Schedule Of Benefits

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Transcription:

Schedule Of Benefits Subject to the exclusions, conditions and limitations of this Plan, a Covered Person is entitled to benefits for the Covered Services described in this Schedule of Benefits during a Benefit Period, subject to any Copayment, Deductible, Coinsurance, Out-of-Pocket Limit or Lifetime Maximum. The percentages for Coinsurance and Covered Services shown in this Schedule of Benefits are not always calculated on actual charges. For an explanation on how Coinsurance is calculated, see the Covered Expense definition in the Defined Terms section. Covered Services may be provided In-Network by a Preferred Provider or Out-of-Network by a Non- Preferred Provider. However, the Covered Person will maximize the benefits available when Covered Services are provided In-Network by a Provider that belongs to the Personal Choice Network (a Preferred Provider) and has a contract with the Carrier to provide services and supplies to the Covered Person. The Your Personal Choice Network Plan section provides more detail regarding Preferred and Non-Preferred Providers and the Personal Choice Network. Some Covered Services must be Precertified before the Covered Person receives the services. Precertification of services is a vital program feature that reviews Medical Appropriateness/Medical Necessity of certain procedures and/or admissions. In certain cases, Precertification helps determine whether a different treatment may be available that is equally effective yet less traumatic. Precertification also helps determine the most appropriate setting for certain services. Failure to obtain a required Precertification for a Covered Service could result in a reduction of benefits. More information on Precertification is found in the Your Personal Choice Network Plan and the Managed Care sections. Covered Services that require Precertification, and any Penalty for failure to obtain a Precertification, are specified on the Schedule of Benefits. Benefit Period Calendar Year Program Deductible (Covered Person s Responsibility) Covered Person s Deductible Preferred Care Non-Preferred Care None $500 per Covered Person per Benefit Period for Non-Preferred Covered Services. This Deductible applies to all Non-Preferred Covered Services except as otherwise specified in the Schedule of Benefits. Family Deductible Preferred Care Non-Preferred Care None The family Deductible amount is equal to 3 times the individual Deductible. In each Benefit Period, it will be applied to all family members covered under a Family Coverage. A Deductible will not be applied to any covered individual family member once that covered individual has satisfied the individual Deductible, or the family Deductible has been satisfied for all covered family members combined. Deductible Carryover Expenses Incurred for Covered Expenses in the last 3 months of a Benefit Period which were applied to that Benefit Period s Deductible will be applied to the Deductible of the next Benefit Period.

Coinsurance (Covered Person s Responsibility) Preferred Care Non-Preferred Care 0% for Covered Services, except as otherwise specified in the Schedule of Benefits. 30% for Covered Services, except as otherwise specified in the Schedule of Benefits. For Treatment of Alcohol and Drug Abuse and Dependency services, in the first instance or course of treatment, no Deductible or Coinsurance shall be less favorable than those applied to similar classes or categories of treatment for physical illness. Out-Of-Pocket Limit Preferred Care None Non-Preferred Care When a Covered Person Incurs $1,500 of Coinsurance expense in one Benefit Period for Non-Preferred Covered Services, the Coinsurance percentage will be reduced to 0% for the balance of that Benefit Period. After 3 times the individual Out-of-Pocket Limit amount has been Incurred for Covered Services by Covered Persons under the same Family Coverage in a Benefit Period, the Coinsurance percentage will be reduced to 0% for the balance of that Benefit Period. However, no family member will contribute more than the individual Out-of-Pocket Limit amount. The dollar amounts specified shall not include any expense Incurred for Mental Health/Psychiatric Care, any Deductible, Penalty, or Copayment amount. Lifetime Maximum Preferred Care Unlimited Non-Preferred Care $1,000,000 per lifetime per Covered Person for Non-Preferred Covered Services. Reinstatement Amounts applied to a Covered Person s Lifetime Maximum are not restorable.

Primary And Preventive Care Plan Office Visits $10 per visit. Pediatric Preventive Care $10 per visit. Pediatric Immunizations 70% Deductible does not apply. Adult Preventive Care $10 per visit. Routine Gynecological Examination, Pap Smear $10 per examination. 70% Deductible does not apply. Mammograms 70% Deductible does not apply. Nutrition Counseling For Weight Management Maximum of six (6) visits per Benefit Period.

Inpatient Benefits Hospital Services Precertification required for all Inpatient admissions other than an admission for Emergency Care or Maternity Care. Benefit Period Maximum: 365 Preferred Inpatient days. Plan Benefit Period Maximum: 70 Non-Preferred Inpatient days. This maximum is part of, not separate from, Preferred days maximum. Medical Care Skilled Nursing Care Facility Maximum of 120 Preferred/Non- Preferred Inpatient days per Benefit Period. Precertification required for all Skilled Nursing Care Facility Inpatient admissions.

Inpatient/Outpatient Benefits Plan Blood Hospice Services Respite Care: Maximum of 7 days every 6 months. Maternity/OB-GYN/Family Services Maternity/Obstetrical Care Professional Service Facility Service, after a single Copayment of $10. Elective Abortions Professional Service Outpatient Facility Charges, after a Copayment of $10. Newborn Care Artificial Insemination, after a Copayment of $10 per visit.

Inpatient/Outpatient Benefits Continued Plan Mental Health/Psychiatric Care Inpatient Treatment Benefit Period Maximum: 30 Preferred Inpatient days. 80% Benefit Period Maximum: 20 Non- Preferred Inpatient days. This maximum is part of, not separate from, Preferred days maximum. Mental Health/Psychiatric Care Inpatient days limits are part of, not separate from, the Inpatient Hospital Services days limit. Outpatient Treatment Benefit Period Maximum: 50 Preferred/Non-Preferred Outpatient visits. 80%, with a maximum payment of $80 per visit 30 Mental Health/Psychiatric Care Inpatient days may be exchanged for additional Partial Hospitalization services or Mental Health/Psychiatric Care Outpatient visits. Each Inpatient day may be exchanged for 4 Outpatient visits or 2 Partial Hospitalization visits. Inpatient Treatment for Serious Mental Illness Benefit Period Maximum: 30 Preferred Inpatient days. 80% Benefit Period Maximum: 30 Non- Preferred Inpatient days. This maximum is part of, not separate from, Preferred days maximum.

Inpatient/Outpatient Benefits Continued Plan Outpatient Treatment for Serious Mental Illness Benefit Period Maximum: 60 Preferred Outpatient visits. 80% Benefit Period Maximum: 60 Non- Preferred Outpatient visits. This maximum is part of, not separate from, Preferred visit maximum. Each available Inpatient Treatment for Serious Mental Illness day may be exchanged for 2 additional Partial Hospitalization days/outpatient Treatment sessions. Surgical Services Outpatient Facility Charges Outpatient Professional Charge Outpatient Anesthesia Second Surgical Opinion $20 per opinion. Failure to Precertify Non- Preferred services will result in a 20% reduction in benefits payable for certain Surgical Services. If more than 1 surgical procedure is performed by the same Professional Provider during the same operative session, the Carrier will pay of the Covered Service for the highest paying procedure and 50% of the Covered Services for each additional procedure. Transplant Services Inpatient Facility Charges Outpatient Facility Charges

Inpatient/Outpatient Benefits Continued Plan Treatment Of Alcohol Or Drug Abuse And Dependency Inpatient Hospital Detoxification and Rehabilitation 7 days per admission Lifetime Maximum of 4 confinements Hospital and-non Hospital Residential Care Benefit Period Maximum: 30 Preferred/Non-Preferred Inpatient days. Lifetime Maximum: 90 Preferred/Non- Preferred Inpatient days. Inpatient treatment days limits are part of, not separate from, the Hospital Inpatient days limits. Outpatient Treatment Benefit Period Maximum: 60 Preferred/Non-Preferred Outpatient visits. Lifetime Maximum: 120 Preferred/Non- Preferred Outpatient visits. $20 per visit 30 Outpatient Treatment of Alcohol or Drug Abuse or Dependency days may be exchanged on a 2-to1 basis for 15 additional days of Non-Hospital Residential Care.

Outpatient Benefits Plan Ambulance Services Emergency services Non-Emergency services Non-Emergency Ambulance Day Rehabilitation Program Benefit Period Maximum: Thirty (30) visits Diabetic Education Program Copayments, Deductibles and Maximum amounts do not apply to this benefit. 0% Benefits for Non-Preferred services are not available. Diabetic Equipment And Supplies 50%, after deductible Benefit Period Maximum: $2,500.00 of Non-Preferred Diabetic Equipment and Supplies Diagnostic Services Routine Diagnostic/Radiology Services Non-Routine Diagnostic/Radiology Services (including MRI/MRA, CT scans, PET scans) Laboratory and Pathology Tests $20 per date of service. $40 per date of service. Failure to Precertify certain Non- Preferred Non-Routine Diagnostic/Radiology services will result in a 20% reduction in benefits payable.

Outpatient Benefits continued Plan Durable Medical Equipment 50%, after deductible Benefit Period Maximum: $2,500.00 of Non-Preferred Durable Medical Equipment Precertification of Non-Preferred supplies is required for items with a billed amount that exceeds $500 (includes replacements and repairs). Emergency Care Services, after a Copayment of $100, after a Copayment of $100 Home Health Care Injectable Medications Biotech/Specialty Injectables Standard Injectables Insulin And Oral Agents If this Plan does not provide coverage for prescription drugs, insulin and oral agents are covered less the applicable Copayment per prescription order: Generic Copayment - $10 Brand Copayment - $15 Medical Foods And Nutritional Formulas

Outpatient Benefits Continued Plan Non-Surgical Dental Services (Dental Services as a result of Accidental Injury) Orthotics 50%, after deductible Precertification of Non-Preferred supplies is required for items with a billed amount that exceeds $500 (including replacement and repairs). Podiatric Care Private Duty Nursing Services Benefit Period Maximum: 360 Preferred/Non-Preferred hours 80% services will result In a 20% Prosthetic Devices 50%, after deductible Precertification of Non-Preferred supplies is required for items with a billed amount that exceeds $500 (including replacement and repairs). Specialist Office Visits Spinal Manipulation Services Benefit Period Maximum: 20 Preferred/Non-Preferred visits

Outpatient Benefits Continued Plan Therapy Services Cardiac Rehabilitation Therapy Benefit Period Maximum: 36 Preferred/Non-Preferred sessions Chemotherapy Dialysis Infusion Therapy reduction in benefits payable for Infusion Therapy. Orthoptic/Pleoptic Therapy Lifetime Maximum: 8 Preferred/Non- Preferred sessions Pulmonary Rehabilitation Therapy Benefit Period Maximum: 36 Preferred/Non-Preferred sessions Physical Therapy/Occupational Therapy Benefit Period Maximum: 30 Preferred/Non-Preferred sessions of Physical Therapy/Occupational Therapy combined Benefit Period Maximum amounts that apply to Physical Therapy do not apply to the treatment of lymphedema related to mastectomy. Radiation Therapy Speech Therapy Benefit Period Maximum: 20 Preferred/Non-Preferred sessions

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