Senate Bill 91 (2011) Standard Plan - EHB and Cost Share Matrix - Updated for 2016 ***NOT INTENDED AS A STATEMENT OF COVERAGE***
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- Solomon Maximilian Wilkinson
- 10 years ago
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1 Deductible Medical: $1,250; Medical: $2,500; Integrated Medical/Rx: Rx: $0 Rx: $0 $5,000 Maximum OOP Combined Medical Combined Medical Combined Medical and and Drug: $6,350 and Drug: $6,350 Drug: $6,350 Family Multiplier 2x Individual 2x Individual 2x Individual Primary Care Office Visit to Treat an Injury or Illness $20 $35 $60 After Deductible Specialist Office Visit $40 $70 $100 After Deductible Primary Care Visit to Treat an Injury or Illness Specialist Visit Other Practitioner Office Visit (Nurse, Physician Assistant) $20 $35 $60 After Deductible Other Practitioner Office Visit (Nurse, Physician Assistant) Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Hospice Respite care - max of 5 consecutive days; lifetime max of 30 days Outpatient Surgery Physician/Surgical Hospice Non-Emergency Care When Traveling Outside the U.S. Routine Dental (Adult) Infertility Treatment Long-Term/Custodial Nursing Oregon Insurance Division Page 1 of 8 Revised 6/22/2015
2 Private-Duty Nursing Routine Eye Exam (Adult) Urgent Care Centers or Facilities $60 $90 $120 After Deductible Urgent Care Centers or Facilities Home Health Care Emergency Room Home Health Care Emergency Room Emergency Transportation/ Ambulance Emergency Transportation/ Ambulance Inpatient Hospital (e.g., Hospital Stay) Inpatient Hospital (e.g., Hospital Stay) Inpatient Physician and Surgical Cosmetic Surgery Skilled Nursing Facility Prenatal and Postnatal Care 60 days per year Inpatient Physician and Surgical Bariatric Surgery Cosmetic Surgery Skilled Nursing Facility Prenatal and Postnatal Care Delivery and All Inpatient for Maternity Care Delivery and All Inpatient for Maternity Care Varies based on Varies based on Varies based on *Mental/Behavioral Health Outpatient type/place of service. Please see the applicable service type/place of service. Please see the applicable service type/place of service. Please see the applicable service Mental/Behavioral Health Outpatient Oregon Insurance Division Page 2 of 8 Revised 6/22/2015
3 *Mental/Behavioral Health Inpatient Varies based on Varies based on Varies based on type/place of service. type/place of service. type/place of service. Substance Abuse Disorder Please see the Please see the Please see the Outpatient applicable service applicable service applicable service Substance Abuse Disorder Inpatient Generic Drugs $10 $15 $20 After Deductible Preferred Brand Drugs $30 $50 $80 After Deductible Non-Preferred Brand Drugs 50% 50% 50% After Deductible Mental/Behavioral Health Inpatient Substance Abuse Disorder Outpatient Substance Abuse Disorder Inpatient Generic Drugs Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Drugs 50% 50% 50% After Deductible *Outpatient Rehabilitation *Inpatient Habilitation $20 (Applies to PT, OT, $60 After Deductible $35 (Applies to PT, OT, (Applies to PT, OT, ST provided in an office 30 (to 60) visits per year 30 days per year.carriers must comply with federal Provider Non-discrimination provisions found in PHSA Section 2706(a). Durable Medical Equipment Specialty Drugs Outpatient Rehabilitation Habilitation Chiropractic Care Durable Medical Equipment Oregon Insurance Division Page 3 of 8 Revised 6/22/2015
4 Hearing Aids Hearing Aids Imaging (CT/PET Scans, MRIs) Imaging (CT/PET Scans, MRIs) ACA Preventive $0 $0 $0 Preventive Care/ Screening/Immunization Routine Foot Care Exams at $0 for these codes: 92002/92004, 92012/92014, S0620/S0621; for other codes cost shares may apply. Routine Foot Care Acupuncture Weight Loss Programs Routine Eye Exam for Children Pediatric Vision Contact lenses - Actuarial equivalent of $150 per year. Frames - Actuarial equivalent of $150 per year. Lenses at $0 for codes V , V , V2121, V2221, V2321; for other codes cost shares may apply. Eye Glasses for Children Dental Check-Up for Children *Outpatient Rehabilitation $20 (Applies to PT, OT, $35 (Applies to PT, OT, $60 After Deductible (Applies to PT, OT, ST provided in an office 30 (to 60) visits per year Rehabilitative Speech Therapy Rehabilitative Occupational and Rehabilitative Physical Therapy Oregon Insurance Division Page 4 of 8 Revised 6/22/2015
5 ACA Preventive $0 $0 $0 Well Baby Visits and Care Diagnostic Test (X-Ray and Lab Work) Laboratory Outpatient and Professional X-rays and Diagnostic Imaging Basic Dental Care - Child Orthodontia - Child Major Dental Care - Child Basic Dental Care - Adult Orthodontia - Adult Major Dental Care - Adult Outpatient Abortion for Which Public Funding is Prohibited Organ Transplants Transplant Emergency Room Accidental Dental Outpatient Dialysis Allergy Injections Allergy Testing Oregon Insurance Division Page 5 of 8 Revised 6/22/2015
6 Chemotherapy Outpatient Radiation Diabetes Education Oregon Mandates (ORS 743 and 743A) Prosthetic Devices Outpatient Outpatient Infusion Therapy Treatment for Temporomandibular Joint Disorders Nutritional Counseling Cosmetic Surgery Reconstructive Surgery Oregon Mandates (ORS 743 and 743A) Clinical Trials Inherited Metabolic Disorder - PKU Specialty Drugs 50% 50% 50% After Deductible Specialty Drugs 50% 50% 50% After Deductible Off Label Prescription Drugs Prescription Drugs Other Oregon Insurance Division Page 6 of 8 Revised 6/22/2015
7 Breast Reconstruction *Outpatient Rehabilitation Biofeedback $20 $35 $60 After Deductible 10 treatments per lifetime 36 sessions of cardiac rehabilitation exercise 30 days per year $60 After Deductible $20 (Applies to PT, OT, $35 (Applies to PT, OT, (Applies to PT, OT, ST provided in an office 30 (to 60) visits per year Cardiac Rehabilitation $20 $35 $60 After Deductible Hospitalization for Dental Proceedures *Inpatient Rehabilitation *Outpatient Habilitation $20 (Applies to PT, OT, $60 After Deductible $35 (Applies to PT, OT, (Applies to PT, OT, ST provided in an office 30 (to 60) visits per year Mastectomy-Related Coverage Brain Injury Covered with same cost shares as Non-Specialist Visit as Rehabilitation and visit of Inpatient and Outpatient Hospital and visit of Inpatient Habilitation and visit as Outpatient Rehabilitation Oregon Insurance Division Page 7 of 8 Revised 6/22/2015
8 Sleep Studies Vasectomy as Outpatient as under Outpatient Surgery *Mental Health covered under Habilitation and Rehabilitation must comply with state and federal rules on Mental Health Parity. Carriers should review state and federal laws regarding mental health parity for benefits and limitations, including visit limitations, in relation to requirements outlined in If carriers apply benefit limitations to mental health services the carrier will be required to prove compliance with state and federal law. Chiropractic Care: Benefits otherwise covered by the plan must be covered if provided by a doctor of chiropractic acting within the scope of their license. (PHSA 2706(a)) Most cost shares apply to in-network benefits only. Out-of-network benefits, if available, are defined by the insurer. Emergency must be covered at the same cost share for both in and out-of-network, however, different maximum out-of-pocket costs and balance billing may apply. Provider contracting varies between insurers. Oregon Insurance Division Page 8 of 8 Revised 6/22/2015
Gundersen Health Plan: MN NJ Silver $2000-0% Coverage Period: 01/01/2015-12/31/2015
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.gundersenhealthplan.org or by calling 1-800-897-1923.
Nationwide Life Insurance Company: Ochsner Clinical School Coverage Period: 1/1/15 12/31/15
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chpstudent.com or by calling 1-800-633-7867. Important
$6,600 /person $13,200 /family Does not apply to preventive care. Yes. $6,600 /person. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthrepublicinsurance.org or by calling 1-888-990-6635.
National Guardian Life Insurance Company: Earlham College Student Health Insurance Plan Coverage Period: 08/01/2015-07/31/2016
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
Student Health Insurance Plan Insurance Company Coverage Period: 07/01/2015-06/30/2016
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
National Guardian Life Insurance Company Maine College of Art Student Health Insurance Plan Coverage Period: 09/01/2015-08/31/2016
J3A59 National Guardian Life Insurance Company This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com
$1,300 /person $2,600 /family Does not apply to preventative care. Yes. $6,350 /person $12,700 /family. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthrepublicinsurance.org or by calling 1-888-990-6635.
CA Short Term Counseling: Cigna Health and Life Insurance Co Coverage Period: 01/01/2013-12/31/2013
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://apps.cignabehavioral.com/web/acref/pmrscontroller?cat=initial
Bowling Green State University : Plan B Summary of Benefits and Coverage: What This Plan Covers & What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at MedMutual.com/SBC or by calling 800.540.2583. Important Questions
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://www.peoplenotprofits.com or by calling 1-888-990-6635.
Health CO-OP Oregon Standard Silver Plan: Oregon s Health CO-OP Coverage Period: 1/1/2014-12/31/2014
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://ohcoop.org/benefits-and-coverage or by calling 1-855-722-8207.
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
In-network: $5,000 per insured/ $10,000 per family per calendar year. Out-of-network: $10,000 per insured / $20,000
Regence BlueShield of Idaho: Coverage Period: Beginning on or after 01/01/2014 Regence Individual Direct Bronze HSA Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:
What is the overall deductible? $250 per person/$500 per family. Are there other deductibles for specific services? No.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions
LGC HealthTrust: MT Blue 5-RX10/20/45 Coverage Period: 07/01/2013 06/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-870-3057. Important Questions
Important Questions Answers Why this Matters: What is the overall deductible?
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in
St Olaf College Coverage Period: Beginning on or after 09-01-2014
St Olaf College Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage Period: Beginning on or after 09-01-2014 Coverage for: Single and family coverage Plan Type: PPO This is
Companion Life Insurance Company: Saint Xavier University Student Health Insurance Plan Coverage Period: 08/11/2015-08/10/2016
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions
What is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket
Regence BlueCross BlueShield of Oregon: Preferred Coverage Period: 08/15/2015-08/14/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family
Important Questions Answers Why this Matters: What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://knowyourbenefits.dfa.ms.gov or by calling 1-866-586-2781.
Important Questions Answers Why this Matters: What is the overall deductible?
Molina Healthcare of Ohio, Inc.: Molina Gold Plan Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family ǀ Plan
TotalIndependence Silver Plan: Health Republic Insurance of New York Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
How To Pay For Health Care With A Health Care Plan With A Premium Rate Of $1,000 A Year
Regence BlueCross BlueShield of Utah: Regence Direct Silver HSA Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual &
Coverage for: Individual, Family Plan Type: PPO. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bbsionline.com or by calling 1-866-927-2200. Important
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
$1,900 individual / $3,800 family. Does not apply to preventive care and prescription drugs. What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.paramount insurancecompany.com or by calling 1-800-462-3589
$1,000 /person $2,000 /family Does not apply to preventative care. Yes. $1,000 /person. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthrepublicinsurance.org or by calling 1-888-990-6635.
Important Questions Answers Why this Matters: $3,000/ person $6,000/family Benefits not subject to deductible include: preventive care.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
Important Questions Answers Why this Matters:
BridgeSpan Health Company: Exchange Silver Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible
Important Questions Answers Why this matters: What is the overall deductible?
Preferred Organization (PPO) This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsvt.com/vfp_cert or by
Important Questions Answers Why this Matters: Individual $6,850 Family of 2 or more $13,700 What is the overall
Molina Healthcare of California: Minimum Coverage HMO Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family I
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://www.aetnastudenthealth.com/uva or by calling 1-800-466-3027.
What is the overall deductible? Are there other deductibles for specific services?
: MyPriority POS RxPlus Silver 1800 Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Subscriber/Dependent Plan Type:
$0 See the chart starting on page 2 for your costs for services this plan covers. Are there other. deductibles for specific No.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at capbluecross.com or by calling 1-800-730-7219. Important
Even though you pay these expenses, they don t count toward the out-ofpocket limit.
Commonwealth of Virginia: COVA Care Basic Coverage Period: 07/01/2014 06/30/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO This
What is the overall deductible?
Regence BlueCross BlueShield of Oregon: HSA 2.0 Coverage Period: 07/01/2013-06/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family
Some of the services this plan doesn t cover are listed on pages 5. See your policy Yes. doesn t cover?
Molina Healthcare of Wisconsin, Inc.: Molina Silver 250 Plan Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family
Coverage for: Group Plan Type: HMO. Important Questions Answers Why this Matters: What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at sutterhealthplus.org or by calling 1-855-315-5800. Important
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
UMC Health Plan Operations Coverage Period: 01/01/2013-12/31/2013
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at [email protected] or by calling
BridgeSpan Health Company: BridgeSpan Oregon Standard Gold Plan MyChoice Northwest
BridgeSpan Health Company: BridgeSpan Oregon Standard Gold Plan MyChoice Northwest Summary of Benefits and Coverage: What this Plan Covers & What it Costs Questions: Call 1 (855) 857-9943 or visit us at
Important Questions Answers Why this Matters: What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at austintexas.gov/benefits or by calling 512-974-3284. Important
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://newjersey.healthrepublic.us/ or by calling 1-888-990-5706.
Healthy Benefits PPO 6000.0 - Zero Cost Sharing Plan Variation Coverage Period: Beginning on or after 1/1/2014 Summary of Benefits and Coverage:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at capbluecross.com or by calling 1-800-730-7219. Important
HUMANA HEALTH PLAN, INC:
HUMANA HEALTH PLAN, INC: Humana Silver 4600/Lexington UK Healthcare HMOx Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage
What is the overall deductible? Are there other deductibles for specific services?
This is only a summary. If you want more detail about your medical/vision coverage and costs, you can get the complete terms in the policy or plan document at www.mycigna.com, by calling 1-800-Cigna24,
2015 WPEG Coinsurance Plan Coverage Period: 1/1/2015-12/31/2015
2015 WPEG Coinsurance Plan Coverage Period: 1/1/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a summary. If you want more detail about your coverage
Aetna HMO 1525 Local Government Active Private Rx
Important Questions This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.state.nj.us/treasury/pensions/health-benefits.shtml
Important Questions Answers Why this Matters: What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cirstudenthealth.com/udmercy or by calling 1-800-322-9901.
Health Alliance Plan. Coverage Period: 01/01/2014-12/31/2014. document at www.hap.org or by calling 1-800-759-3436.
Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014-12/31/2014 Coverage for: Individual Family Plan Type: HMO This is only a summary.
What is the overall deductible?
Regence BlueCross BlueShield of Oregon: Innova Coverage Period: 10/01/2013-09/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family
Aetna Student Health: University of Pennsylvania Coverage Period: beginning on or after 8/15/2013
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://www.aetnastudenthealth.com/upenn or by calling 1-800-841-5374.
Manhattan School of Music: BCS Insurance Company Coverage Period: 8/27/2014-8/27/2015 Summary of Benefits and Coverage:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cirstudenthealth.com/msmnyc or by calling 1-800-322-9901.
Assurant Health. Time Insurance Company. Summary of Benefits and Coverage for Assurant Health individual major medical Silver plans
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Coverage Period: 8/1/2013-7/31/2014 Coverage for: Insured Student+Dependent Plan Type: PPO. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.gallagherkoster.com/colgate or by calling 1 877-371-9621.
Coverage for: Individual Plan Type: PPO. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chpstudent.com or by calling 1-800-633-7867. Important
Yes, $100 individual/$300 family for speech therapy. There are no other specific deductibles. Is there an out of pocket limit on my expenses?
Yale Health Plan: Faculty, Managerial & Professional, Post-doctoral Associates and Fellows Coverage Period: 1/1/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage
You can see the specialist you choose without permission from this plan.
Primary Select Silver I Plan: Health Republic Insurance of New York Coverage Period: 01/01/2014 12/31/2014 This is only a summary. If you want more detail about your coverage and costs, you can get the
HUMANA MEDICAL PLAN, INC:
HUMANA MEDICAL PLAN, INC: Humana Platinum 1000/South Florida HUMx (HMOx) Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage