COMPREHENSIVE MEDICAL BENEFIT PLAN (40XX0629 R01/08) ENHANCED PPO BENEFIT PLAN SCHEDULE OF BENEFITS OPTION II

Transcription

1 COMPREHENSIVE MEDICAL BENEFIT PLAN (40XX0629 R01/08) ENHANCED PPO BENEFIT PLAN SCHEDULE OF BENEFITS OPTION II GROUP NAME Lafayette Parish School Board GROUP NUMBER and Depts. GROUP'S ORIGINAL GROUP S AMENDED GROUP'S ANNIVERSARY EFFECTIVE DATE BENEFIT PLAN DATE DATE January 1, 1996 January 1, 2008 January 1 BENEFITS PROVIDED Lifetime Maximum: $2,000, per Member Benefit Period Deductible Amount: Individual $ Family Deductible Amount $2, A Member does not have to meet the individual Deductible Amount to be eligible for the aggregate family Deductible Amount. The Benefit Period Deductible Amount does not apply to the following: Preventive or Wellness Care Oral Surgical Procedures Coinsurance: Group Member PPO Preferred Care Providers 80% 20% All Other Providers * 60% 40% Special Coinsurance: Preventive or Wellness Care 100% 0% Second Surgical Opinion 100% 0% Pre-Admission Diagnostic Services 100% 0% * A reduction in Benefits will be applied for using a Nonparticipating Provider Hospital as described in the Introduction section of the Benefit Plan. Out-of-Pocket Amount Per Benefit Period (Does NOT include the Deductible Amount): PPO Preferred Care Providers All Other Providers $3, per Member $4, per Member

2 Special Notes: The Member s remaining expenses incurred from Oral Surgery Procedures is not eligible for satisfying the Out-of-Pocket Amount. The Out-of-Pocket Amount incurred for Participating Providers is eligible for satisfying the Out-of-Pocket Amount for Other Providers. The Out-of-Pocket Amount incurred for Other Providers is eligible for satisfying the Out-of-Pocket Amount for Participating Providers. Physician s Office Visit Copayment: $30.00 per visit Outpatient services (described in the Benefit Plan) are available when rendered in a Physician s, Optometrist s, podiatrist s or chiropractor s office or clinic, or when rendered in an Urgent Care Center or federally qualified rural health clinic. Hospital Emergency Room Copayment: $50.00 per visit The Copayment is waived if the visit results in an Inpatient Hospital Admission or if the diagnosis is determined to be life-threatening. Hospice Care: Bereavement Counseling Services Benefit Period Maximum: $ Preventive or Wellness Care: Routine physical exam maximum Durable Medical Equipment, Orthotic Devices, and Prosthetic Appliances: Aggregate Benefit Period Maximum: Aggregate Lifetime Maximum: Organ, Tissue, and Bone Marrow Transplant Benefits (Authorization is required prior to the services being performed): Lifetime Maximum for all covered transplants combined: Benefits paid will accrue to the overall Lifetime Maximum Benefit amount shown above Acquisition Expense Maximum per covered transplant: For a living donor For a non-living donor Private Duty Nursing Maximum Transportation, Lodging and Meals Maximum $25, per Benefit Period $ per Day 2

3 Mental Disorders, Alcohol and/or Drug Abuse: Coinsurance: Group Member PPO Preferred Care Providers 80% 20% All Other Providers 60% 40% Member s remaining Coinsurance is eligible for satisfying the Out-of-Pocket Amount. Benefit Period Maximum Inpatient Outpatient 30 Days for each Member 40 Visits for each Member Inpatient Hospital Admissions for Alcohol and/or Drug Abuse are limited to a lifetime maximum of two (2) confinements for each Member. Pregnancy Care: Pregnancy Care Benefits are available under this Benefit Plan. Any limitations stated are applicable. Pregnancy Care Benefits for a Minor Dependent of the Subscriber or spouse are limited to a lifetime maximum payment of $25, for each Member. Accidental Injury Benefit: $ per Accident Temporomandibular and/or Craniomandibular Joint Disorders: Lifetime Maximum Benefit $2, Rehabilitative Care Services: Speech Therapy is limited to thirty-two (32) treatments per Benefit Period for each Member. Oral Surgery Procedures: Maximum Reimbursement Incision and Drainage of Intraoral Abscess $42.00 Extraoral Abscess $ Alveolectomy/Alveoplasty per quadrant $30.00 Removal of Ankylossed Tooth $60.00 Apicoectomy $90.00 Excision of Cysts of the Jaw (Mandible or Maxilla) involving One or two teeth $90.00 Three or four teeth $ Five or more teeth $ Excision of Fibroma, Epulis $42.00 Excision or Incisional Biopsy $

4 Excision of Impacted Tooth One tooth $67.50 Two teeth $ Three teeth $ Four teeth $ Mandibular Tori per quadrant $ AUTHORIZATION OF SERVICES AND SUPPLIES Authorization of Inpatient and Emergency Admissions: Inpatient Admissions must be Authorized. Refer to Authorization of Services and Supplies and if applicable Pregnancy Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Inpatient Admissions, for Concurrent Review of an Admission in progress, or other Covered Services and supplies must be made to Blue Cross and Blue Shield of Louisiana by calling Additional Member responsibility if Authorization is not requested Fifty percent (50%) of the Allowable Charge up to $1, Authorization of Other Covered Services and Supplies: The following services and supplies require Authorization prior to the services being rendered or supplies being received. Bone growth stimulator Day Rehabilitation Programs Electric & Custom Wheelchairs Home Health Care Hospice Care Hyperbarics Implantable Medical Devices over $ such as Implantable Defibrillator and Insulin Pump Non-Emergency Air Ambulance Nuclear Cardiology PET Scans Prosthetic Appliances Sleep Studies Stereotactic Radiosurgery, including but not limited to gamma knife and cyberknife procedures Vacuum Assisted Wound Closure Therapy Refer to the Authorization of Services and Supplies, and if applicable, Pregnancy Care Benefits section of the Benefit Plan for complete information. 4

5 PRE-EXISTING CONDITION EXCLUSION PERIOD Initial Members covered under the Benefit Plan on the Group's Effective Date are not subject to a twelve (12) month waiting period in connection with a Pre-Existing Condition. Subsequent Members not covered under the Benefit Plan on the Group's Effective Date, and who apply for coverage within the initial eligibility period are not subject to a twelve (12) month waiting period in connection with a Pre-Existing Condition. Initial and Subsequent Members not covered under the Benefit Plan on the Group's Effective Date, and who do not apply for coverage within the initial eligibility period are subject to a twelve (12) month waiting period for a Pre-Existing Condition as stated in the Limitations and Exclusions article of the Benefit Plan. A Member may receive credit toward this exclusionary period for any time he served toward a Pre-Existing Condition Exclusion Period under his prior coverage. Refer to the Benefit Plan for complete information. Active Employees: ELIGIBILITY WAITING PERIOD The eligibility date is the first billing date on or after completion of one (1) calendar month of employment. Retirees: Eligible Persons who satisfy the eligibility requirements as specified by the Group and who are eligible to participate in the Group s health care benefit plan are eligible the first billing date following the date of retirement if the Employee and Dependents were covered immediately prior to the date of the Employee s retirement. Refer to the Schedule of Eligibility provisions in the Benefit Plan for complete information. H:\2008 Lafayette Parish School Board - Enhanced PPO Benefit Plan SOB - Option II (clean copy#2).doc 5