam after No applies No applies Maximum visits per year* 1 visit 1 visit 1 visit *Please call your Administrator to determine if the Maximum is determined by or by visits over 12 consecutive months. 3

4 ROUTINE HEARING EXAM Preventive Exam Office Visit for Children (until age 21) (Maximum visit one per year)* 100% per exam No applies 100% per exam No applies 40% per exam after Maximum exams per 24 month period* (other than preventive care hearing exam) 1 exam 1 exam 1 exam *Please call your Administrator to determine if the Maximum is determined by or by visits over 12 consecutive months. ROUTINE CANCER SCREENINGS ROUTINE CANCER SCREENING OUTPATIENT No No 40% per exam after Maximums Subject to any age and visit limits provided for in the current recommendations of the United States Preventive Services Task Force and comprehensive guidelines supported by the Health Resources and Services Administration. Subject to any age and visit limits provided for in the current recommendations of the United States Preventive Services Task Force and comprehensive guidelines supported by the Health Resources and Services Administration. Subject to any age and visit limits provided for in the current recommendations of the United States Preventive Services Task Force and comprehensive guidelines supported by the Health Resources and Services Administration. For details, contact your Physician, or call your Administrator. For details, contact your Physician, or call your Administrator. For details, contact your Physician, or call your Administrator. 4

5 PRENATAL CARE OFFICE VISITS No Copay or No Copay or Important Note: Refer to the Physician Services and Pregnancy Expenses sections of the Benefit Plan Booklet for more information on coverage levels for pregnancy expenses under this Plan, including other prenatal care, delivery and postnatal care office visits. COMPREHENSIVE LACTATION SUPPORT AND COUNSELING SERVICES Lactation Counseling Services - Facility or Office Visits No Copay or Calendar Year No Copay or Calendar Year Lactation Counseling Services Maximum Visits either in a group or individual setting 6* visits per 12 months 6* visits per 12 months Not Applicable *Important Note: Visits in excess of the Lactation Counseling Maximum as shown above, are covered under the Physician Services office visit section of the Schedule of Benefits. Breast Pumps & Supplies 100% per item No Copay or 100% per item No Copay or 40% per item after Important Note: Limit of one breast pump every 36 months (no dollar limit). Refer to your Administrator for all details on limitations on breast pumps and supplies. 5

6 FAMILY PLANNING SERVICES Female Contraceptive Counseling Services Office Visits No Copay or Calendar Year No Copay or Calendar Year Contraceptive Counseling Services - Maximum visits either in a group or individual setting 2* visits per 12 months 2* visits per 12 months Not Applicable *Important Note: Visits in excess of the Contraceptive Counseling Maximum as shown above, are covered under the Physician Services office visit section of the Schedule of Benefits. FAMILY PLANNING SERVICES - OTHER VOLUNTARY STERILIZATION FOR MALES Outpatient... FAMILY PLANNING SERVICES VOLUNTARY STERILIZATION FOR FEMALES Inpatient No Copay or No Copay or. Outpatient No Copay or No Copay or. 6

7 PLAN FEATURES IN NETWORK OUT OF NETWORK FAMILY PLANNING SERVICES - FAMILY CONTRACEPTIVES Female Contraceptive Generic Prescription Drugs (associated office visit is payable in accordance with the type of expense incurred and the place where service is provided) 100% per Prescription or Refill for approved Brand and Generics No 50% per Prescription or Refill after Female Contraceptive Devices (associated office visit is payable in accordance with the type of expense incurred and the place where service is provided) 100% per Prescription or Refill for approved Brand and Generics No 50% per Prescription or Refill after. 7

8 PHYSICIAN SERVICES Office Visits to Primary Care Physician Office visits to non- Specialist (non-surgical) Specialist Office Visits Physician Office Visits- Surgery 8

9 Walk-In Clinic Visit (Non-Emergency) Preventive Care Services* Immunizations No Copay or No Copay or For details, contact your Physician, or call your Administrator. For details, contact your Physician, or call your Administrator For details, contact your Physician, or call your Administrator Individual Screening and Counseling Services for Tobacco Use No Copay or No Copay or Maximum Benefit per visit Individual Screening and Counseling Services for Tobacco Use Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for Maximums that may apply to these types of services. Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for Maximums that may apply to these types of services. Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for Maximums that may apply to these types of services. Individual Screening and Counseling Services for Obesity No Copay or No Copay or Maximum Benefit per visit Individual Screening and Counseling Services for Obesity Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for Maximums that may apply to these types of services. Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for Maximums that may apply to these types of services. Refer to the Preventive Care Benefit section earlier in this Schedule of Benefits for Maximums that may apply to these types of services. *Important Note: Not all Preventive Care Services are available at all Walk-In Clinics. The types of services offered will vary by the Provider and location of the clinic. These services may also be obtained from your Physician. Depending on the services received, you may be responsible for a Copay in the amount appropriate for either Primary Care Physician Services or Specialty Care Services. 9

10 All Other Services Physician Services for Inpatient Facility and Hospital Visits* Administration of Anesthesia *Important Note: Please note that all inpatient admission to the Hospital through the Hospital s Emergency Room will be covered at the Tier 1 benefit level regardless of the normal tier of the admitting Facility (until you can safely be transferred to a Tier 1 Facility). EMERGENCY MEDICAL SERVICES Hospital Emergency Facility and Physician* 90% after 90% after 90% after See Note below in italics *Important Note: Please note that all inpatient admission to the Hospital through the Hospital s Emergency Room will be covered at the Tier 1 benefit level regardless of the normal tier of the admitting Facility (until you can safely be transferred to a Tier 1 Facility). Please note that as these Providers are not Network Providers and do not have a contract with your Administrator, the Provider may not accept payment of your cost share (your and Payment Percentage), as payment in full. You may receive a bill for the difference between the amount billed by the Provider and the amount paid by this Plan. If the Emergency Room Facility or Physician bills you for an amount above your cost share, you are not responsible for paying that amount. Please send us the bill at the address listed on the back of your member ID card and we will resolve any payment dispute with the Provider over that amount. Make sure your member ID number is on the bill. Non-Emergency Care in a Hospital Emergency Room Not Covered Not Covered Not Covered 10

11 URGENT CARE SERVICES Urgent Medical Care (at a non-hospital free standing facility) Urgent Medical Care (from other than a non- Hospital free standing facility) Refer to Emergency Medical Services and Physician Services above. Refer to Emergency Medical Services and Physician Services above. Refer to Emergency Medical Services and Physician Services above. Non-Urgent Use of Urgent Care Provider (from other than a non- Hospital free standing facility) Refer to Emergency Medical Services and Physician Services above. Refer to Emergency Medical Services and Physician Services above. Refer to Emergency Medical Services and Physician Services above. OUTPATIENT DIAGNOSTIC AND PREOPERATIVE TESTING COMPLEX IMAGING SERVICES Complex Imaging 90% per test after 70% per test after 40% per test after DIAGNOSTIC LABORATORY TESTING Diagnostic Laboratory 90% per procedure after 70% per procedure after 40% per procedure after DIAGNOSTIC X-RAYS (EXCEPT COMPLEX IMAGING SERVICES) Diagnostic X-Rays 90% per procedure after 70% per procedure after 40% per procedure after 11

12 OUTPATIENT SURGERY Outpatient Surgery 90% per visit/surgical procedure after Calendar Year 70% per visit/surgical procedure after Calendar Year 40% per visit/surgical procedure after Calendar Year INPATIENT FACILITY EXPENSES Birthing Center Hospital Facility Expenses* Room and Board (including maternity) Other than Room and Board Skilled Nursing Inpatient Facility Maximum days per year** 90 days 90 days 90 days *Important Note: Please note that all inpatient admission to the Hospital through the Hospital s Emergency Room will be covered at the Tier 1 benefit level regardless of the normal tier of the admitting Facility (until you can safely be transferred to a Tier 1 Facility). **Please call your Administrator to determine if the Maximum is determined by or by visits over 12 consecutive months. 12

13 SPECIALTY BENEFITS Home Health Care (Outpatient) Maximum visits per year* *Please call your Administrator to determine if the Maximum is determined by or by visits over 12 consecutive months. HOSPICE BENEFITS Maximum Benefit per lifetime Unlimited days Unlimited days Unlimited days Hospice Care Facility Expenses (Room and Board) Hospice Care Other Expenses During a Stay Hospice Outpatient visits 13

14 INPATIENT TREATMENT OF MENTAL DISORDERS MENTAL DISORDERS Hospital Facility Expenses* Room and Board Other than Room and Board Physicians Services Check with Administrator on Copayment/Coinsurance requirements Check with Administrator on Copayment/Coinsurance requirements Check with Administrator on Copayment/Coinsurance requirements Inpatient Residential Treatment Facility Expenses Inpatient Residential Treatment Facility Expenses Physician Services 90% after 70% after 40% after *Important Note: Please note that all inpatient admission to the Hospital through the Hospital s Emergency Room will be covered at the Tier 1 benefit level regardless of the normal tier of the admitting Facility (until you can safely be transferred to a Tier 1 Facility). OUTPATIENT TREATMENT OF MENTAL DISORDERS Outpatient Services 14

15 INPATIENT TREATMENT OF SUBSTANCE ABUSE Hospital Facility Expenses* Room and Board Other than Room and Board Physicians Services Check with Administrator on Copayment/Coinsurance requirements Check with Administrator on Copayment/Coinsurance requirements Check with Administrator on Copayment/Coinsurance requirements Inpatient Residential Treatment Facility Expenses Inpatient Residential Treatment Facility Expenses Physician Services 90% after 70% after 40% after *Important Note: Please note that all inpatient admission to the Hospital through the Hospital s Emergency Room will be covered at the Tier 1 benefit level regardless of the normal tier of the admitting Facility (until you can safely be transferred to a Tier 1 Facility). OUTPATIENT TREATMENT OF SUBSTANCE ABUSE Outpatient Treatment 15

16 PLAN FEATURES TRANSPLANT SERVICES FACILITY AND NON-FACILITY EXPENSES Transplant services and expenses are only covered when certain approved facilities are used. Please contact Member Services at your Administrator for guidance on covered facilities. OBESITY TREATMENT Obesity services are only covered when certain approved facilities are used. Please contact Member Services at your Administrator for guidance on covered facilities. Obesity Treatment Non-Surgical Outpatient Morbid Obesity Treatment (non-surgical) a $1,000 Obesity Treatment Obesity Treatment Surgical Inpatient Morbid Obesity Surgery (includes Surgical Procedure and Acute Hospital Services) Outpatient Morbid Obesity Surgery Maximum Benefit Morbid Obesity Surgery (Inpatient and Outpatient) a $1,000 Obesity Treatment 90% per service after a $1,000 Obesity Treatment $12,000 per person per lifetime 16

17 OTHER COVERED HEALTH EXPENSES Ground, Air or Water Ambulance 90% after 90% after 90% after Durable Medical and Surgical Equipment 90% per item after 70% per item after 40% per item after Kidney Dialysis There are specific kidney dialysis Providers that you are required to use and services will only be covered if you are using an approved facility for kidney dialysis services. Please contact your Administrator for more information. Jaw Joint Disorder Treatment Maximum Lifetime Benefit $1,000 $1,000 $1,000 Oral and Maxillofacial Treatment (Mouth, Jaws, and Teeth) Payable in accordance with the type of expense occurred and the place where service is provided. Payable in accordance with the type of expense occurred and the place where service is provided. Payable in accordance with the type of expense occurred and the place where service is provided. Prosthetic Devices 90% per item after 70% per item after 40% per item after 17

18 OUTPATIENT THERAPIES Chemotherapy Infusion Therapy Radiation Therapy SHORT TERM OUTPATIENT REHABILITATION THERAPIES Outpatient Physical, Occupational, and Speech Physical Therapy Maximum visits per year* Occupational Therapy Maximum visits per year* Speech Therapy Maximum visits per year* *Please call your Administrator to determine if the Maximum is determined by or by visits over 12 consecutive months. The 60 visit Maximum applies annually per member regardless of multiple diagnoses. **Please note that Habilitation (or Habilitative) Services are covered only for Autism services for dependents age 21 or younger. Plan must be met before Coinsurance 18

19 SPINAL MANIPULATION Spinal Manipulation Maximum visits per year* 20 visits 20 visits 20 visits *Please call your Administrator to determine if the Maximum is determined by or by visits over 12 consecutive months. 19

20 PLAN FEATURES TIER 1 PRESCRIPTION DRUG Retail Prescription Drugs (30-day or less) $10 Copay for Generic Drugs* 20% of the cost of formulary Drugs** ($25 minimum/$150 maximum) 20% of the cost of non-formulary Drugs** ($50 minimum/$300 maximum) 20% of the cost of specialty Drugs ($50 minimum/$200 maximum) Mail Order Prescription Drugs (90-day) $10 Copay for Generic Drugs* 20% of the cost of formulary Drugs** ($50 minimum/$150 maximum) 20% of the cost of non-formulary Drugs** ($100 minimum/$300 maximum) 20% of the cost of specialty Drugs ($100 minimum/$400 maximum) Important Notes: *Certain generic medications may be priced at a higher Brand Name tier due to cost and availability of less expensive, therapeutically equivalent alternatives available. To inquire about these generics, please contact Rx Plus Pharmacy at **Certain preferred brand-name drugs are in what is called a formulary a list of brand-name drugs that are preferred over other brand-name drugs that may be prescribed for the same condition. You pay less for formulary drugs than non-formulary drugs. A list of these drugs can be found online at and may change from time to time. All eligible covered expenses count toward the. The must be met before the Prescription Drug copay applies (certain preventive drugs are not subject to the ). A list of these drugs can be found online at You can obtain short-term prescriptions through your local Pharmacy, and maintenance medications through the Rx Plus Mail Order program. Specific specialty medications are required to be obtained through the Rx Plus Pharmacy. 20

21 Expense Provisions The following provisions apply to your health expense plan. This section describes cost sharing features, benefit Maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits. This Schedule of Benefits replaces any Schedule of Benefits previously in effect under your plan of health benefits. KEEP THIS SCHEDULE OF BENEFITS WITH YOUR BENEFIT PLAN BOOKLET. Provisions Covered expenses applied to the Out-of-Network Provider s will only be applied to satisfy the Out-of-Network Provider s. Covered expenses applied to the Network Provider s will not be applied to satisfy the Out-of-Network Provider s. Tier 1 and Tier 2 limits are combined to ensure that the member/family does not exceed the health care reform limit maximums, but benefits are maximized when Tier 1 Providers are used. All covered expenses accumulate toward the Network Provider and Out-of-Network Provider s except for those covered expenses identified later in this Schedule of Benefits. You and each of your covered dependents have separate s. This Plan has individual and family Calendar Year s. For purposes of provision below, an individual means an employee enrolled for self only coverage with no dependent coverage and a family means an employee enrolled with one or more dependents. The family can be met by one family member, or a combination of family members. Network Provider Individual This is the amount of covered expenses that you incur each from a Network Provider for which no benefits will be paid. After covered expenses reach this individual, this Plan will begin to pay benefits for covered expenses that you incur from a Network Provider for the rest of the. Family This is the amount of covered expenses that you and your covered dependents incur each from a Network Provider for which no benefits will be paid. After covered expenses reach this family, this Plan will begin to pay benefits for covered expenses that you and your covered dependents incur from a Network Provider for the rest of the Calendar Year. 21

22 Out-of-Network Provider Individual This is the amount of covered expenses that you incur each from an Out-of-Network Provider for which no benefits will be paid. This individual applies separately to you. After covered expenses reach this individual ; this Plan will begin to pay benefits for covered expenses that you incur from an Out-of-Network Provider for the rest of the. Family This is the amount of covered expenses that you and your covered dependents incur each from an Out-of-Network Provider for which no benefits will be paid. After covered expenses reach this family, this Plan will begin to pay benefits for covered expenses that you and your covered dependents incur from an Out-of-Network Provider for the rest of the. Payment Provisions Payment Percentage This is the percentage of your covered expenses that the plan pays and the percentage of covered expenses that you pay. The percentage that the plan pays is referred to as the Plan Payment Percentage. Once applicable s have been met, your plan will pay a percentage of the covered expenses, and you will be responsible for the rest of the costs. The Payment Percentage may vary by the type of expense. Refer to your Schedule of Benefits for Payment Percentage amounts for each covered benefit. For purposes of the following Coinsurance provisions, an individual means an employee enrolled for self only coverage with no dependents coverage and a family means an employee enrolled with one or more dependents. Maximum Out-of-Pocket Limit The Maximum Out-of-Pocket Limit is the Maximum amount you are responsible to pay for covered expenses during the. This Plan has an individual and family Maximum Out-of-Pocket Limit. Certain covered expenses do not apply toward the Maximum Out-of-Pocket Limit. See list below. 22

23 Network Provider Maximum Out-of-Pocket Limit Individual Once the amount of eligible Network Provider expenses you have paid during the meets the individual Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered expenses that apply toward the limit for the remainder of the for that person. Family The Family Maximum Out-of-Pocket Limit can be met by a combination of family members or by any single individual within the family. Once the amount of eligible Network Provider expenses paid during the meets this family Maximum Out-of- Pocket Limit, this Plan will pay 100% of such covered expenses that apply toward the limit for the remainder of the for all covered family members. Tier 1 and Tier 2 limits are combined to ensure that the member/family does not exceed the health care reform limit maximums, but benefits are maximized when Tier 1 Providers are used. Expenses That Do Not Apply to Your Out-of-Pocket Limit Certain covered expenses do not apply toward your plan Out-of-Pocket limit. These include: Charges over the recognized charge; Non-covered expenses; Expenses for non-emergency use of the emergency room General This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your Plan of benefits. Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot be accepted. This Schedule is part of your Benefit Plan Booklet and should be kept with your Benefit Plan Booklet. 23