PLAN CODE: 3000A-10 MERCY HEALTH PLANS SCHEDULE OF COVERAGE AND BENEFITS

Transcription

1 PPO INDIVIDUAL HDHP/HSA PLAN PLAN CODE: 3000A-10 MERCY HEALTH PLANS SCHEDULE OF COVERAGE AND BENEFITS With Mercy Health Plans PPO, You can choose to receive either Network Benefits or Non-Network Benefits. To obtain Network Benefits You must see a Network Physician or other Network Provider. You must show Your identification card (ID card) every time You request health care services from a Network Provider. If You do not show Your ID card, Network Providers have no way of knowing that You are enrolled under a Mercy Health Plans PPO Policy. As a result, they may bill You for the entire cost of the services You receive. Please refer to Your Policy for a detailed explanation of covered and non-covered services, as well as Prior Authorization requirements. Just because a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under this Schedule of Coverage and Benefits. All capitalized terms shall have the meaning assigned to them in Your Policy. AMOUNT PAYMENT INFORMATION NETWORK MEDICAL Annual Deductible - Combined Medical and Pharmacy The Deductible must be met before medical or pharmacy Benefits are payable, except for preventive health/wellness services, routine immunizations. Coinsurances are not included in Your Deductible. $3,000 per Covered Person per Calendar Year, not to exceed $6,000 for all Covered Persons in a family. $6,000 per Covered Person per Calendar Year, not to exceed $12,000 for all Covered Persons in a family. Out-of-Pocket Maximum Combined Medical & Pharmacy Only Coinsurances apply towards Your Outof-Pocket Maximum. Coinsurance is the amount You pay after You meet Your Deductible. $0 per Covered Person per Calendar Year, not to exceed $0 for all Covered Persons in a family. Out-of-Pocket Maximum does not include the Annual Deductible. $1,500 per Covered Person per Calendar Year, not to exceed $3,000 for all Covered Persons in a family. Out-of-Pocket Maximum does not include the Annual Deductible. Maximum Policy Benefit No Maximum Policy Benefit No Maximum Policy Benefit Alcoholism/Chemical Dependency Services Outpatient services - 26 days each Calendar Year. Residential Treatment Program - 21 days each Calendar Year. Detoxification in a medical or social setting - 6 days each Calendar Year. NETWORK Outpatient Services: Outpatient Services: Residential Treatment Program: Inpatient Services: Residential Treatment Program: Inpatient Services: Coverage is provided for 10 Episodes of treatment per lifetime. This limitation will not apply to Benefits received for medical detoxification for a life-threatening situation. In this case, Benefits are payable even after the ten (10) Episode limit is reached if both of the following conditions are met: The Episode is determined to be lifethreatening by the treating Physician and The Episode is documented as life threatening to Our satisfaction within forty-eight (48) hours after treatment is given. - Requires Prior Authorization. Refer to Your Policy for details. PHI MO INDIV SCH (01/09) 1

2 Plan Code: 3000A-10 Allergy Services Office Visits Injections/Treatment Ambulance Services - Emergency Only Ground Transportation Air Transportation Clinical Trials Cancer Coverage is only available for the routine patient care costs related to the phase II, III or IV clinical trials. Dental Anesthesia and Facility Charges Coverage is limited to: A child under the age of five (5); or A Covered Person who is severely disabled; or A Covered Person has a medical or behavioral condition that requires hospitalization or general anesthesia when dental care is provided. Dental Services - Accident only Initial contact with a Physician or dentist must have occurred within 72 hours of the accident. In no case will accidental dental coverage extend more than 12 months from the date of Injury. Any further visits for post-emergency treatment must be preapproved by the Plan. NETWORK Office Visit: per office visit for Primary care per office visit for Specialist care Injections/Treatment: Ground Transportation: Air Transportation: per transport PPO INDIVIDUAL HDHP/HSA PLAN Office Visit: Injections/Treatment Ground Transportation: Air Transportation: per transport Diabetes Services Medically appropriate and necessary equipment, supplies and self-management training for the management and treatment of diabetes. Services are provided for persons with gestational, type I or type II diabetes. Dialysis Covered In Network Only Covered In Network Only Durable Medical Equipment See Health Reform Amendment to the 2008 and Emergency Room Services Eye Examinations (Routine Only). Hearing Screenings for Newborns Home Health Care Services received from a Home Health Agency that are ordered by a physician, - Requires Prior Authorization. Refer to Your Policy for details. PHI MO INDIV SCH (01/09) 2

3 Plan Code: 3000A-10 provided by or supervised by a registered nurse in Your home, and You are Homebound or Your physical or mental condition pose a serious and significant impediment to receiving medically necessary services outside the home. Benefits are available only when the Home Health Agency services are provided on a part-time, intermittent schedule and when skilled care is required. Coverage is limited to a maximum of 60 visits per Calendar Year. NETWORK PPO INDIVIDUAL HDHP/HSA PLAN Hospice/Palliative Care Benefit is available once per lifetime for a terminally ill person with a life expectancy of less than six (6) months. Coverage is limited to a hundred-and-eighty (180) days during the entire period of time You are covered under this Policy. Human Leukocyte Antigen Testing - For bone marrow transplantation donor See Health Reform Amendment to the 2008 and Immunizations (Routine Only) See Health Reform Amendment to the 2008 and Injectables/Infusions (received in a physician s office, infusion center or through home health) A list of injectables/infusions requiring Prior Authorization can be obtained at or by calling Our Customer Contact Center at the number listed on Your ID card. 0% Coinsurance after deductible per injectable/infusion per injectable/infusion Inpatient Hospital Services Semi-private room covered. Mental Health Services Any combination of Network and Non- Network Benefits is limited as follows: Outpatient Mental Health : 90 visits regardless of the length of each session. Intensive Outpatient Program (IOP): Intensive outpatient program (IOP) visits are included in the outpatient mental health visit limit listed above. Residential Treatment Program: Up to a maximum of 90 days per Calendar Year Inpatient Mental Health Services: There is no limit on inpatient mental health services. Outpatient Mental Health Visits: Intensive Outpatient Program (IOP): Residential Treatment Program: Inpatient Mental Health Services: Outpatient Mental Health Visits: Intensive Outpatient Program (IOP): Residential Treatment Program: Inpatient Mental Health Services: - Requires Prior Authorization. Refer to Your Policy for details. PHI MO INDIV SCH (01/09) 3

4 Plan Code: 3000A-10 Partial Hospital Treatment Program: There is no limit on partial hospital treatment services. PPO INDIVIDUAL HDHP/HSA PLAN NETWORK Partial Hospital Treatment Program: Partial Hospital Treatment Program: Neuropsychological Testing Nutritional Counseling Up to three (3) visits per Calendar Year for only certain conditions as limited in Your Policy. Nutritional Supplements Covered benefit only when tube feeding (enteral administration) using nutritional supplements is the sole source of a member s nutrition for a permanent condition, or when parenteral (intravenous administration) nutritional requirements exists (i.e., hyperemesis of pregnancy) under certain conditions. Observation Care Coverage for up to 48 hours. We must preapprove services that exceed one (1) day stay. Orthotics See Health Reform Amendment to the 2008 and Osteoporosis Services/Bone Mineral Density (BMD) Testing See Health Reform Amendment to the 2008 and Outpatient Diagnostics Outpatient Surgery/ Hospital Procedures Physician s Office Services per visit to a PCP per visit to a Specialist No office visit Copayment applies when no Physician charge is assessed. PKU Formula and Low Protein Modified Food Products for Metabolic Disorders Coverage for the treatment of phenylketonuria (PKU) or any inherited disease of amino and organic acids. Applies to children under age six (6). Preventive Health/Wellness Services See Health Reform Amendment to the 2008 and - Requires Prior Authorization. Refer to Your Policy for details. PHI MO INDIV SCH (01/09) 4

5 Plan Code: 3000A-10 Professional Fees for Surgical and Medical Services PPO INDIVIDUAL HDHP/HSA PLAN NETWORK Prosthetic Devices See Health Reform Amendment to the 2008 and Reconstructive Procedures See Your Policy for coverage description and limitations. Rehabilitation Services Skilled Nursing Facility (SNF) Any combination of Network and Non- Network Benefits is limited up to a maximum of 60 days per Calendar Year. Tobacco Cessation Education Program $0 Copayment per program Covered In Network Only Transplant Services We have specific guidelines regarding Benefits for transplant services. Contact Us at the telephone number on Your ID card for information about these guidelines. Urgent Care Center Services Covered Health Services received at an Urgent Care Center that are required to prevent serious deterioration of Your health within twenty-four (24) hours of the onset of an unforeseen Sickness, Injury, or the onset of acute or severe symptoms When services to treat urgent health care needs are provided in a Physician's office, Benefits are available as described under Physician s Office Services above. Covered In Network Only RIDERS Birth Control Services Outpatient Prescription Drug (PHI MO/INDIV AMEND 3-09 NETWORK: Note: If a Prescription Drug is prescribed in a single dosage amount for which the particular Prescription Drug is not manufactured in such single dosage amount and requires dispensing the particular Prescription Drug in a combination of different manufactured dosage amounts, We will only impose one co-payment for the dispensing of the combination of manufactured dosages that equal the prescribed dosage for such Prescription Drug. for up to a 30-day supply of Tier One drugs for up to a 30-day supply of Tier Two drugs for up to a 30-day supply of Tier Three drugs for up to a thirty (30) day supply of Tier Four drugs Mail order for up to a 90-day supply. Service Charge for Brand-Name Drugs When a Generic is Available If a Brand-name Drug is dispensed when a Generic equivalent that is subject to a Maximum Allowable Cost is available, the Member pays the Generic Copayment plus a Service Charge. A Service Charge is equal to the difference between the cost of the Brand-name drug and the cost of the Generic substitute, reflected by the Maximum Allowable cost. The Member pays a Service Charge whether he or she chooses to receive the Brand-name drug or the Prescriber requests that the Brand- Your Annual Deductible noted above must be satisfied before Benefits are payable under this Rider name drug be dispensed when a Generic equivalent is available. (MAC A) - Requires Prior Authorization. Refer to Your Policy for details. PHI MO INDIV SCH (01/09) 5

6 Plan Code: 3000A-10 RIDERS PPO INDIVIDUAL HDHP/HSA PLAN HSA/HDHP Amendment The greater of 50% Coinsurance of the retail cost of a Prescription Drug or the Network Copayment/Coinsurance including any applicable Service Charge for up to a 30-day supply per Prescription Order or Refill. PLAN OPTIONS Eligible Subscribers and Dependents who qualify for a Health Savings Account (HSA) will have High Deductible Health Plan (HDHP) Benefits as outlined in this Schedule of Coverage and Benefits, and the HSA Amendment. You may use Your HSA account to pay for non-qualified medical expenses, although withdrawals for such expenses are subject to federal, state, and local taxes, as applicable, and in most cases, a penalty tax. Any unused balance in your account at Year-end is carried forward to the next Calendar Year. You are required both to determine whether withdrawals are used for qualified medical purposes and to report on Your annual tax return the amount withdrawn that is used for qualified medical expenses. Neither Mercy Health Plans nor its HSA banking partner will monitor this. Be sure to keep records (for example, receipts) so that You can prove to the IRS that the withdrawals are for qualified medical expenses that were not otherwise reimbursed. For examples of qualified medical expenses, see Your HSA Amendment. - Requires Prior Authorization. Refer to Your Policy for details. PHI MO INDIV SCH (01/09) 6

7 Mercy Health Plans AMENDMENT To the 2008 and 2009 PHI MO INDIV SCH (01/09) PHI MO INDIV SCH v.2 (01/08) This Amendment describes certain changes in your Policy. Except as modified or superceded by the coverage provided under this Amendment, all other terms, conditions, exclusions in the Certificate of Coverage and Schedule of Coverage and Benefits remain unchanged and in full force and effect. I. The Schedule of Coverage and Benefits listed above are amended by - Deleting these benefits below in their entirety and replacing as follows: Durable Medical Equipment (DME) and Medical Supplies Eye Examinations (Routine Only) Expenses for one (1) routine eye exam each Calendar Year by an Ophthalmologist or Optometrist. Neuropsychological Testing Covered only for an individual with cognitive impairment due to medical or psychiatric conditions, and who meet certain conditions as described in the Certificate of Coverage. Orthotics Outpatient Diagnostics Covered Health Services received on an outpatient basis at a Physician s office, Hospital or Alternate Facility include: Laboratory services X-Ray/Imaging Other diagnostic & therapeutic services MRA MRI CT Scan PET Scan Nuclear Cardiology Imaging studies Outpatient diagnostics received in the locations listed above will incur the applicable outpatient diagnostic Copayment or Deductible and Coinsurance, in addition to any cost-sharing for the Physician s office visit, regardless of whether other health services are received. Regardless of the place where these services are performed, the cost-sharing for outpatient diagnostics will See Health Reform Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND See Health Reform Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND Laboratory services: X-ray/Imaging: Other diagnostic/therapeutic services: Network Providers - Prior Authorization required. PHI MO/INDIV AMEND Schedule 2009

8 apply. A list of diagnostic/imaging services requiring Prior Authorization can be obtained at or by calling Our Customer Contact Center at the number listed on Your ID card. MRA, MRI, CT Scan, PET Scan, and Nuclear Cardiology Imaging Studies: Outpatient Surgery/ Hospital Procedures Coverage includes surgical services and Hospital procedures received on an outpatient basis at a Physician s office, Hospital or Alternate Facility. Outpatient surgery/procedures received in these locations will incur the applicable Copayment or Deductible and Coinsurance, in addition to any cost-sharing for the Physician s office visit, regardless of whether other health services are received. Regardless of the place where these services are performed, the cost-sharing for outpatient surgery will apply. A list of outpatient surgical and hospital procedures requiring Prior Authorization can be obtained at or by calling Our Customer Contact Center at the number listed on Your ID card. Surgical Implants Implants for cosmetic or psychological reasons are excluded; see Section 12, L. in Your Policy. Preventive Health Screenings Routine Only. Prosthetic Devices Rehabilitation Services Outpatient Rehabilitation Therapy Any combination of Network and Non-Network Benefits is limited as follows: Limited up to 60combined visits per Calendar Year for Physical, Occupational and Speech Therapy. 36 visits of Pulmonary Rehabilitation therapy within a 12- week period per Calendar Year. 36 visits of Cardiac Rehabilitation therapy within a 12-week period per Calendar Year. Inpatient Rehabilitation Services Any combination of Network and Non-Network Benefits is limited up to a maximum of 60 days per Calendar Year. Outpatient Surgery/ Hospital Procedures: per outpatient surgery or procedure. per outpatient surgery or procedure. Surgical Implants: Copayment/Coinsurance consistent with type of service received. See Health Reform Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND See Health Reform Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND Outpatient Rehabilitation Therapy PT/OT/ST: Pulmonary Rehabilitation: Network Providers Cardiac Rehabilitation: - Prior Authorization required. PHI MO/INDIV AMEND Schedule 2009

9 Inpatient Rehabilitation Services: Deleting the Birth Control Services section in its entirety and replacing with the following: Birth Control Services Required only if Prescription Drug Services covered. RIDERS Contraceptives (oral, topical, injectable), intrauterine devices (IUDs), and insertion and routine removal of implantable contraceptives no more than once every three (3) Rolling Years, unless Medically Necessary. II. The Schedules of Coverage and Benefits listed above are amended by Deleting The First Steps Infant & Toddler Early Intervention Program benefit in its entirety. This is not a covered benefit. Charles S. Gilham, Vice-President Mercy Health Plans - Prior Authorization required. PHI MO/INDIV AMEND Schedule 2009

10 PLAN #: 3000A-10, 5000A-10 Mercy Health Plans HEALTH REFORM AMENDMENT To the 2008 and 2009 PHI MO INDIV SCH (01/09) PHI MO INDIV SCH v.2 (01/08) This Amendment describes certain changes in your Policy. Except as modified or superceded by the coverage provided under this Amendment, all other terms, conditions, exclusions in the Individual Comprehensive Health Insurance Policies and Schedule of Coverage and Benefits remain unchanged and in full force and effect. The Schedule of Coverage and Benefits listed above are amended by deleting the benefits below in their entirety and replacing as follows: Durable Medical Equipment (DME) and Medical Supplies Standard Basic Hospital-type medical Equipment (and its associated supplies) that meets the following criteria in addition to those described in our Certificate of Coverage: Ordered or provided by a Physician for outpatient use; Used for medical purposes; Not consumable or disposable; and Not of use to a person in the absence of a disease or disability. Durable Medical Equipment in excess of $1, (either purchase price or cumulative rental of a single item) must be approved in advance by the Plan. The following Medical Supplies are covered: Diabetic supplies (see Diabetes Services above); Standard ostomy supplies; Catheters (urinary and respiratory) and associated supplies such as drainage bags and irrigation kits; Sterile surgical wound supplies; Jobst stockings or other support hose ordered by a physician and determined to be Medically Necessary, but only two (2) support stockings per Calendar Year are covered. Some DME and medical supply services require Prior Authorization, including DME and medical supplies that cost more than $1,000 (either purchase price or cumulative rental of a single item). A list of services requiring Prior Authorization can be obtained at or by calling Our Customer Contact Center at the number listed on Your ID card. Unless we pre-approve the services requiring Prior Authorization, or services that are over $1,000, Network and Non- Network Benefits will be reduced by 100% of the Eligible Expenses. Human Leukocyte Antigen Testing - For bone marrow transplantation donor One (1) test per lifetime for bone marrow transplantation donor. Lab Benefit will apply to testing for all other purposes. Immunizations (Routine Only) Routine immunizations for children and adults as recommended by the Department of Health and Senior Services and Federal law. Applicable cost-share for office visit(s) will apply for all other medical services besides immunization that are received in the same office visit. 0% Coinsurance after deductible 25% Coinsurance after deductible and no Deductible and no Deductible Orthotics Covered orthotic equipment is the Standard Basic Equipment necessary to continue - Prior Authorization required. Prior Authorization can be found at or by calling Our Customer Contact Center at the number listed on Your ID card. PHI MO/INDIV AMEND5-10 1

11 PLAN #: 3000A-10, 5000A-10 the Instrumental Activities of Daily Living (IADL). The following items are covered when ordered and provided by a Participating Physician and obtained from a Participating Orthotic Provider: Braces/support including necessary adjustments to shoes to accommodate braces. Braces that stabilize an Injured body part are considered Durable Medical Equipment and are a Covered Health Service Trusses Splints Collars Foot orthotics are a covered treatment only for neuropathy causing loss of protective reflexes, or severe vascular insufficiency due to diabetes, or vascular disease. Any combination of Network and Non-Network Benefits for orthotic devices is limited to $5,000 per Calendar Year. Some orthotic devices require Prior Authorization, including orthotics in excess of $1, A list of services requiring Prior Authorization can be obtained at or by calling Our Customer Contact Center at the number listed on Your ID card. Unless we pre-approve the services requiring Prior Authorization, or services that are over $1,000, Network and Non-Network Benefits will be reduced by 100% of the Eligible Expenses. Osteoporosis Services/Bone Mineral Density (BMD) Testing Preventive Health Screening for women according to the USPSTF guidelines and Federal law. A list of osteoporosis services requiring Prior Authorization can be obtained at or by calling Our Customer Contact Center at the number listed on Your ID card. Facility: Professional Fees: Office Visit: Preventive Health Screenings Routine Only Preventive Health Screenings in accordance with the American Cancer Society guidelines, Federal law and additional preventive Benefits provided by Mercy Health Plans. The Plan pays 100% for these Preventive Health Screenings only when you use Network providers. Deductible and Coinsurance will apply to services received from Non-Network Providers. Services may be performed in a Physician s Office or an Outpatient Facility and may incur both a professional fee and/or outpatient facility charges. Preventive Health Screenings include, but are not limited to, the services listed below. Any health screenings not listed here, or not required by Federal law, will be paid consistent with other services under the health benefit plan. These Preventive Health Screenings are limited to one (1) routine test of each of the following every Calendar Year, unless otherwise indicated: Cholesterol Tests Colon Screening: Fecal Occult Blood Test Colonoscopy one (1) routine screening every ten (10) Rolling Years starting at age 50 Double-contrast Barium Enema one (1) routine screening every Cholesterol Tests: Colon Screening(Fecal Occult Blood, Colonoscopy, Double-contrast Barium Enema, and Flexible Sigmoidoscopy): Mammography: - Prior Authorization required. Prior Authorization can be found at or by calling Our Customer Contact Center at the number listed on Your ID card. PHI MO/INDIV AMEND5-10 2

12 PLAN #: 3000A-10, 5000A-10 five (5) Rolling Years starting at age 50 Flexible Sigmoidoscopy one (1) routine screening every five (5) Rolling Years starting at age 50 Mammography starting at age 35 and older Pap Test Pelvic Exam Prostate Exam PSA test starting at age 40 Preventive Health Screening in a Physician s office including one (1) annual physical exam per Calendar Year for adults, and periodic visits for well-baby and well-child care as follows: 10 visits, birth to 24 months 1 visit per Calendar Year for ages 2 18 years Note: All other Covered Services in a physician s office will be covered under Physician s Office Services. Pap/Pelvic: Prostate Exam: PSA Test: Annual Physical Exam and well-child visits in a Physician s office: Prosthetic Devices Covered prosthetic equipment is the standard, basic equipment necessary to continue average daily activities. Breast prosthesis as required by the Women's Health and Cancer Rights Act of 1998 is also covered. No time limit will be imposed for the receipt of breast prosthesis and related reconstructive breast surgery following a mastectomy. Coverage also includes post-mastectomy brassiere. Some prosthetic services require Prior Authorization, including prosthetics that cost more than $1,000. A list of services requiring Prior Authorization can be obtained at or by calling Our Customer Contact Center at the number listed on Your ID card. Unless we pre-approve the services requiring Prior Authorization, or services that are over $1,000, Network and Non-Network Benefits will be reduced by 100% of the Eligible Expenses. Charles S. Gilham, Secretary Mercy Health Plans - Prior Authorization required. Prior Authorization can be found at or by calling Our Customer Contact Center at the number listed on Your ID card. PHI MO/INDIV AMEND5-10 3