SCHEDULE OF MEDICAL BENEFITS
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1 Annual Deductibles Annual Out-of-Pocket Maximums Inpatient Hospital Copayment (Excludes Deductible) $250 Individual $1,000 Individual $100 per day, not to exceed $500 Family $2,000 Family $600 per admission $500 Individual $3,000 Individual $1,000 Family $6,000 Family Lifetime Benefit Maximum (Includes All Other Maximums) ne The following schedule summarizes coinsurance amounts paid by the Plan, benefit maximums, and any additional explanation needed for your benefits. The Plan s coinsurance will be reduced if you do not follow the procedures outlined in the Clinical Management section of this Handbook. Please refer to the text for additional Plan provisions that may affect your benefits. Our Benefits: Although a specific service may be listed as a covered expense, it may not be covered unless it is medically necessary for the prevention, diagnosis or treatment of an illness or condition. COVERED HEALTH SERVICE Acupuncture Allergy Testing (Injections) Ambulance Diagnostic Tests/X-Ray and Laboratory 50% 50% if office visit charged & 20% 20% Limited to 12 visits per year. Benefits are not subject to reduction for usual and customary charges. Benefit includes allergy injections/serum and physician allergy testing/treatment. You must pay a $25 copay per visit to a network provider if professional services charged in addition to the injection for serum preparation or physician supervision. Benefit for services performed in an independent lab facility or doctor s office not related to a routine exam. Durable Medical Equipment (DME) You should notify Aetna by calling the toll-free number prior to purchasing or renting any durable medical equipment.
2 COVERED HEALTH SERVICE Emergency Room & $50 per visit Your $50 copay will be waived if you are admitted to the hospital. There is no coverage for non-emergency treatment. Home Health Care Limited to 200 visits per plan year; precertification is required. You should notify Aetna by calling the toll-free number prior to receiving any home health care. Hospice Care Limited to 210 visits per member. Benefits include bereavement counseling. Hospital (Inpatient) $100 per day copay, $600 maximum per inpatient stay. The plan s coinsurance for hospital expenses will be reduced to 50% if you do not follow the procedures required by the Clinical Managment Program. This penalty does not apply to the outof-pocket maximum. Benefits include, but are not limited to, hospital semi-private room, miscellaneous fees, anesthesia, surgeons fees, physician visits, x-ray, lab and therapy expenses. Hospital (Outpatient) Benefits include but are not limited to outpatient surgery, physician, anesthesiology, x-ray & laboratory, and therapy expenses in a hospital or ambulatory surgical center. Hypnosis 50% 50% Limited to 6 visits per year. Maternity Hospital Subject to a $100 copay per day, $600 maximum per inpatient stay The Plan s coinsurance for hospital expenses will be reduced to 50% if you do not follow the procedures required by the Medical Management Program. This penalty does not apply to the outof-pocket maximum. Outpatient $25 for first visit only
3 COVERED HEALTH SERVICE Nutritional Counseling Limited to 6 visits/sessions per calendar year. Outpatient Therapy Benefits include physical, occupational, and speech therapy. Limited to 60 visits each per year. Physician s Office Your copay applies to the office visit only. All services performed during the visit will be considered as All Other Covered Medical Expenses or according to regular plan provisions. To locate a network provider, contact Aetna via the toll-free number or check the web site. Routine & Preventive Routine Exams Routine Exam X-Rays & Laboratory Well-Child Checkups Mammograms Routine Colonoscopy Routine Sigmoidoscopy Other Routine $0 n/a Benefits include the office visit and vaccinations, innoculations, and immunizations. Well-Child checkups are limited to 7 exams 1st 12 months; 3 exams age 13 to 24 months; 3 exams age 25 to 36 months; and 1 exam per year thereafter. Adult exams are limited to 1 exam per year. Adult exams are limited to 1 exam per year. Benefits include routine physicals, including gynecological exams and mammograms, limited to 1 age 35-39, then 1 per year age 40 and older, and digital rectal exam males age 40 and older, limited to 1 per year. Skilled Nursing Facility Limited to 60 days per year.
4 COVERED HEALTH SERVICE Spinal Treatment Limited to 20 outpatient visits per year for spinal manipulation. Surgical Treatment of Morbid Obesity Limited to 1 procedure per lifetime. Must be preauthorized by Aetna. Urgent Care & $25 Benefits are limited to urgent care only. nurgent care received at an urgent care facility is not covered. Clinical Management Program toll-free number: (877) NOTES: The word lifetime refers to the period of time you or your eligible dependents participate in this plan or any other plan funded by the Medical Trust. This benefit summary is provided for informational purposes, is not all-inclusive, and does not constitute an agreement. Additional limitations and explanations, including specific benefit maximums will be provided to eligible, enrolled members in the Plan Document Handbook. In the event of a conflict between this document and the official plan documents, the official plan documents will govern. The Episcopal Church Medical Trust retains the right to amend, terminate or modify the terms of the plan at any time, without notice and for any reason.
5 SCHEDULE OF MENTAL HEALTH/SUBSTANCE ABUSE BENEFITS CIGNA BEHAVIORAL HEALTH FOR MEMBERS ENROLLED IN THE The following schedule summarizes your mental health and substance abuse benefits, coinsurance amounts, benefit maximums, and any additional explanation needed for your benefits. Please refer to the Mental Health/Substance Abuse chapter for additional Plan provisions. All coinsurances apply to your health plan s out-of-pocket maximums. COVERED HEALTH SERVICE Outpatient Mental Health/ Substance Abuse Inpatient Mental Health/ Substance Abuse Intensive Outpatient Mental Health/Substance Abuse Employee Assistance Program (EAP) Colleague Groups $20 per visit $100 per day, not to exceed $600 per admission $150 per program, payable at admission $0 N/A There is no annual limit. All admissions must be precertified. There is no annual limit. Plan coverage is reduced to 50% if there is no precertification. Emergency room, ambulance, and lab work charges are covered by your medical plan. All programs must be precertified. There is no annual limit. Plan coverage is reduced to 50% if there is no precertification. Benefits include (but are not limited to) unlimited telephonic and work/life services, crisis intervention, referrals to community resources, legal consultations, and a large online resource library. You may also receive up to 10 face-to-face counseling sessions per issue, but they must be precertified by CIGNA Behavioral. Benefit is limited to minute sessions per calendar year. Up to 12 of the 24 sessions may be used for individual consultation. The Plan will reimburse 70% up to $40. CIGNA Behavioral Health Member Toll-Free Number: (866) Everything you discuss with your counselor or care provider is kept in the strictest confidence in accordance with applicable state and federal laws. Your employer is not notified of your visits or given specific information about your treatment without your written permission. The general health privacy and security standards of the Episcopal Church Medical Trust apply.
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