General Cost Sharing Features In-Network Out-of-Network
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- Rosamund Grant
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1 SECTION A. Summary of Benefits 9-RCF, 10/09 This Summary is part of your Benefit Handbook. It states the Cost Sharing amounts that you must pay for Covered Benefits and some important limitations on your coverage. It also identifies any supplemental medical benefits covered by your Plan. For complete information on Covered Benefits, including limitations on your coverage, you must refer to Section C of the Benefit Handbook and if applicable, Section D for Supplemental Benefits and Section O for prescription drugs. For information on how the Best Buy HSA PPO Plan works, please see Section B of the Benefit Handbook. Please note when using Non-Participating Providers, you are financially responsible for any difference between the Usual, Customary and Reasonable Charge (UCR) amount allowed by your Plan and the amount charged by the Provider. Please refer to Section B.3.g. for additional information about Usual, Customary and Reasonable Charges. General Cost Sharing Features See below See below Copayment See below None Deductible $3,000 per Member (with $7,500 per family (with $6,000 per Member (with $15,000 per family (with If a family Deductible applies, no Member in a family is eligible for Covered Benefits until the family Deductible is met. Please see your Benefit Handbook for details on how the Deductible works. Out-of-Pocket Maximum $10,000 per Member (with $25,000 per family (with $10,000 per Member (with $50,000 per family (with If you have a family plan, the per Member Out-of-Pocket Maximum does not apply. Please see your Benefit Handbook for details on how the Out-of-Pocket Maximum works. Lifetime Benefit Maximum None $1,000,000 per Member Penalty Payment None $500 S1
2 Outpatient Professional Services Ambulance Transport, Non-Emergency Cardiac Rehabilitation Diagnostic Laboratory and X-rays Dialysis Early Intervention Services - $3,200 per calendar year, up to $9,600 per lifetime Formulas and Low Protein Foods Home Health Care and Hospice Services Physical, Speech and Occupational Therapies - combined up to 30 visits per calendar year Physician Services, except for the Preventive Care Services listed below Preventive Care Services - the Deductible and Deductible do not apply to the following services Preventive Care by a Physician $20 Copayment 40% Preventive Maternity Care None 40% Preventive Tests and Procedures None 40% Surgical Day Care Urgent Care Services Vision Hardware for Special Conditions Same as S2
3 Emergency Services Ambulance Transport, Emergency Emergency Dental Care - in a professional office within 72 hours of injury Emergency Room Care Same as Same as Inpatient Services Acute Hospital Care Maternity Care Rehabilitation Hospital Care and Skilled Nursing Facility Care - limited to a combined 100 days per calendar year Mental Health Services Inpatient Care Partial Hospitalization Outpatient Care Group and Individual Therapy Medication Management Psychological Testing S3
4 Drug and Alcohol Rehabilitation Services Inpatient Care Partial Hospitalization Outpatient Care Group and Individual Therapy Inpatient Detoxification Outpatient Detoxification S4
5 Durable Medical Equipment and Prosthetic Devices Limited to $3,500 per calendar year for all covered equipment. This limit does not apply to the following items listed below. Blood Glucose Monitors, Insulin Pumps and Infusion Devices Breast Prostheses, including replacements and Mastectomy Bras Medical Equipment and Supplies for Diabetes Treatment Oxygen and Respiratory Equipment Prosthetic Arms and Legs Telemedicine Services Outpatient and Inpatient Telemedicine Services Your Member Cost Sharing will depend upon the types of services provided, as listed in this Summary of Benefits. For example, for services provided by a physician, see Physician Services. For inpatient hospital care, see Inpatient Acute Hospital Care Your Member Cost Sharing will depend upon the types of services provided, as listed in this Summary of Benefits. For example, for services provided by a physician, see Physician Services. For inpatient hospital care, see Inpatient Acute Hospital Care. Supplemental Benefits Annual Eye Examination $20 Copayment 40% Chiropractic Care - limited to 12 visits per calendar year Voluntary Sterilization Voluntary Termination of Pregnancy S5
6 The Plan does not cover the following: 1. Services for cosmetic purposes, except as described in this Handbook. 2. Commercial diet plans, or weight loss programs and any services in connection with such plans or programs. 3. Gender reassignment surgery and all related drugs or procedures. 4. Dental Care, except those specific dental services described in this Handbook. 5. Any products or services, including, but not limited to, drugs, devices, treatments, procedures, and diagnostic tests, that are Experimental, Unproven, or Investigational. 6. Refractive eye surgery, including, but not limited to, laser surgery, orthokeratology and lens implantation for the correction of myopia, hyperopia and astigmatism. 7. Transportation other than by ambulance, except those specific transportation services described in this Handbook. 8. Cost for any services for which you are entitled to treatment at government expense, including military service connected disabilities. 9. Costs for any services covered by a Workers Compensation plan or by an Employer under state or federal law. 10. Hair removal or restoration, including, but not limited to, electrolysis, laser treatment, transplantation or drug therapy. 11. Educational services or testing. No benefits are provided: (1) for educational services intended to enhance educational achievement; (2) to resolve problems of school performance; or (3) to treat learning disabilities. 12. Sensory integrative praxis tests. 13. Testing of central auditory processing. 14. Physical examinations and testing for insurance, licensing or employment. 15. Routine foot care, biofeedback, pain management programs, and sports medicine clinics. 16. Vocational rehabilitation, or vocational evaluations on job adaptability, job replacement, or therapy to restore function for a specific occupation. 17. Charges after the date on which your membership ends. 18. Charges for missed appointments. 19. All institutional charges over the semi-private room rate, except when a private room is Medically Necessary. 20. Inpatient charges after your hospital discharge. 21. Rest or custodial care. 22. Personal comfort or convenience items (including telephone and television charges). 23. Exercise equipment. 24. Repair or replacement of durable medical equipment or prosthetic devices as a result of loss, negligence, willful damage, or theft. 25. Non-durable medical equipment, unless used as part of the treatment at a medical facility or as part of approved home health care services. 26. Any devices or special equipment needed for sports or occupational purposes. 27. Any home adaptations, including, but not limited to home improvements and home adaptation equipment. 28. Reversal of voluntary sterilization (including any services for infertility related to voluntary sterilization). 29. Any form of surrogacy. 30. Infertility treatment for Members who are not medically infertile. 31. Care by a chiropractor outside the scope of standard chiropractic practice, including but not limited to, surgery, prescription or dispensing of drugs or medications, internal examinations, obstetrical practice, or treatment of infections and diagnostic testing for chiropractic care other than an initial X-ray. 32. Services for which no charge would be made in the absence of insurance. 33. Charges for any products or services, including, but not limited to, professional fees, medical equipment, drugs, and hospital or other facility charges, that are related to any care that is not a Covered Benefit under this Handbook. 34. Services for Non-Members. S6
7 35. Services or supplies provided by: (1) anyone related to you by blood, marriage, or adoption, or, (2) anyone who ordinarily lives with you. 36. Birth control drugs, implants, injections and devices, unless your Plan includes coverage for prescription drugs. 37. Home health care services that extend beyond care on a short-term intermittent basis. 38. Private duty nursing, unless received during an inpatient care service. 39. A provider's charge to file a claim or to transcribe or copy your medical records. 40. Any service or supply furnished along with a non-covered Benefit. 41. Taxes or governmental assessments on services or supplies. 42. Eyeglasses, contact lenses and fittings, except as listed in the Handbook. 43. Acupuncture, aromatherapy and alternative medicine. 44. Myotherapy. 45. Methadone maintenance. 46. Services for which no coverage is provided in this Handbook, including the Summary of Benefits (Section A) and Prescription Drug Coverage (Section P). 47. Private duty nursing. 48. Massage therapy when performed by anyone other then licensed physical therapist, physical therapy assistant, occupational therapist, or certified occupational therapy assistant. 49. Health resorts, recreational programs, camps, wilderness programs, outdoor skills programs, relaxation or lifestyle programs, including any services provided in conjunction with, or as part of, such types of programs. 50. Unless otherwise specified in this Benefit Handbook or the Summary of Benefits (and required by New Hampshire law), the Plan does not cover food or nutritional supplements, including FDA-approved medical foods obtained by prescription. 52. Services for any condition with only a V Code designation in the Diagnostic and Statistical Manual of Mental Disorders, which means that the condition is not attributable to a mental disorder. The following are excluded unless specifically listed as a Supplemental Benefit in the Summary of Benefits (Section A): 1. Preventive dental care for children. 2. Extraction of teeth impacted in bone. 3. Annual eye examinations. 4. Chiropractic care. 5. Therapeutic donor insemination, including related sperm procurement and banking. 6. Advanced reproductive technologies, including, but not limited to, in-vitro fertilization, gamete intrafallopian transfer, zygote intrafallopian transfer, intra-cytoplasmic sperm injection, and donor egg procedures, including related egg and inseminated egg procurement, processing and banking. 7. Voluntary sterilization, including tubal ligation and vasectomy. 8. Voluntary termination of pregnancy. 9. Foot orthotics. 10. Hearing aids. 51. Telemonitoring, telemedicine services involving , fax, or audio-only telephone, telemedicine services involving stored images forwarded for future consultation, i.e. store and forward telecommunication. S7
SECTION A. Summary of Benefits LW-V, 10/09
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