Humana Health Plans of Puerto Rico, Inc. POS Deluxe $15

Transcription

1 Humana Health Plans of Puerto Rico, Inc. POS Deluxe $15 ANNEX I HMO: Section VI Schedule of Covered Services, Benefits and Copayments A. Physician Services Physician and consulting and supplies provided by or under the direction of the member s primary care physician and as specified herein: Not Office Visits to the member s primary care physician or a consulting physician to whom the member has $15 per visit $17 per visit $17 per visit been referred by the primary care physician. Specialist visits $20 per visit $22 per visit $22 per visit Allergy Services, including physician, injections and medications. Injections in conformity with the accepted medical practices. the office visit the office visit the office visit Home visits by a provider, if medically necessary. $15.00 per visit $25.00 per visit $25.00 per visit Physician provided by pathologists and radiologists to hospitalized members. Surgery, including reconstructive surgery after accident or illness. Services of professional health care doctor being Anesthesiology and Assistant Surgeon. Hospital and skilled nursing facility visits, as part of the continued supervision of covered.. Audiology and Ophtalmology evaluations for adults, including audiology and optometric or ophtalmologist exam as preventives. Health Education and orientation $20 per visit Not covered the office visit the office visit $22 per visit Not covered the office visit Health planning the office visit the office visit the office visit Chiropractic Services, covered fifteen (15) manipulations per subscriber, per contract year. $20 visit $22 visit $22 visit Podiatric for the treatment of diseases and disorders of the foot and ankle, including injections and surgical procedures when medically necessary $20 visit $20 visit $22 visit Eye refraction test, one (1) per subscriber per contract year $20 visit $20 visit $22 visit POS Deluxe-SB Rev / Effective Page 1 de 14

2 Immunodeficiency syndrome diagnostic test and treatment Tabacco treatment according to Law 21 dated February 29, Maximum up to $400 per subscriber per contract year Services for the treatment of morbid obesity, whenever medically necessary and authorized by Humana. One (1) surgery per lifetime using one of the following techniques: gastric bypass, adjustable lap band, sleeve gastrectomy, in accordance with Law 212 of August 9, B. Preventive Services Annual preventive are all covered at 100% ($0 ) when offered by contracted in Humana Health Plans network and recommended by the US Preventive Task Force (USPTF), Advisory Commitee Inmunization Practices of the Centers for Disease Control and Prevention and Health Resources and Services Administration: Not Out Of Plan Copay Routine physical exam the office visit Blood pressure screening the office visit Cholesterol screening the office visit Colorectal cáncer screening, including Colonoscopy (adults years) Obesity screening & counseling Tobacco use screening Diet counseling Type 2 Diabetes screening / Detection of gestational diabetes Alcoholism Abuse screening & Counseling Alcoholism Substance Abuse evaluation for children and young Immunization shots for infants, child and adults, depending on age, according with The Advisory Commitee Inmunization Practices of the Centers for Disease Control and Prevention and the American Academy of Pediatrics,while included as subscriber under this contract. Including Human Papiloma Virus vaccine according to Law Num, 9 the office visit POS Deluxe-SB Rev / Effective Page 2 de 14

3 dated on January 20, Human papillomavirus (HPV) testing, including the HPV vaccine, as required by the Food and Drug. the office visit Well woman visits Screening mammography, according to established guidelines recommended by the Puerto Rico Health Department and the Health Resources and Services Administration according to the Law Num. 161 of November 1, This includes chemoprevention and breast cancer chemioprevention counseling for women. Pap Smear Test Prostatic Specific Antigen (PSA) Counseling on sexually transmitted diseases Human immunodeficiency virus (HIV) counseling and screening Interpersonal and domestic violence counseling and screening Autism screening Hearing screening for all newborns Lead screening for children at risk of exposure One lifetime Abdominal Aortic Aneurism screening for men years old who have ever smoke Aspirin counseling, for both genders, years, with Cardiovascular risk Folic acid counseling for women who may become pregnant Iron supplements counseling for children 6 to 12 months and pregnant women at risk for anemia Medical exam for: congenital hypothyroidism for newborns, phenylketonuria (PKU) for newborns, tuberculin for newborns, hematocrit or hemoglobin in children, cervical dysplasia, dyslipidemia for children, syphilis,gonorrhea for all women at higher risk, BRCA Not covered Not covered Not covered Medical exam for woman: osteoporosis (for women 60 years or more), chlamydia infection for younger women, 24 years or less, sexually active and at higher risk Medical exam for pregnant woman: anemia, bacteriurea, Rh incompatibility (and for high risk woman), hepatitis B Preventive covered at 100% (without copay) when provided within the Humana Not covered POS Deluxe-SB Rev / Effective Page 3 de 14

4 Providers Network and recommended by the US Preventive Task Force (USPTF) and the Health Resources and Services Administration: a. Contraception and contraception counseling. All contraceptive methods approved by FDA, by prescription, and the placement, removal, or management, including sterilization. Preventive covered at 100% (without copay) for pregnancy when provided within the Humana Providers Network and recommended by the US Preventive Task Force (USPTF) and the Health Resources and Services Administration. For this service, please call Humana Beginnings at : Not covered Breastfeeding support with necessary guidance and supplies, including the breast pump C. Maternity Services The minimum hospital stay for both patient and newborn has been established by Law 248 of the Commonwealth of Puerto Rico dated August 15, 1999, at 48 hours for a normal delivery, without complications, and 96 hours for a Cesarean section delivery. Hospital discharges prior to length of stays stipulated by the law must have the consent of the patient. The maternity benefit covers a follow up visit during the 48 hour period following discharge, at which time the newborn infant can also be checked. Services will include, but not be limited to support and physical care for the benefits of the minor, education to both parents on caring for the minor, support and training on breast feeding, orientation on support at home and the performance of any treatments and medicine test both for the infant and the mother. Maternity benefits include the following : Not Illimited Pre and Post Natal Care visits $15 per visit $17 per visit $17 per visit Hospitalization, including delivery, Cesarean or Natural section, delivery and recovery rooms Nursery and incubator Neonatal intensive care unit ( NICU ) Fetal monitoring during delivery RhoGAM vaccine the admission the admission the admission the office visit $50 per admission (If it is precertificated) the admission the admission the admission the office visit $50 per admission (If it is precertificated) POS Deluxe-SB Rev / Effective Page 4 de 14

5 Genetic amniocentesis the office visit the office visit Ambulatory fetal monitoring Spontaneous abortion aplicable Biophysical profile covered for high risk cases Vaccine for the treatment of the Respiratory Syncitial Virus according to Law 165 dated August 30, 2006 and protocol approved by Puerto Rico s Department of Health. the office visit the office visit D. Hospital Services Hospital admissions must be pre authorized by HUMANA and ordered by the member s primary care physician, or by a consulting physician to whom the member has been referred by the primary care physician. Admissions thru Emergency Room will not require pre notification Hospital include: Not Semiprivate room and board, including general duty nursing care. $100 admission $150 admission $150 admission Private room and board, when medically necessary and authorized by the primary care physician or by a consulting physician to whom the member has been referred by the primary care physician. the admission In patient therapeutic and supportive care, including necessary supplies and appliances, and in specialized intensive care and coronary care units. Universal Neonatal Hearing Screening according to Law 311 dated December 19, 2003, which includes: hearing evaluations for the follow up treatment needed by the patient. Mastectomy benefits: (a) all phases of reconstruction where the mastectomy was made (b) surgery for both breast, and (c) prosthesis and any physical complication of the mastectomy, including linfidema. Use of surgery room, delivery room, recovery room and treatment rooms, and their respective the admission the admission the admission the admission POS Deluxe-SB Rev / Effective Page 5 de 14

6 equipment.. Laboratory tests, X rays, EKG, EEG and other diagnostic tests performed in conjunction with a member s admission to the hospital and other necessary uses of hospital facilities. Anesthetics, oxygen, medications, and other biologicals. Dressings, casts, and other special equipment supplied by the hospital for use in the hospital. Special diets, while a member is hospitalized. Radiotherapy inhalation therapy while a member is hospitalized. Short term rehabilitation while a member is hospitalized, including physical therapy, occupational therapy, and speech therapy. Use of ambulatory surgery facilities for surgical procedures performed or authorized by a plan physician. Ambulatory authorized by a plan provide with the exception of the Section VI (D, E, G, I, J, K, N, O, R).. Ambulatory covered can be provided in a hospital or other healthcare facility approved by Humana. the admission the admission the admission the admission $25 per admission $25 per admission Administration of whole blood or plasma. Hospital for the acquired immunodeficiency syndrome (AIDS). Treatment and for morbid obesity as medically necessary. One (1) surgery using one of the following techniques: gastric bypass, adjustable gastric band or sleeve gastrectomy per lifetime, according to Law 212 dated August 9, 2008 the admission the admission E. Emergency Services Emergency healthcare will be provided as follows: Not Emergency health care $50 per visit $60 per visit $60 per visit In the event a medical emergency occurs outside the area of service and the member requires emergency health provided by non participating providers, Humana will pay as if he/she were a participating provider and the corresponding will apply, so long as there is a sound medical reason for not transferring the patient to a participating provider. In the event that the patient is provided health care after the emergency, or post stabilization, which would be covered POS Deluxe-SB Rev / Effective Page 6 de 14

7 under the health care plan, were it not for the fact that they are provided by a non participating provider, Humana will compensate the patient for the part of the cost relative to said received that would have been paid with arrangement by the plan, so long as there is a sound medical reason for not transferring the patient to a participating provider. Once the emergency or stabilization have been completed, Humana will transfer the member to a Humana facility as soon as is medically possible. Said transfer shall in no way endanger or be detrimental to the member's health or medical treatment. Humana will assist with the coordination of said transfer as stipulated in Law 194 of August 25, The following rules apply for Emergency Healthcare Services: mentioned in Section VI. E, numbers 1 and 2: (a) The member must notify Humana within twenty four (24) hours after receiving the emergency health rendered, or as soon as possible, full details regarding the emergency medical condition and any emergency healthcare rendered shall be made available. As soon as it is medically appropriate, at the request of Humana, hospitalized members may be transferred to a contracted hospital, upon request by Humana. (b) Emergency healthcare, whether rendered within or outside the service area, are subject to all the limitations and exclusions of this contract. Note: Accident emergencies are covered at 100%, Psychiatric emergency is covered to the applicable. The Emergency room does not apply if the patient is admitted; apply. Services by the Emergency System are covered as required by the Law Num. 383 dated September 6, F. Hospice Not Hospice Care Program Hospice Care Program means a coordinated, interdisciplinary program designed to meet the special physical, psychological, spiritual and social needs of the terminally ill insured person and his or her insured family members, by providing palliative and supportive medical, nursing and other through at home or inpatient care. The hospice must be licensed according to the laws of the Commonwealth of Puerto Rico. It must provide a program of treatment for a person who have been medically diagnosed as having no reasonable prospect of cure for their illness and, as estimated by a physician, are expected to live less than 6 months as a result of that illness. Humana will pay benefits for charges for a hospice care program, which is submitted in writing and approved by us. The insured person must submit in writing his or her intent to enroll in a hospice care program approved by us. All the hospice are subject to the maximum limits specified under the policy, including any applicable, coinsurance or deductible. All must be received within a 12 month period. G. Pediatric Health Services The pediatric are provided to a subscriber by the primary care physician, including: Not POS Deluxe-SB Rev / Effective Page 7 de 14

8 Universal Neonatal Hearing Screening, including audio evaluations according to Law 311 dated December 19, 2003, which includes: hearing evaluations for the follow up treatment needed by the patient. Annual exam according to Law 296 dated September 1st, 2000, which includes: physical and mental evaluation, oral health, hearing and vision screening, and screenings recommended by the American Academy of Pediatrics Periodic Heath evaluations, including audiology and optometric or ophtalmologist exam as preventive. Pediatric care since born. Immunizations according to established medical practices and as recommended by the Advisory Committee on Immunization Practices (CDC) and the American Academy of Pediatrics, while included as insured under the contract. Human Papiloma Virus vaccine according to Law Num, 9 dated on January 20, Coverage for technological equipment of ventilators for children, including eight (8) hours daily shift of a skilled nurse with knowledge in respiratory therapy or specialist in respiratory therapy, equipment supplies, physical and occupational therapy according with Law 125 dated on September 21, Vaccine for the treatment of the Respiratory Syncitial Virus according to Law 165 dated August 30, 2006 and according with the protocol approved by Puerto Rico s Department of Health. the office visit the office visit the office visit the office visit aplicable aplicable aplicable H. Cancer Service Not Ambulatory for the treatment of radiotherapy and/or chemotherapy, including oral, intratacal and intravenous drugs. Medically necessary oral and parenteral medication for pain management of patients suffering terminal cancer. All the benefits included in the hospital, less hospital admission s. the admission POS Deluxe-SB Rev / Effective Page 8 de 14

9 Stoma care and maintenance: colostomy, gastrostomy and cystostomy. For the insured who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, the coverage includes: a) all stages of reconstruction of the breast on which the mastectomy has been performed b) surgery and reconstruction of the other breast to produce a symmetrical appearance c) prosthesis and physical complications of mastectomy, including lymphedemas the admission the admission Human Papiloma Virus vaccine according to Law Num, 9 dated on January 20, 2010 I. Mental Health Services Office visits to psychiatrist or psychologist. $20 per visit Hospital covered. Two (2) days of partial hospitalization are equivalent to one (1) day of regular hospitalization. Not $22 per visit $22 per visit $100 per admission $150 per admission $150 per admission J. Alcohol and Substance Abuse Services Not Alcoholism Abuse screening & Counseling Alcoholism Substance Abuse evaluation for children and young Treatment and monitoring of one or more levels of service that can combine multiple types of therapy. Office visits, with a maximum of fifteen (15) visits per member, per contract year, minus the corresponding. Hospital up to a maximum of thirty (30) days per member, per contract year, minus the $20 per visit $22 per visit $22 per visit $100 per admission $150 per admission $150 per admission POS Deluxe-SB Rev / Effective Page 9 de 14

10 corresponding admission. Two (2) days of partial hospitalization are equivalent to one day of regular hospitalization. Home care treatment up to a maximum of ninety (90) days per member, per contract year. Requires medical justification. aplicable aplicable aplicable copaymena NOTE: For groups of more than 50 employees (51+) the maximum limits for office visits, group therapy and days of treatment do not apply. These groups are subject to comply with the Mental Health Parity Act which requires that the same treatment and monetary limits apply to the mental health and substance abuse benefits K. Dialysis Hemodialysis and the peritoneal dialysis (CAPD) when authorized by, or under the direction of the member s plan primary care physician or a consulting physician to whom the member has been referred by primary care physician, and when authorized in advance by Humana for the treatment of renal failure. Not L. Diagnostic Laboratory and Diagnostic and Therapeutic Radiology Services The following outpatient will be provided when ordered by the member s plan primary care physician or by a consulting physician to whom the members has been referred by primary care physician when in support of the other health in Section VI. (a) Laboratory tests (b) Electrocardiograms (c) Electroencephalograms (d) X rays (e) Other diagnostic procedures Not The genetic Studies required pre certification. M. Skilled Nursing Facility Room and board, and other necessary furnished by a Skilled Nursing Facility will be Not $25 per admission $25 per admission POS Deluxe-SB Rev / Effective Page 10 de 14

11 provided when a member requires skilled nursing care of the type provided by the facility, when arranged and authorized by the member s plan primary care physician or by a consulting physician to whom the member is referred by the primary care physician, and when is authorized in advance by Humana. Maximum sixty (60) days during member s lifetime. M. Home Intravenous Teraphy Intravenous therapy will be covered when authorized in advance by the member s plan primary care physician and Humana. Not N. Medical Rehabilitation Services Impatient short time Medical Rehabilitation Services in a hospital, skilled nursing facilityhouse or office, including physical therapy, occupational, and speech therapy. For conditions subject to improvement in a sixty (60) days period. These have to be with pre authorization. Not O. Durable Medical Equipment, Orthotic Equipment and Prosthesis Mechanisms Not Durable Medical Equipment, Orthotic Equipment, prosthesis Mechanisms The purchase or rental of medically necessary Durable Medical Equipment, including diabetes paraphernalia. As Humana option, the cost or rent of the medical equipment is covered. If the cost of the rented equipment is higher than the cost of the equipment, only the cost of the equipment will be covered. Humana will not pay for equipment not designed or managed for the treatment of an injury or illness. The prosthesis mechanisms are cover only for a extremity or other body part replacement after a accidental renoval or a surgery until the patient is a Humana subscriber and/or when it need a replacement due to a growth body. The breath prosthesis that require a reconstruction surgery will be provided with Humana pre authorization. POS Deluxe-SB Rev / Effective Page 11 de 14

12 P. Home Health Care Services Home Health Services 1 Home Health Services at the insured s home, when authorized by the attending physician and Humana. Not Home health care must be provided by a licensed dedicated home health care agency that is run according to rules established by a group of professional medical people that maintains clinical records on all patients, and operates according to the laws of the Commonwealth of Puerto Rico. All care must be provided under the supervision of physicians or registered nurses. These must begin within 30 days after an insured s person discharge from a hospital or skilled nursing facility or may be provided in substitution of an admission. The Home health care must be requested by the insured s attending physician. Who must submit a plan of care and the expected duration of the according to the patient s individual needs. The program will provide education to patient and his/her responsible relative care givers. This benefit will be effective for thirty (30) days initially and thirty (30) more days as a certified medical necessity. Home health care include: a. Nursing cares by or under the supervision of a R.N. b. Respiratory therapy care c. Collection of samples for laboratory studies d. Care and maintenance of catheters e. Administration of intravenous antibiotics, as per Humana s case management program f. Ulcer care as per Humana s case management program R. Ambulance Services Emergencies handled through the Emergency System refer to the public safety answering point through 9 1 1, created by virtue of Law Number 144 of December 22, 1994, as amended, known as Rapid Response Law for Public Safety Answering Point or Enhanced Law. Services provided under the Emergency System are covered as required by Law Number 383 of September 6, Ground emergency transportation within Humana's area of service by an ambulance authorized by the Public Service Commission and the Department of Health in accordance with that established in the last paragraph of Article 4.20 (b) of Law Number 183 of August 6, Including to a hospital or between health facilities, for example: from one hospital to another, from a hospital to a radiological institute, or from a hospital to a Skilled Nursing Not $25 per trip $25 per trip $25 per trip POS Deluxe-SB Rev / Effective Page 12 de 14

13 Air ambulance transportation provided to the continental United States when it has been previously authorized and arranged for by a Humana plan physician and by Humana Air ambulance is provided from or to the municipal islands of Vieques and Culebra when it is authorized and arranged for by the primary care physician and Humana S. Autism Disorders within the Continum of Autism are recognized as physicomental health conditions. In compliance with Law of Puerto Rico with the Puerto Rico Department of Health and utilizing as reference the guidelines of the American Association of Pediatrics coverage for these conditions will include diagnostic and therapeutic in persons diagnosed with disorders within the continuum of Autism. Covered benefits include visits to physicians and other health providers and the ordered tests and procedures determined to be medically necessary. aplicable Not aplicable T. Special Provisions Organ and Tissue Transplant Benefits We will pay benefits for the expense of a Covered Organ Transplant, incurred by an insured person for an organ transplant approved in advance by Humana, subject to those terms, conditions and limitations described in the Member Contract. The covered organ transplant includes pre transplant, Not Not Covered POS Deluxe-SB Rev / Effective Page 13 de 14

14 transplant inclusive of any chemotherapy and associated, post discharge, and treatment of complications after transplantation of the following organs or procedures only: Heart, Lung(s), Heart lung, Liver, Kidney, Bone Marrow, Intestine, Simultaneous pancreas/kidney, Pancreas following kidney, Any organ not listed above required by state or federal law. For other details covered, please refer to the Member Contract. U. Deductible out of plan Not Deductible Per Person N/A N/A $ Deductible Per Family N/A N/A $ V. Pharmacy Benefits: F-50 MAC A (first option generic drugs) Generic Drugs $10.00 c/u Orden por correo suplido de noventa (90) días $20.00 c/u Brand $25.00 c/u $50.00 c/u POS Deluxe-SB Rev / Effective Page 14 de 14