Independence Blue Cross Plan Summary MLH Select Medical Plan
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1 TO: FROM: SUBJECT: MLH Medical Plan Participants MLH Human Resources Benefits Team Independence Blue Cross Plan Summary MLH Select Medical Plan Attached you will find the Independence Blue Cross (IBC) Plan Summary for the MLH Select Medical Plan effective January 1, The summary provides information about the coverage the plan offers for various common medical plan services. It also includes a summary of services not covered by the plan. This summary represents only a partial listing of the benefits and exclusions of the Keystone POS program. Benefits and exclusions may be further defined by IBC medical policies which are available at the web portal. This plan may not cover all of your health care expenses. If you have questions about plan coverage, please contact IBC at ASK-BLUE to speak with a customer service representative. Definitions for Terms Found on the Plan Summary Keystone Point of Service Primary Care Physician (PCP) MLH Select Plan Referred (or Referral) Self-Referred ACO PLUS Network Keystone Network This refers to Keystone Health Plan East (KHPE), the business unit of IBC that administers your plan and manages the KHPE provider network. This refers to a type of medical plan. It combines some features of an HMO, like needing to select a Primary Care Physician and using referrals, with those of a PPO plan, where participants have the freedom to use any in or out-of-network provider. This is a doctor trained to treat a wide variety of health-related problems, and responsible for referral to specialists as needed. The term includes Family Practice, Internal Medicine, Pediatrician, OB/GYN and General Medicine This is the ACO based Medical plan introduced by MLH in January 1, IBC refers to this as a Point of Service Plan because of how the plan is designed. Referred care means your PCP has determined that you need to see a Specialist to receive care for your medical condition and has authorized the care through your insurance plan. This is sent electronically from your PCP to the Specialist physician s office. Self-Referred care means you choose to see a Specialist without a referral from your PCP. Under the MLH Select Plan you are able to seek care from any provider, but you cost will be higher without obtaining a referral. This is IBC s general name for the network of physicians and facilities that participate with your plan. This network is used by employees of MLH, Jefferson and Magee Rehab. MLH refers to this network as the SelectPLUS Network. This is the KHPE network of physicians and facilities available in the Philadelphia region.
2 Keystone Point-of-Service Main Line Health MLH Select Plan Keystone Point-of-Service lets you maintain freedom of choice by allowing you to select your own doctors and hospitals. You maximize your coverage by having care provided or referred by your Primary Care Physician. Of course, with Keystone Point-of-Service, you have the freedom to self-refer your care to a Keystone participating provider or to providers who do not participate in our network however, higher out-of-pocket costs apply. This program may not cover all your health care services. Services may not be covered because they are Not covered under your benefit contract Not medically necessary Limited by a benefit maximum Referred Self-Referred / DEDUCTIBLE Individual $0 $0 $500 (Self Referred) / $1,000 Family $0 $0 $1,500 (Self Referred) / $3,000 OUT-OF-POCKET MAXIMUM (includes copays,deductible and coinsurance) Individual 2 $2,500 $2,500 $2,500 (Self Referred) / $5,000 Family 2 $4,500 $4,500 $4,500(Self Referred) / $10,000 LIFETIME MAXIMUM Unlimited Unlimited Unlimited DOCTOR'S OFFICE VISITS Primary Care Services $0 Copayment $20 Copayment $35 Copayment (Self Referred) / Specialist Services $10 Copayment $30 Copayment $40 Copayment (Self Referred) / Referred benefits are underwritten or administered by Keystone Health Plan East; Self-Referred benefits are underwritten or administered by QCC Insurance Company, subsidiaries of Independence Blue Crossindependent licensees of the Blue Cross and Blue Shield Association. 05/14 - PA MLH Select Plan POS PHO
3 SPECIALTY CARE Allergy Testing and Treatment 100% 100% 100% (Self Hearing Screening 100% 100% 100% (Self Hearing Aid (2 hearing aids every 36 months) 2 25% 25% 25% after deductible (Self Referred) / 25% after PREVENTIVE CARE FOR ADULTS AND CHILDREN 100% 100% 100% NO deductible (Self Referred) / PEDIATRIC IMMUNIZATIONS 100% ** 100% ** 100% NO deductible (Self Referred) / ** ROUTINE GYN/PAP (no referal required) 100% 100% 100% NO deductible (Self Referred) / ROUTINE EYE EXAM $10 Copayment $30 Copayment $40 Copayment (Self Referred) / (once every two calendar years) 2 MAMMOGRAM (no referral required) NUTRITIONAL COUNSELING FOR WEIGHT MANAGEMENT 100% 100% 100% NO Deductible(Self Referred) / 100% 100% 100% NO Deductible (Self Referred) / 60% after OUTPATIENT LABORATORY/PATHOLOGY 4 100% 100% 100% NO Deductible(Self Referred) / MATERNITY First OB visit $0 Copayment $20 Copayment $20 Copayment (Self Referred) / Hospital 100% $700 Copayment per INPATIENT HOSPITAL SERVICES Facility 100% $700 Copayment per 1 Inpatient Physician/Surgeon 100% 100% 80% after deductible (Self Referred) / INPATIENT HOSPITAL DAYS Unlimited Unlimited 70 (Self Referred) / 70 1 OUTPATIENT SURGERY Facility 100% $300 Copayment per occurance $300 Copayment per occurence then 80% after deductible (Self Referred) / Physician/Surgeon 100% 100% 80% after deductible (Self Referred) / EMERGENCY ROOM 3 $125 Copayment (Copayment waived if $125 Copayment (Copayment waived if $125 Copayment (self referred)(copayment waived if / $125 Copayment (out of network) (Copayment waived if URGENT CARE $50 Copayment $70 Copayment $70 copayment, no deductible (Self Referred) / $70 copayment, no deductible ** Office visit subject to copayment. 1 Inpatient hospital day limit combined for all self-referred inpatient medical, maternity, maternity, mental health, serious mental illness, substance abuse and detoxification services.
4 AMBULANCE Emergency 100% 100% 100% (self referred) / 100% Non-Emergency 80% 80% 80% no deductible (Self Referred) / OUTPATIENT X-RAY/RADIOLOGY *** Routine Radiology/Diagnostic $15 Copayment $30 Copayment 70% after deductible (Self Referred) / MRI/MRA, CT/CTA Scan, PET Scan **** $15 Copayment $30 Copayment 70% after deductible (Self Referred) / THERAPY SERVICES Physical and Occupational $15 Copayment $30 Copayment $30 Copayment NO deductible (Self 60 visits per calendar year 2 Speech Therapy 30 visits per calendar year 2 $15 Copayment $30 Copayment $40 Copayment NO deductible (Self Cardiac Rehabilitation 36 visits per calendar year 2 $15 Copayment $30 Copayment $40 Copayment NO Deductible(Self Pulmonary Rehabilitation 12 visits per calendar year 2 $15 Copayment $30 Copayment $40 Copayment NO deductible(self Respiratory Therapy $15 Copayment $30 Copayment $40 Copayment NO deductible (Self Referred) / 60%; after Orthoptic/Pleoptic 8 sessions lifetime maximum 2 $15 Copayment $30 Copayment $40 Copayment NO deductible (Self SPINAL MANIPULATIONS 30 visits per calendar year Not Available $30 Copayment $40 Copayment; NO deductible (Self deductible CHEMO/RADIATION/DIALYSIS 100% 100% 80% after deductible (Self Referred) / OUTPATIENT PRIVATE DUTY NURSING 360 hours per calendar year 2 100% 100% 80% after deductible (Self Referred) / SKILLED NURSING FACILITY 100% $700 Copayment per 120 days per calendar year 2 occurance HOSPICE 100% 100% 70% after deductible (Self Referred) / HOME HEALTH CARE 100% 80% NO Deductible 80% after deductible (Self Referred) / DURABLE MEDICAL EQUIPMENT Not Available 90% NO Deductible 80% NO deductible (Self Referred) / PROSTHETICS Not Available 90% NO Deductible 80% NO deductible (Self Referred) / *** Copayment not applicable when service performed in Emergency Room or office setting. **** Preauthorization required. Preauthorization is not a determination of eligibility or a guarantee of payment. Coverage and payment are contingent upon, among other things, the patient being eligible, i.e., actively enrolled in the health benefits plan when the preauthorization is issued and when approved services occur. Coverage and payment are also subject to limitations, exclusions and other specific terms of the health benefits plan that apply to the coverage request.
5 MENTAL HEALTH CARE/ SERIOUS MENTAL ILLNESS Outpatient $0 Copayment $30 Copayment $30 Copayment NO deductible (Self Reffered) / Inpatient 100% $700 copayment per 1 SUBSTANCE ABUSE TREATMENT Outpatient/Partial Facility Visits $0 Copayment $30 Copayment $30 Copayment NO deductible (Self deductible Rehabilitation 100% $700 copayment per Detoxification 100% $700 copayment per Inpatient hospital day limit combined for all self-referred inpatient medical, maternity, maternity, mental health, serious mental illness, substance abuse and detoxification services. What Is Not Covered? Services not medically necessary Services or supplies which are experimental or investigative except routine costs associated with clinical trials Assisted fertilization techniques such as, in-vitro fertilization, GIFT and ZIFT Reversal of voluntary sterilization Expenses related to organ donation for non-member recipients Alternative Therapies/complementary medicine Dental care, including dental implants, and non-surgical treatment of temporomandibular joint syndrome (TMJ) Music therapy, equestrian therapy and hippotherapy Treatment of sexual dysfunction not related to organic disease except for sexual dysfunction resulting from injury Routine foot care, unless medically necessary or associated with the treatment of diabetes Foot orthotics, except for orthotics and podiatric appliances required for the prevention of complications associated with diabetes Cranial prostheses including wigs intended to replace hair Routine physical exams for non-preventive purposes such as insurance or employment applications, college, or premarital examinations Immunizations for travel or employment Service or supplies payable under Workers' Compensation, Motor Vehicle Insurance, or other legislation of similar purpose Cosmetic services/supplies Self-Injectables (effective 1/2010) This summary represents only a partial listing of the benefits and exclusions of the Keystone POS program described in this summary. If your employer purchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by medical policy. As a result, this managed care plan may not cover all of your health care expenses. Read your HMO group contract/member handbook and Self-Referred group health benefits booklet/certificate carefully to determine which health care services are covered. If you need more information, please call (if calling within Philadelphia) or (outside Philadelphia).
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