Summary of Benefits Prominence HealthFirst Small Group 2-50

Transcription

1 HMO Ded 9 Value Summary of Benefits All specialty care services will require a PCP or emergency care practitioner referral Calendar Year Deductible (CYD) 1 Coinsurance - Applies to outpatient facility and outpatient surgery physician/ surgical services. Out-of-Pocket Maximum - Deductibles, coinsurance and copays all accrue towards the out-of-pocket maximum. 2 Physician Office Visits Primary care practitioner (PCP) 3 Specialist office visit - will require a referral from your PCP and prior authorization 4 PCP and specialist copay applies to all services in the practitioner s office unless the service is also listed on this summary of benefits with an additional copay. Alternative Medicine - Homeopathy, acupuncture and integrated medicine. $1,500 maximum per calendar year. No prior authorization required for initial visit. 4 Ambulance Services - Medically necessary only. Air ambulance Ground ambulance Diabetic Products Generic Preferred Brand Non-Preferred Brand Durable Medical Equipment 5 Rental Items approved for purchase Emergency Care - Includes surgeon and physician costs. Emergency room - The copay is waived when the member is admitted as an inpatient directly from the emergency room. Urgent care - In and 0ut-of-area urgent care services are covered for medically necessary covered services. Members should call Prominence Health Plans Member Services for assistance prior to obtaining out-of-area urgent care services. Health and Wellness Services Online Wellness Assessment - OWA Link: prominencehealthplan.com Telephonic health coaching - Six sessions per condition per calendar year (diabetes management, tobacco cessation and weight management) Hearing Aids - Limited to one every three years. Home Health Care - Includes private-duty nursing; maximum 30 visits per calendar year. 5XHMD9VSG $5,500 single/ 2x family Pediatric Dental - $50 single/ 3x family 5% Coinsurance $6,600 single/ 2x family $200 copay per trip $200 copay per trip $15 copay $75 copay $150 copay $50 copay per item $400 copay per visit Page 1

2 Summary of Benefits HMO Ded 9 Value Hospice Care Hospice care Respite inpatient - Limited to 10 days per 6 months. copay per day for a maximum of 3 days. Respite outpatient - Limited to 10 visits per year. Bereavement services - Limited to 5 visits per year. Hospital/Outpatient/Ambulatory Services 6 - *Includes surgeon, facility and anesthesia charges Inpatient* - copay per day for a maximum of 3 days. Outpatient surgery* Observation* - No additional copay if transferred from outpatient surgery. Inpatient skilled nursing - Limited to 100 days per calendar year. copay per day for a maximum of 3 days. Acute rehabilitation - Limited to 60 visits per condition per member per calendar year (combined with physical occupational and speech therapies); includes outpatient rehabilitation visits. copay per day for a maximum of 3 days. Infertility Treatment Services Office visit evaluation - Please refer to the applicable surgical procedure copay and/or coinsurance amount for any surgical infertility procedures performed. Infusion Therapy* Performed and billed by a physician s office or free-standing, outpatient facility Performed and billed by a hospital outpatient facility * Special pharmaceuticals incur 20% coinsurance Kidney Dialysis Services - Covered to the extent not covered by Medicare. Laboratory and Pathology Services Laboratory Pathology Mastectomy Reconstructive Services Inpatient surgery - copay per day for a maximum of 3 days. Outpatient surgery Maternity Physician: prenatal and delivery - $200 copay applies to all obstetrician services associated with the birth. Delivery room and nursery hospital care for mother and baby - copay per day for a maximum of 3 days. Ancillary maternity charges Medical Nutrition Therapy Counseling - Limited to 25 visits per calendar year. Page 2 $250 copay per visit $200 copay per delivery

3 HMO Ded 9 Value Summary of Benefits Mental Health Services Severe Mental Illness Inpatient - copay per day for a maximum of 3 days. Day treatment program Outpatient Outpatient office visit General Mental Health Outpatient office visit Alcohol and Drug Abuse Services Inpatient withdrawal - copay per day for a maximum of 3 days. Inpatient rehabilitation - copay per day for a maximum of 3 days. Outpatient rehabilitation/day treatment Outpatient office visit Morbid Obesity - Includes inpatient or outpatient services. Bariatric Gastric Restrictive surgery. - copay per day for a maximum of 3 days. One procedure every three years; includes surgical complications. Nutritional Supplements - Enteral Therapy and Parenteral Nutrition. Maximum 120 days supply for special food products. Organ Transplants - copay per day for a maximum of 3 days. Ostomy Supplies $40 copay per 30 day supply Pediatric Dental - Pediatric Dental Coverage up to Age 19 In-Network Out-of-Network Calendar Year Deductible $50 single/ 3x family $50 single/ 3x family Diagnostic and Preventive Services - Not subject to the Deductible 30% Coinsurance Basic Restorative Procedures - Subject to the Deductible 20% Coinsurance 50% Coinsurance Major Restorative Procedures - Subject to the Deductible 50% Coinsurance 80% Coinsurance Orthodontia 4 - Subject to the Deductible 50% Coinsurance 80% Coinsurance Prescription Drugs FDA - approved oral contraceptive drugs $0 copay Generic $15 copay Preferred brand $75 copay Non-preferred brand $150 copay Special pharmaceuticals CYD/20% Coinsurance Preventive Services - For a complete list of covered services, visit Colorectal cancer screening, colonoscopy, sigmoidoscopy, or fecal occult blood test Mammograms - baseline and annual Pap and pelvic exams Periodic health assessments for hearing and vision for ages 19 and under Page 3

4 Summary of Benefits HMO Ded 9 Value Preventive Services (continued) BRCA genetic counseling and testing services Prenatal well visits Prostate screenings Well baby and child visits, immunizations/vaccinations for children through age 17 Preventive sterilization Prosthetics and Orthotics Prosthetics and orthotics - Foot orthotics limited to one pair per member per calendar year. Dental/oral orthotic appliances, TMJ and/or sleep apnea Limited to one appliance per member per calendar year. Radiation Oncology Therapy Professional read/specialist visit Hospital outpatient therapy facility fee Radiology and Diagnostic Services 7 Routine X-ray and Routine Diagnostic Tests Performed and billed by a free-standing, outpatient facility Performed in and billed by a hospital outpatient facility CT SCAN and MRI Performed and billed by a free-standing, outpatient facility Performed and billed by a hospital outpatient facility Complex Diagnostic Testing Performed and billed by a free-standing, outpatient facility Performed and billed by a hospital outpatient facility Spinal Manipulation Temporomandibular Joint Dysfunction TMJ surgery - inpatient hospital - copay per day for a maximum of 3 days. TMJ non-surgical outpatient office visit Therapies Physical, occupational and speech - Limited to 60 visits per condition per member per calendar year combined with acute rehabilitation visits. Habilitative - Limited to 60 visits per condition per member per calendar year. Rehabilitative - Limited to 60 visits per condition per member per calendar year combined with acute rehabilitation visits. Autism spectrum disorders - Limited to 200 visits per member per calendar year. Page 4 $50 copay per test $250 copay per test $600 copay per test $1,200 copay per test $600 copay per test $1,200 copay per test

5 HMO Ded 9 Value Summary of Benefits Vision - Pediatric - Coverage up to age 19 Eye exam - Limited to one routine eye exam per child per year. Low-vision exam - Limited to one routine eye exam per child per year. Glasses - Limited to one pair of basic frames and lenses. Post-cataract services - Limited to one pair of basic frames and lenses. $100 copay The Evidence of Coverage (EOC) sets forth in detail the rights and obligations of both you and the insurance company. It is important you review the EOC once you are enrolled. This disclosure statement provides only a brief description of some important features and limitations of your policy. If you have questions about this summary of benefits (SOB), please call Prominence Health Plan Member Services at , or (TTY Operator Assistance) Our website,, also serves as an important resource and includes information about provider directories, urgent care and emergency care locations and more. Except for an emergency, all health care services must be coordinated and obtained by a primary care practitioner (PCP) unless otherwise authorized. All specialty care services will require a PCP or emergency care practitioner referral. 1. Deductible - a set amount of covered charges occurring each calendar year which must be paid by the member before benefits are payable under this plan. 2. Deductibles, coinsurance and copays accrue to the out-of-pocket maximum (OOPM). The following services cannot be used to satisfy the out-of-pocket maximum: 01. Penalty for failure to obtain prior authorization; and 02. Use of emergency room for non-emergency. 3. Each member must choose a PCP who is responsible to provide, arrange and coordinate all of the health care services to ensure continuity of care for you and initiating any referrals and prior authorizations for specialized care you may require. 4. Prior authorization is the standard process of receiving approval for certain procedures and medical services to ensure that the requested medical care is appropriate and necessary. Not all referrals require a prior authorization from Prominence Health Plan. Your PCP (or specialist) obtains this on your behalf. For a complete list of services that require prior authorization, please visit or call to confirm if prior authorization has been obtained if required. A referral is required when your PCP or emergency care/specialty care practitioner recommends that you be evaluated and/or treated by a specialist and it is also required if you want to see one on your own. A referral from your PCP to a specialist helps assure care continuity and coordination, and minimize the chance that you receive duplicate or unnecessary testing, imaging, or treatment. The referring practitioner is responsible for providing the consultation request and related information to the receiving specialist. 5. Durable medical equipment (DME) is covered when medically necessary, authorized by Prominence Health Plan and is in accordance with Medicare DME guidelines. 6. Ambulatory and day-surgery services performed in hospital or other facility. 7. Some invasive diagnostic procedures are treated as outpatient hospital visits. Choosing your primary care practitioner (PCP) As a HMO member, you must select a primary care practitioner (PCP) to manage all of your medical care. If you have already selected a PCP, his or her name and contact number will appear on your member ID card. If Call for PCP is printed on your ID card, you must select a PCP by following the instructions below. Page 5

6 Summary of Benefits HMO Ded 9 Value How to locate a PCP 1. Go to 2. Select Click here to view printable provider directories. 3. Choose your plan s provider directory to review the list of available PCPs. How to select or change your PCP 1. Call Member Services at or (8 a.m. - 5 p.m. Pacific Time, Monday-Friday) 2. Be prepared to indicate your PCP selection to Member Services. You must use your selected PCP to manage your care If you see a primary care practitioner who is not your assigned PCP, your claim(s) may be denied. Always check with your PCP before seeking care from a specialist. Your PCP can determine if specialty care (i.e., cardiology, gastroenterology, neurology, etc.) is needed and can provide you with the required referral. If you see a specialist without a referral, your claim(s) may be denied. Access to pediatricians For children, you may designate a pediatrician as the primary care practitioner. Access to OB/GYN physicians You do not need prior authorization from or from any other person (including a PCP) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Prominence Health Plan Member Services at and Rescissions will not rescind coverage once a member is enrolled unless the individual (or a person seeking coverage on behalf of the individual) performs an intentional act, practice or omission that constitutes fraud, or unless the individual makes an intentional material misrepresentation of fact, as prohibited by the terms of the Evidence of Coverage. will provide at least 30 days advance written notice to each participant who would be affected before coverage will be rescinded. Emergency Services are provided as follows: a. Without prior authorization requirement, even for out-of-network services; b. Without regard to whether the provider of the services is in-network; c. If the services are out-of-network, without any administrative requirements or coverage limitations that are more restrictive than those imposed on in-network services; and d. Without regard to any other tem or condition of the coverage other than: (1) the exclusion of or coordination of benefits; (2) an affiliation or waiting period permitted under ERISA, the PHSA, or the Internal Revenue Code; or (3) applicable cost sharing. Page 6