HPHC Insurance Company, Inc. THE HPHC INSURANCE COMPANY DEDUCTIBLE TIERED COPAYMENT PPO PLAN MAINE

Transcription

1 ID: MD X Schedule of s HPHC Insurance Company, Inc. THE HPHC INSURANCE COMPANY DEDUCTIBLE TIERED COPAYMENT PPO PLAN MAINE This Schedule of s summarizes your benefits under the The HPHC Insurance Company Deductible Tiered Copayment PPO Plan(the Plan) and states the amounts that you must pay for Covered s. However, it is only a summary of your benefits. Please see your Handbook and Prescription Drug Brochure (if you have the Plan s outpatient pharmacy coverage) for detailed information on benefits covered by the Plan and the terms and conditions of coverage. There are two levels of coverage: and. coverage applies when you use a Plan Provider for Covered s. When using, coverage is based on the contracted rate between HPHC and the Provider. coverage applies when you use a Non-Plan Provider for Covered s. When using, the Plan pays only a percentage of the cost of the care you receive up to the Allowed Amount for the service. In most cases, this will be higher than the HPHC contracted rate. If a Non-Plan Provider charges any amount in excess of the Allowed Amount, you are responsible for the excess amount. Please refer to section I.E.6. in your Handbook for additional information about Charges in Excess of the Allowed Amount. You always have coverage for care in a Medical Emergency. In a Medical Emergency, you should go to the nearest emergency facility or call 911 or other local emergency number. Your emergency room is listed below under the heading Emergency Room Care. Member Responsibility for Notification and Prior Approval Members must contact HPHC for coverage of a number of services. These are listed below. Mental Health and Drug and Alcohol Rehabilitation Services. Prior Approval must be obtained before receiving certain mental health and drug and alcohol rehabilitation services. Please refer to our internet site, or contact the Member Services Department at for a list of services for which Prior Approval is required. To obtain Prior Approval for mental health or drug and alcohol rehabilitation services, please call the Behavioral Health Access Center at Medical Services. Members are required to notify HPHC before the start of any planned inpatient admission to a Non-Plan Medical Facility. Members are also required to obtain Prior Approval from HPHC for certain services. Before you receive services from a Non-Plan Provider, please refer to our internet site, or contact the Member Services Department at for a list of services for which Prior Approval is required. If you do not provide Notification or obtain Prior Approval when required, you will be responsible for paying the Penalty amount stated in this Schedule of s in addition to any applicable. No coverage will be provided if HPHC determines that the service is not Medically Necessary, and you will be responsible for the entire cost of the service. EFFECTIVE DATE: 01/01/2014 FORM #1605_MD3250_01 SCHEDULE OF BENEFITS 1

2 Emergency Care. You do not need to contact HPHC before receiving care in a Medical Emergency. In the event of an emergency hospital admission to a Non-Plan Provider, you must notify HPHC within 48 hours of the admission or as soon as possible, unless notification is not possible because of your condition. If notice is given to HPHC by an attending emergency physician, no further notification is required. Please call to notify us of an emergency admission to a Non-Plan facility. Clinical Review Criteria We use clinical review criteria to evaluate whether certain services or procedures are Medically Necessary for a Member s care. Members or their practitioners may obtain a copy of our clinical review criteria applicable to a service or procedure for which coverage is requested. Clinical review criteria may be obtained by calling ext Deductible A Deductible is a specific annual dollar amount that is payable by the Member for Covered s received each calendar year before any benefits subject to the Deductible are payable by the Plan. If a family Deductible applies, it is met when any combination of Members in a covered family incur expenses for services to which the Deductible applies. Not all services under this Plan are subject to the Deductible. Deductible amounts are incurred on the date of service. Your Plan Deductible amounts are listed below. Your Plan has both an individual Deductible and a family Deductible. However, please note that a family Deductible only applies if you have Family Coverage. Unless a family Deductible applies, you are responsible for the individual Deductible for Covered s each calendar year. If you are a Member with a family Deductible, your Deductible can be satisfied in one of two ways: a. If a Member of a covered family meets the individual Deductible, then services for that Member that are subject to that Deductible are covered by the Plan for the remainder of the calendar year. b. If any number of Members in a covered family collectively meet the family Deductible, then all Members of the covered family receive coverage for services subject to that Deductible for the remainder of the calendar year. Although some services are exempt from the Deductible, you are responsible for the Member Cost Sharing, if applicable, listed in this Schedule of s. After you meet the Deductible, which applies to most Covered s, you are responsible for the applicable Copayments or as noted in this Schedule of s. An office visit is an outpatient visit with a clinician for evaluation and management, including routine care, preventive care, and sick visits,. An office visit excludes treatments and procedures provided by a clinician, such as x-rays, blood tests, and mammograms, and professional services not billed as an office visit. Please read through this Schedule of s to see if a service provided during an office visit is exempt from the Deductible or if the Deductible applies. Copayments A Copayment is a dollar amount that is payable by the Member for certain covered services. The Copayment is due at the time services are rendered or when billed by the provider. Different Copayments apply depending on the type of service, the specialty of the provider and the location of service. FORM #1605_MD3250_01 SCHEDULE OF BENEFITS 2

3 There are two types of outpatient Copayments that apply to your Plan. A lower Copayment, known as Copayment Level 1, applies to some outpatient services, including most primary care, obstetrical care, gynecological care, and mental health and drug and alcohol rehabilitation services. Most outpatient specialty care requires payment of a higher Copayment, known as Copayment Level 2. The Level 1 and Level 2 Copayments that apply to your Plan are listed below. Copayment Level 1 Level 1 Services: Copayment Level 1 always applies to the following outpatient services regardless of the provider or location of service: Administration of allergy injections Mental health and drug and alcohol rehabilitation services In addition to the Level 1 list, Copayment Level 1 applies to covered outpatient professional services, other than the preventive services with no and the services received at a professional office operated by a hospital, from the following types of providers: All Primary Care Providers. The term Primary Care Provider (PCP) includes physicians and nurse practitioners in the following specialties: Internal Medicine, Family Practice, General Practice and Pediatrics Obstetricians and Gynecologists Certified Nurse Midwives Nurse Practitioners who bill independently Copayment Level 2 Copayment Level 2 applies to the following outpatient professional services: Any covered services or provider either not listed under Copayment Level 1 or not offered as a preventive service with no or Any service provided in a hospital operated doctor s office, except for the preventive services with no and Level 1 Services listed above. If a provider is categorized as both a Copayment Level 1 provider and a Copayment Level 2 provider, Copayment Level 1 applies. For example, if a provider is both a PCP and a cardiologist, you will be responsible for Copayment Level 1. A Copayment applies to all services except where specifically stated in the tables below. Please Note: Occasionally the Copayment may exceed the contract rate payable by the Plan for a service. If the Copayment is greater than the contract rate, you are responsible for the full Copayment, and the provider keeps the entire Copayment. Your Covered s are administered on a calendar year basis. General Cost Sharing Features: Tiered Copaymentsj : Copayment Level 1: Your Plan has a $35 Copayment Level 2: Your Plan has a $50 FORM #1605_MD3250_01 SCHEDULE OF BENEFITS 3

4 General Cost Sharing Features: : Tiered Copayments (Continued) Please see the section titled Copayments above for an explanation of your Level 1 and your Level 2 Copayments. and Copaymentsj See Covered s below and Copaymentsj See Covered s below Deductiblej Deductiblej Out-of-Pocket Maximumj Includes all Member Cost Sharing except for prescription drugs and pediatric dental services. Out-of-Pocket Maximumj Includes all except Copayments, Deductible and amounts for prescription drugs. Any charges above the Allowed Amount and any penalty for failure to receive Prior Approval when using do not apply to the Out-of-Pocket Maximum. $2,000 per Member per calendar year $4,000 per family per calendar year $4,000 per Member per calendar year $8,000 per family per calendar year $5,000 per Member per calendar year $10,000 per family per calendar year $6,000 per Member per calendar year $12,000 per family per calendar year Penalty Payment j does not count toward the Deductible $500 or Out-of-Pocket Maximum. Deductible Rolloverj Your Plan has a Deductible Rollover that applies to any Deductible amount that is incurred for services during the last 3 months of the calendar year and is applied toward the Deductible requirement for the next calendar year. Ambulance Transportj Emergency ambulance transport 30% Same as Non-emergency ambulance transport Autism Spectrum Disorders Treatment for Members up to the age of 6j Applied Behavior Analysis - limited to Copayment Level 1: $ hours per calendar year 30% FORM #1605_MD3250_01 SCHEDULE OF BENEFITS 4

5 Breast Cancer Treatmentj Your will depend upon the types of services provided, as listed in this Schedule of s. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. Chemotherapy and Radiation Therapy - Other than Inpatientj Outpatient hospital or other facility Physician office visit Copayment Level 1: $35 30% Chiropractic Carej Limited to 40 visits per calendar year Dental Servicesj Emergency dental care Your will depend upon the types of services provided, as listed in this Schedule of s. For example, for services provided in a dentist s office, see Physician and Other Professional Office Visits. For services provided in a hospital emergency room, see Emergency Room Care. Extraction of teeth impacted in bone Important Notice: Coverage of Dental Services is very limited. Please see your Handbook for the details of your coverage. Dialysisj Dialysis services Durable Medical Equipment j Durable medical equipment Blood glucose monitors, infusion No Charge devices, and insulin pumps (including supplies). No Charge Oxygen and respiratory equipment No Charge 20% Early Intervention Services for Members up to the age of 3j Limited to 40 visits per calendar year Emergency Admissionj Emergency Room Carej 30% Same as Same as FORM #1605_MD3250_01 SCHEDULE OF BENEFITS 5

6 Hearing Aids (for Members up to the age of 19)j Limited to 1 hearing aid per hearing impaired ear every 36 months Home Health Carej Hospice Outpatient Servicesj Hospital Inpatient Services j Acute Hospital Care Inpatient Maternity Care Inpatient Routine Nursery Care, including prophylactic medication to prevent gonorrhea Inpatient Rehabilitation Limited to 100 days per calendar year Day limits combined with Skilled Nursing Facility Care Skilled Nursing Facility Limited to 100 days per calendar year Day limits combined with Rehabilitation Hospital Care 30% Laboratory and Radiology Servicesj Laboratory and x-rays Non-routine mammograms No charge 20% Advanced Radiology CT scans PET scans MRI MRA Nuclear medicine services Low Protein Foods j No applies to certain preventive care services. For a list of covered preventive services, please see the Preventive Services notice on our website at: members/for_members/preventive_ care_cc4297.pdf. Maternity Care Outpatientj Routine outpatient prenatal and postpartum care No charge 20% Please note: Routine prenatal and postpartum care is usually received and billed from the same Provider as a single or bundled service. Different may apply to any specialized or non-routine service that is billed separately from your routine outpatient prenatal and postpartum care. For example, for services provided by another physician or specialist, see Physician and Other Professional Office Visits for your applicable. Please see your Handbook for more information on maternity care. FORM #1605_MD3250_01 SCHEDULE OF BENEFITS 6

7 Medical Formulas j State mandated formulas Mental Health and Drug and Alcohol Rehabilitation Servicesj Inpatient Services Mental health services Drug and alcohol rehabilitation services Detoxification Partial Hospitalization Services Partial hospitalization for mental health and drug and alcohol rehabilitation services Outpatient Services Mental health services Group therapy $10 Individual therapy Copayment Level 1: $35 Mental health services in the home Copayment Level 1: $35 Drug and alcohol rehabilitation Group therapy $10 services Individual therapy Copayment Level 1: $35 Detoxification services Copayment Level 1: $35 Medication management Copayment Level 1: $35 Psychological Testing Ostomy Suppliesj 30% 30% 30% 30% 30% Physician and Other Professional Office Visits (This includes all covered Providers unless otherwise listed in this Schedule of s)j Routine examinations for No charge 20% preventive care, including immunizations Consultations, evaluations and Copayment Level 1: $35 30% sickness and injury care Administration of allergy injections Copayment Level 1: $35 30% FORM #1605_MD3250_01 SCHEDULE OF BENEFITS 7

8 Preventive Services and Testsj Preventive care services, including all FDA approved contraceptive devices. Under the federal health care reform law, many preventive services and tests are covered with no member cost sharing. For a list of covered preventive services, please see the Preventive Services Notice on our website at: portal/docs/page/members/for_ members/preventive_ care_cc4297.pdf You may also get a copy of the Preventive Services Notice by calling the Member Services Department at No charge 20% Under federal law the list of preventive services and tests covered above may change periodically based on the recommendations of the following agencies: a. Grade A and B recommendations of the United States Preventive Services Task Force; b. With respect to immunizations, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and c. With respect to services for women, infants, children and adolescents, the Health Resources and Services Administration. Information on the recommendations of these agencies may be found on the web site of the US Department of Health and Human Services at: HPHC will add or delete services from this benefit for preventive services and tests in accordance with changes in the recommendations of the agencies listed above. You can find a list of the current recommendations for preventive care on Harvard Pilgrim s web site at Additional Preventive Services and Tests No charge 20% Alpha-Fetoprotein (AFP) Fetal ultrasound Group B Streptococcus (GBS) testing Hepatitis C testing Prostate-specific antigen (PSA) screening Routine hemoglobin tests Routine urinalysis Prostheticsj Prosthetic Devices Prosthetic Arms and Legs 20% 40% Rehabilitation Therapy - Outpatientj Cardiac rehabilitation Limited to 36 visits per cardiac episode Pulmonary rehabilitation therapy Copayment Level 1: $35 30% FORM #1605_MD3250_01 SCHEDULE OF BENEFITS 8

9 Rehabilitation Therapy - Outpatient (Continued) Physical, speech and occupational therapies combined Limited to 60 visits per calendar year Please note: Outpatient physical, occupational and speech therapies are covered to the extent Medically Necessary for: (1) children under the age of three and (2) the treatment of Autism Spectrum Disorders. 30% Scopic Procedures - Outpatient Diagnostic and Therapeutic j Colonoscopy, endoscopy and sigmoidoscopy Your will depend upon where the service is provided as listed in this Schedule of s. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided in a physician s office, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. No applies to certain preventive care services. For a list of covered preventive services, please see the Preventive Services notice on our website at: members/for_members/preventive_ care_cc4297.pdf. Surgery Outpatientj Telemedicinej Outpatient and Inpatient Telemedicine services Vision Services j Urgent eye care Copayment Level 1: $35 Routine adult eye examinations limited to 1 exam per calendar year Routine pediatric eye examinations limited to 1 exam per calendar year Please Note: You have additional coverage for vision hardware for children up to age 19. Please see your pediatric vision rider for more details. Vision hardware for special conditions (see the Handbook for details) Your will depend upon where the service is provided, as listed in this Schedule of s. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. Copayment Level 1: $35 Copayment Level 1: $35 30% 30% 30% FORM #1605_MD3250_01 SCHEDULE OF BENEFITS 9

10 Voluntary Sterilizationj Voluntary Termination of Pregnancyj Please Note: No applies to certain preventive care services. For a list of covered preventive services, please see the Preventive Services Notice on our website at: members/for_members/preventive_ care_cc4297.pdf. FORM #1605_MD3250_01 SCHEDULE OF BENEFITS 10