BENEFITS-AT-A-GLANCE
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- Opal Anne Bryan
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1 BENEFITS-AT-A-GLANCE Plan Name: Type of Plan: PPO Network: Pre- Certification Requirements: Orange Ulster School Districts Health Plan Indemnity with PPO Benefit; No Referral Required Basic hospital benefits; Medical services following calendar year deductible, co-insurance and co-pay for out-of-network providers; or PPO services with only a per-day/per service co-payment. Blue Cross/Blue Shield Association s BlueCard PPO Program File all claims with the Blue Cross/Blue Shield Plan in the state where services are rendered. Envoy Payer ID (INDECS Corporation) In-Patient Hospital and 2 nd Surgical Opinion: Contact HealthCare Strategies (800) Physical Medicine (PT, OT & Chiro): Contact OptumHealth (formerly MPN/ACN) (888) Behavioral Health-Inpatient & Out-patient: Contact Quantum Health Solutions (888) Plan Office: 1(845) Exec. Director: Mr. Ike Lovelass Claims & INDECS Corporation Eligibility: 1(888) 4-INDECS ( ) Plan Document (Online): Click on: INDECS Connection then select either Member or Provider Login. At this point, you must have a password or register for one. COB: Medicare Primary: This Plan contains a Coordination of Benefit provision which complies with the State of New York COB regulations. Send Medicare primary claims to Medicare. Send secondary claims directly to INDECS Corp., PO Box 668, Lyndhurst, NJ with Medicare provider s or member s EOB. Medicare secondary benefits are out-of-network provider benefits (below) with Medicare primary benefits being carved-out from Plan Out-Of-Network benefits. Deductible and co-insurance apply. CO-PAYS DO NOT. OU_baag_ doc Page 1 of 6
2 Annual Deductible $300/$800 Calendar Year (CY) (Ded.) 20% (after co-pay and CY Co-Insurance deductible) of Usual & Customary (U&C) allowance Applies before deductible and coinsurance-see service for amount of Co-Payment (Co-pay) See service for amount of copay (1) per day or per service co-pay (1) Out-of-pocket $1,000/$1,800 (co-pays do not apply Not applicable maximum to out-of-pocket maximum) Calendar Year Medical Benefit Maximum (excludes basic hospital services) Lifetime medical benefit maximum $500,000 (combined limit for in and out-of-network. Hospital benefits do NOT accrue to calendar year max) Unlimited; Except for $25,000 lifetime limit for qualified infertility procedures* $500,000 (the same combined limit for In and Out-of-Network) Unlimited; Except for $25,000 lifetime limit for qualified infertility procedures* HOSPITAL BASIC BENEFITS* (Basic benefits do not accrue toward Medical CY or Lifetime Maximums.) Hospital Inpatient 100% up to 365 days maximum* 100% U&C,$500 ded for each precert admission; up to 365 days max* Hospital ER Hospital Outpatient Surgery* Hospital Outpatient Other (incl. Phys.Therapy*) Rehab Hospital Pre-admission testing*, Hemodialysis, Chemotherapy & radiation therapy Home Health Care & SNF Hospice & Birthing Centers Hospital/Ambulance 100% after $50 co-pay 100% after $35.00 co-pay* 100% after $35.00 co-pay 100% up to 100 days maximum* 100% (no co-pay) 100% up to 180 visits per CY* 100%* 100% limited to $50 per trip (basic benefit); balance to Medical Benefit 100% of U&C after $70 co-pay 100% of U&C after $70.00 co-pay* 100% of U&C after $70.00 co-pay 100% up to 100 days maximum* 100% of U&C (no co-pay) 100% U&C up to 180 days per CY* 100% U&C* 100% U&C limited to $50 per trip: (basic benefit) balance to Medical Benefit OU_baag_ doc Page 2 of 6
3 MEDICAL BENEFITS All after CY deductible Physician Office Visit 80% of U&C charges; after $15 $15.00 co-pay (1) (1) co-pay (1); after CY deductible Physician Inpatient Care, Surgery*, 80% of U&C charges; after $15 Anesthesia, Lab co-pay (1); after CY deductible $15.00 co-pay (1) (1), X-Ray (1), Radiology (1), Infertility Care Maternity Physician Services Hospital Services* Nursery Care (Well Baby) Physical Therapy Chiropractic Benefit Home Infusion & IV Therapy; Speech Therapy and Durable Medical Equipment Mental Health Inpatient Oupatient Substance Abuse Inpatient Outpatient 100%* 100% 100% after per schedule* 100% after * 80% after plan deductible. Rental up to purchase price. 100% up to 100 days/cy* $15.00 co-pay up to 100 visits/cy* 100%; up to 4 weeks per confinement; 6 weeks per calendar year* 100%; up to 60 visits per CY, including 20 family visits* OU_baag_ doc Page 3 of 6 80% of U&C charges after $15 copay (1) & calendar year deductible 100% U &C, $500 ded per admission* 100% U &C, $500 ded per admission* 1-15 th visit: 80% of MPN rate + 16 th + visit: 50% of MPN rate th visit: 80% of MPN rate + 16 th + visit:50% of MPN rate + %15 copay 80% of U&C after deductible. Rental up to purchase price. Pre-certified - 50% U&C allowable charges, $500 ded., 30 day maximum* 50% of U&C plus co-pay up to 30 visits per CY, 60 visits per lifetime* 50% of U&C charges; after $500 deductible per admission; up to 4 weeks per confinement; 6 weeks per CY* 50% of U&C charges; up to 60 visits per CY, including 20 family visits*
4 WELLNESS BENEFITS: Adult Well Care Benefits: Available to ACTIVE employees (includes pre-medicare retirees) and their dependent spouses only. Age 19 65; prior to Medicare $15.00 co-pay/one annual visit, plus eligible immunizations (1) Covered only through In-Network Providers Adult Well Care Benefits: Available to retirees and spouses with Primary (pays first) Medicare coverage. 80% of U&C after deductible, one Age 65+ with Medicare annual visit, plus eligible primary immunizations. Routine Screenings and Examinations: Breast Cancer (Mammography) Age Age 40 and older High Risk any age Cervical Cancer (Pap Smears) Routine Gynecological Examinations Contraception Services, Implant Devices, etc. 100% for one baseline mammography 100% - one per calendar year 100% - one per calendar year 100% after ment ; one per calendar year: includes exam, pap smear, lab & diagnostic services (1) 100% after ment (2 per CY) (1); includes HPV immunization for 11 through 26 year olds 100% after co-payment 100% of U&C for one baseline mammography 100% of U&C for one per calendar year 100% - one per calendar year 100% of U&C after $15 copayment; one per calendar year: includes exam, pap smear, lab & diagnostic services (1) 100% of U&C after ment (2 per CY) (1); includes HPV immunization for 11 through 26 year olds 80% of U&C charges after $15 copay & calendar year deductible. OU_baag_ doc Page 4 of 6
5 WELLNESS BENEFITS Cont d: Osteoporosis-Bone Mineral Density Measurement & Testing (Requirements exist for coverage-see Plan Doc) Prostate Cancer (PSA Testing) Age 50+ or 40+ with family history Colon Cancer (Colonscopy) Age 50+; younger if due to family history (See Plan Doc) 100% - ment one per CY 100% as part of Routine Physical Exam (RPE) one per calendar year (1) One every 60 months (1) ment; 80% of U&C after deductible-one per CY Child Well Care Benefits: Routine Physical Exams (PEs) include eligible immunizations. Age 0 to 2 years old Age 2 through 5 yrs old Age 6 through 18 yrs old Age 19 through 25 (only with approved student extension) 100%; 100% 100% (Visitation schedule established by American Academy of Pediatrics as adopted by NYSID.) 100%; after ; one per 2 calendar years (1) 100% of U&C 100% of U&C 100% of U&C (Visitation schedule established by American Academy of Pediatrics as adopted by NYSID.) (In-network only) PRESCRIPTION DRUG BENEFITS (Administered by CVS/Caremark) Enrollee Co-pays: Retail Mail-Order $5 generic, $20 preferred brand, $40 non-preferred brand $7.50 generic, $30 preferred brand, $60 non-preferred brand Reimbursed to the amount the Plan would have paid had the Rx been from an in-network pharmacy Not covered OU_baag_ doc Page 5 of 6
6 Drugs or devices limited or excluded from coverage: drugs not requiring a written prescription (except insulin); drugs that have over-the-counter equivalents; artificial appliances, therapeutic devices, hypodermic needles and similar devices (except for insulin injection); administration of injection drugs; appetite suppressants; non-prescription vitamins or any herbal products. Drugs for: cosmetic purposes (such as hair growth stimulants and wrinkle removers); immunization agents, biological sera, blood or blood plasma; sexual performance or stimulation improvement; patients in facilities, or limited or excluded in the Plan as listed below. Drugs limited in coverage are: solid food products (limited to $2,500 CY); specialty Rx as administered by CVS/Caremark and medicines that require preauthorization through CVS-Caremark, such as drugs for anti-obesity, arthritis, ADD and migraine headaches. Benefits for the following services or circumstances may be limited as detailed in the Plan Document, or excluded from coverage: Acupuncture/Hypnosis/Biofeedback, Blood Products, Cosmetic Services, Criminal Behavior, Custodial and Maintenance Care, Dental Care, Developmental Delay, Durable Medical Equipment, Prosthetic Devices, Medical Supplies, Experimental and Investigational Treatment, Free Care, Genetic Testing, Government Programs, Late Claims Submission (15 months after service), Military Service-Connected Conditions, No-Fault Automobile Insurance, Non-Covered Services, Nutritional Therapy, Personal Comfort Services, Podiatry and Routine Foot Care, Prohibited Referral, Self-Help Diagnosis (Training & Treatment), Services starting before Coverage begins, Sexual Dysfunction, Smoking Cessation Programs, Special Charges, Social Counseling and Therapy, Timothy s Law Exclusions, Transsexual Surgery and Related Services, Unlicensed Provider, Vision and Hearing Examinations-Therapies and Supplies, War, Weight Loss Services, Workers Compensation. All services must be Medically Necessary (as defined by the Plan, using Medicare Guidelines), ordered by a covered provider and included as Eligible and Covered under the Plan. Only Usual and Customary charges are allowed, as determined by the Plan. Refer to the Plan Document. NOTICE: This group health plan believes this Plan is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator. You may also contact the U.S. Department of Health and Human Services at OU_baag_ doc Page 6 of 6
BENEFITS-AT-A-GLANCE Effective: October 1, 2017 September 30, 2018
BENEFITS-AT-A-GLANCE Effective: October 1, 2017 September 30, 2018 Plan Name: Middletown City Schools Health Benefit Plan Type of Plan: Indemnity with PPO Benefit; No Referral Required Basic hospital benefits;
BENEFITS-AT-A-GLANCE Effective: January 1, 2019
BENEFITS-AT-A-GLANCE Effective: January 1, 2019 Plan Name: Orange Ulster School Districts Health Plan Type of Plan: Indemnity with PPO Benefit; No Referral Required Basic hospital benefits; Medical services
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