Schedule of s NPVR00004656 Harvard Pilgrim Health Care of New England, Inc. THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO LP - NEW HAMPSHIRE Coverage under this Plan is under the jurisdiction of the New Hampshire Insurance Commissioner. IMPORTANT INFORMATION: This policy reflects the known requirements for compliance under The Affordable Care Act as passed on March 23, 2010. As additional guidance is forthcoming from the U.S. Department of Health and Human Services, and the New Hampshire Insurance Department, those changes will be incorporated into your health insurance policy. This Schedule of s summarizes your s under The Harvard Pilgrim Best Buy Tiered Copayment HMO LP (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. Services are covered when Medically Necessary. Subject to the exceptions listed in the section of the Handbook titled, How The Plan Works all services must be (1) provided or arranged by your Primary Care Provider (PCP) and (2) provided by a Plan Provider. These requirements do not apply to care needed in a Medical Emergency. In a Medical Emergency, you should go to the nearest emergency facility or call 911 or other local emergency number. A Referral from your PCP is not needed. Your emergency room Member Cost Sharing, including your Deductible if applicable, is listed in the tables below. 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 1-888-888-4742 ext. 38723. Outpatient Surgery, Laboratory and Scopic Procedures - Outpatient Diagnostic and Therapeutic Services HPHC-NE has designated certain outpatient surgical centers, laboratory and scopic procedure facilities as Select LP Providers. These providers were chosen based on their cost efficiency and render the same quality of service at a lower cost than other providers in the network. When you receive services from a Select LP Provider, your Member out-of-pocket costs will be less than if you received the same service from providers that are not Select LP Providers. The tables set forth below list the for each type of Select LP Provider. The Plan s Provider Directory lists all Plan Providers including those providers that are Select LP Providers. You can access the Provider Directory at www.harvardpilgrim.org. You may also obtain a paper copy of the directory, free of charge by calling the Member Services Department at 1-888-333-4742. HPHC-NE establishes its list of Select LP Providers in January of each year. HPHC-NE will not remove providers from its Select LP Provider List during January through the following December of each year. HPHC-NE may also add Select LP Providers to its list any time during the year. EFFECTIVE DATE: 01/01/2017 SCHEDULE OF BENEFITS I 1
Deductible A Deductible is a specific 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. Your Deductible amounts are listed below. Your Plan may have both an individual Deductible and a family Deductible. 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 an 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. Once a Deductible is met, coverage by the Plan is subject to any other that may apply. Copayment A Copayment is a fixed dollar amount that is payable by the Member for certain Covered s. 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. 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. There are two types of outpatient Copayments that apply to your Plan. A lower Copayment, known as Copayment Level 1 and a higher known as Copayment Level 2. Copayment Level 1 applies to covered outpatient professional services 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 Licensed mental health professionals Certified midwives Nurse practitioners who bill independently Most outpatient specialty care requires payment of Copayment Level 2. 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. SCHEDULE OF BENEFITS I 2
Please Note: The Level 1 and Level 2 Copayments that apply to your Plan, and the services to which they apply, are listed in the table below. COVERED BENEFITS Your Covered s are administered on a Calendar Year basis. General Cost Sharing Features: Tiered Copayments Coinsurance and Other Copayments Deductible Deductible Rollover : Copayment Level 1: Your Plan has a $30 Copayment per visit Copayment Level 2: Your Plan has a $60 Copayment per visit See Covered s below $5,000 per Member per Calendar Year $12,000 per family per Calendar Year 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 year. Durable Medical Equipment and Prosthetic Devices Deductible $100 per Member per Calendar Year Out-of-Pocket Maximum Includes all Prior Carrier Credit $6,500 per Member per Calendar Year $13,000 per family per Calendar Year Your Plan has a Prior Carrier Credit for the first year of coverage toward the Deductible and Coinsurance that applies to your Out-of-Pocket Maximum. See Prior Carrier Credit in your Handbook for details. Acupuncture Treatment for Injury or Illness Limited to 20 visits per Calendar Year Copayment Level 1: $30 Copayment per visit Ambulance Transport Emergency ambulance transport Non-emergency ambulance transport Autism Spectrum Disorders Treatment Applied behavior analysis Copayment Level 1: $30 Copayment per visit SCHEDULE OF BENEFITS I 3
Bariatric Surgery Chemotherapy and Radiation Therapy Chemotherapy Radiation therapy Chiropractic Care 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. Limited to 12 visits per Calendar Year Copayment Level 1: $30 Copayment per visit Dental Services Important Notice: Coverage of Dental Care is very limited. Please see your Handbook for the details of your coverage. Accidental injury 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 Not covered Preventive dental care for children, Not covered only the following services are included: cleaning fluoride treatment teaching plaque control x-rays 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: www.harvardpilgrim.org. Outpatient surgery expenses for dental care Dialysis Dialysis services Installation of home equipment is covered up to $300 in a Members lifetime Durable Medical Equipment 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 day surgery, see Surgery Outpatient. Durable medical equipment Durable Medical Equipment and Prosthetic Devices Deductible, then 20% Coinsurance Blood glucose monitors, infusion devices and insulin pumps (including supplies) Oxygen and respiratory equipment SCHEDULE OF BENEFITS I 4
Early Intervention Limited to $3,200 per Member per Calendar Year, up to $9,600 per lifetime Emergency Room Care Gender Reassignment Surgery Hearing Aids Limited to $1,500 per hearing aid every 60 months, for each hearing impaired ear Home Health Care Copayment Level 1: $30 Copayment per visit Deductible, then $250 Copayment per visit This Copayment is waived if admitted to the hospital directly from the emergency room. 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. Please Note: If your Home Health Care services include the administration of drugs, please see the benefit for Medical Drugs for details. Hospice - Outpatient Hospital Inpatient Services 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 inpatient rehabilitation care Infertility Services and Treatments The Plan covers the following diagnostic services for infertility: Consultation Evaluation Laboratory tests Infertility treatment (see the Handbook for details) Copayment Level 1: $30 Copayment per visit Copayment Level 2: $60 Copayment per visit Not covered SCHEDULE OF BENEFITS I 5
Laboratory and Radiology Services Laboratory Select LP Providers Other Plan Providers X-rays Advanced radiology CT scans PET scans MRI - MRA Nuclear medicine services 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: www.harvardpilgrim.org. Low Protein Foods Limited to $1,800 per Member per Calendar Year Maternity Care Outpatient Routine outpatient prenatal and postpartum care Cost sharing may apply to prenatal ultrasounds when billed as a specialized or non-routine service. See Laboratory and Radiology Services for your applicable. 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. Medical Drugs (drugs that cannot be self-administered) Medical drugs received in a doctor s office or other outpatient facility Coverage may also be provided under the Specialty Pharmacy Program. Please see your Prescription Drug Brochure for details. Medical drugs received in the home Coverage may also be provided under the Specialty Pharmacy Program. Please see your Prescription Drug Brochure for detaiis. Please Note: You may also have the Plan s outpatient prescription drug coverage. That benefit provides coverage for most prescription drugs purchased at an outpatient pharmacy. Some medical drugs received in a physician s office or outpatient facility may be provided by the Specialty Pharmacy Program under your outpatient prescription drug benefit. If you have outpatient prescription drug coverage, your Member Cost Sharing will be listed on your ID Card. Please see the Prescription Drug Brochure, included in your Member Kit, for a detailed explanation of your benefits. Medical Formulas SCHEDULE OF BENEFITS I 6
Mental Health and Drug and Alcohol Rehabilitation Services Inpatient Services Mental health services Drug and alcohol rehabilitation services Detoxification services Partial Hospitalization Services Partial hospitalization for mental health and drug and alcohol rehabilitation Outpatient Services Group therapy Mental health services $10 Copayment per visit Drug and alcohol rehabilitation Individual therapy services Copayment Level 1: $30 Copayment per visit Detoxification services Copayment Level 1: $30 Copayment per visit Medication management Copayment Level 1: $30 Copayment per visit Methadone maintenance $30 Copayment per week Psychological testing Copayment Level 1: $30 Copayment per visit evisits Ostomy Supplies Durable Medical Equipment and Prosthetic Devices Deductible, then 20% Coinsurance Physician and Other Professional Office Visits (This includes all covered Plan Providers unless otherwise listed in this Schedule of s) Routine examinations for preventive care, including immunizations Consultations, evaluations, sickness Copayment Level 1: $30 Copayment per visit and injury care Copayment Level 2: $60 Copayment per visit Treatment and procedures including but not limited to: Casting, suturing and the application of dressings Non-routine foot care Surgical procedures Administration of allergy injections $5 Copayment per visit evisits Preventive Services and Tests 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: www.harvardpilgrim.org. You may also (Continued on next page) SCHEDULE OF BENEFITS I 7
Preventive Services and Tests (Continued get a copy of the Preventive Services Notice by calling the Member Services Department at 1 888 333 4742. 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 U.S. Department of Health and Human Services at: www.healthcare.gov/what-are-my-preventive-care-benefits/#part=1. Harvard Pilgrim 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 www.harvardpilgrim.org. Prosthetic Devices Durable Medical Equipment and Prosthetic Devices Deductible, then 20% Coinsurance Rehabilitation Therapy - Outpatient Cardiac rehabilitation Pulmonary rehabilitation therapy Occupational, physical and speech therapy limited to 60 visits combined per Calendar Year Please Note: Outpatient physical, occupational and speech therapies are covered to the extent Medically Necessary for children under the age of three. Scopic Procedures - Outpatient Diagnostic and Therapeutic Colonoscopy, endoscopy and sigmoidoscopy Copayment Level 1: $30 Copayment per visit Copayment Level 2: $60 Copayment per visit Copayment Level 2: $60 Copayment per visit Select LP Providers $100 Copayment per visit Other Plan Providers Please Note: No applies to certain preventive care services, including screening colonoscopies. For a list of covered preventive services, please see the Preventive Services Notice on our website at: www.harvardpilgrim.org Surgery Outpatient Select LP Providers $100 Copayment per visit Other Plan Providers Telemedicine Outpatient and inpatient telemedicine services 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. SCHEDULE OF BENEFITS I 8
Urgent Care Services Convenience care clinic Copayment Level 1: $30 Copayment per visit Urgent care clinic $60 Copayment per visit Hospital urgent care clinic Deductible, then $75 Copayment per visit Please Note: Additional may apply. Please refer to the specific benefit in this Schedule of. For example, if you have an x-ray or have blood drawn, please refer to Laboratory and Radiology Services. Vision Services Routine eye examinations limited to Copayment Level 1: $30 Copayment per visit 1 exam per Calendar Year Vision hardware for special conditions (see the Handbook for details) Voluntary Sterilization 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. 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: www.harvardpilgrim.org. Voluntary Termination of Pregnancy 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 Services. Wigs and Scalp Hair Prostheses as required by law Visits. For inpatient hospital care, see Hospital Inpatient See the Handbook for details Durable Medical Equipment and Prosthetic Devices Deductible, then 20% Coinsurance SCHEDULE OF BENEFITS I 9