XV-2 $30/$60/$200/$1,000/80% R NEIGHBORHOOD HEALTH PARTNERSHIP POS SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to the Point of Service (POS) Plan you have with Neighborhood Health Partnership (NHP). The Summary of Benefits, although a helpful tool, is only a summary. Always refer to your Handbook for a fuller explanation of your coverage or call Customer Services at the phone number on your NHP ID Card when you have a question about your plan. In the event of a conflict between this Summary of Benefits and the Handbook, the Handbook will control. As a Member of the POS Plan, you are eligible to receive the HMO Benefit Level by accessing all of your care through your Primary Care Physician (PCP). In other words, if the health care services you receive are provided or arranged upon referral of your PCP, you are accessing your health care through your HMO Benefit Level. When obtaining Covered Services under your HMO Benefit Level, you will only be responsible for paying copayments for designated Covered Services. Important aspects of your POS Plan: In addition to direct access to certain Plan Providers under your HMO Benefit Level, you may access other health care providers without a referral from your PCP. You may access Plan Providers or Non-Plan Providers. Your Benefit Level, Deductibles, Coinsurance and Out of Pocket Maximum are affected by whether you access a Plan Provider or a Non-Plan Provider under your POS Plan. For example: If your Physician is a Non-Plan Provider, all related Covered Services will be paid at the POS Benefit Level, regardless of the status of other providers and facilities. Except for designated direct access services, when you access providers without a referral from your PCP, you are obtaining your healthcare services through the POS Benefit Level. Even when your Plan includes a POS Rider, you must select a PCP or NHP will assign one to you. If you need assístance, call Customer Services. Features Copayments Your Responsibility for Coverage When Care Is Managed By Your PCP Please note: if your Plan has a deductible, the deductible must be satisfied first unless otherwise noted below. You are also responsible for any copayments and/or coinsurance listed below. Primary Care Physician (PCP) $30 copayment per visit (Office Visit) NHP POS HSA 9/10 Rev2-1- XV2 $30/$60/$200/$1,000/80% R
Features Your Responsibility for Coverage When Care Is Managed By Your PCP Specialist (Office Visit) $60 copayment per visit Urgent Care Center $50 copayment per visit Outpatient Therapy $50 copayment per visit Inpatient Hospital $250 copayment per admission and 20% after deductible Radiology No copayment for minor diagnostics; $200 copayment for major diagnostics, including CT, MRI, MRA, PET scans and nuclear imaging Emergency Room $200 copayment per visit Allergy Testing $30 copayment per visit Deductible All benefits not subject to a copayment are subject to a calendar year deductible $1,000 per member, or $3,000 per family, whichever comes first. All individual deductible amounts will count toward the family deductible. However, an individual will not have to pay more than the individual deductible amount. Coinsurance All benefits not subject to a copayment are subject to coinsurance of 20% once the calendar year deductible is met. Out of Pocket The limit which you are your eligible family members must pay in Maximum coinsurance per calendar year is $3,000 per member. All individual Out of Pocket Maximum amounts will count toward the family Out of Pocket Maximum. However, an individual will not have to pay more than the individual Out of Pocket Maximum amount. Maximum Benefit Primary Care Referrals Prescription Drugs No Maximum Benefit. Your PCP is responsible for coordinating all your health care services, including referrals to Specialists. Your PCP or Physician Specialist must obtain Pre- Authorization for designated services including, but not limited to all inpatient care, outpatient surgical procedures, durable medical equipment (DME), home health services, home infusion, hospice care, rehabilitation, skilled nursing facility and transplant services. Your PCP is responsible for coordinating all referrals to specialists, except for the following specialties which you may access directly: Podiatry. Chiropractic. Coverage is limited to 12 visits per year. Dermatology (5 visits per calendar year). Additional visits require referrals. Gynecology Substance Use Disorders. Services must be provided by NHP s behavioral health network. Mental Health. Services must be provided by NHP s behavioral health network. Neurobiological Disorder Services Autism Spectrum Disorder. Services must be provided by NHP s behavioral health network. If your Employer has elected to provide coverage for prescription drugs, you will receive a copy of a Prescription Drug Rider which explains your prescription drug coverage. NHP POS HSA 9/10 Rev2-2- XV2 $30/$60/$200/$1,000/80% R
Your Payments When You Access Services through Your POS Plan Note: No referrals are required for POS Benefits Maximum Benefit Per Member Deductible per calendar year Per Member Per Family No Maximum Benefit $2,000 $6,000 Coinsurance For Plan Providers For Non-Plan Providers 40% 40% Out of Pocket Maximum per calendar year Per Member Per Family (Note: See page 1 for your Out of Pocket Maximum for Copayments under the HMO Benefit Level). $10,000 $20,000 NHP POS HSA 9/10 Rev2-3- XV2 $30/$60/$200/$1,000/80% R
IMPORTANT NOTICE: YOUR NHP PLAN COVERAGE Unless otherwise stated, care, services or treatment not managed by your Primary Care Physician, not Medically Necessary, or not pre-certified by NHP are not considered HMO Covered Services. HMO Services must be provided by Plan Providers, except when pre-certified or in the case of an Emergency Medical Condition. You must check your Handbook for further details relating to your coverage. Services & Supplies Ambulance Autism Spectrum Disorder limited to $36,000 per calendar year and $200,000 during the entire time covered by NHP. This benefit only applies to Large Employer Groups. Chiropractic Services limited to 12 treatments per calendar year. PCP referral is not required. Dermatology Diabetes Your Responsibility for HMO Benefits Please note: if your Plan has a deductible, the deductible must be satisfied first unless otherwise noted below. You are also responsible for any copayments and/or coinsurance listed below. 20% in emergency situations or when authorized by NHP to transfer you to a NHP facility. Covered as any other eligible service, based on place of service. Your Responsibility for POS Benefits The deductible must be satisfied. You are also responsible for any coinsurance listed below. $60 copayment per visit $60 copayment per visit PCP referral not required for 5 visits per calendar year; further visits require PCP referral. $60 copayment per visit Services include outpatient self management training and educational services. NHP POS HSA 9/10 Rev2-4- XV2 $30/$60/$200/$1,000/80% R
Services & Supplies Durable Medical Equipment (DME) and disposable medical supplies. limited to $2,500 per calendar year. Emergency Room Services Enteral Formula Family Planning Gynecology Hearing Aids limited to $2,500 per year and to a single purchase (including repair/replacement) every three years. Hearing Exams (children through age 21) Home Health Services limited to 60 visits per calendar year. Custodial care is not covered. Your Responsibility for HMO Benefits Your Responsibility for POS Benefits 20% after deductible $200 copayment per visit Any deductible and/or copayment for the emergency room is waived if the patient is admitted to the hospital. 20% after deductible Limited to $2,500 per calendar year Covered as any other eligible service, based on place of service. Limited to surgical sterilization, implantable contraceptives and intrauterine birth control devices. $60 copayment per visit PCP referral not required. Benefits paid at the HMO Benefit Level. Benefits accessed only through HMO Benefit Level. 20% after deductible No copayment when performed by PCP to determine need for hearing correction. Limited to one exam per calendar year. Benefits accessed only through HMO Benefit Level 20% after deductible NHP POS HSA 9/10 Rev2-5- XV2 $30/$60/$200/$1,000/80% R
Services & Supplies Home Infusion Services limited to 60 visits per calendar year. Hospice Care limited to a Maximum Benefit of 180 days of inpatient and/or outpatient care for a terminally ill member. Hospital Facility Care Your Responsibility for HMO Benefits Your Responsibility for POS Benefits 20% after deductible 20% after deductible Inpatient: $250 copayment per admission and 20% after deductible Outpatient: $250 copayment per visit and 20% after deductible Inpatient $250 copayment per admission and 40% after deductible Outpatient: $250 copayment per visit and 40% after deductible Minor Diagnostic/X- Ray No copayment Major Diagnostic $200 copayment per service Services, including CT, MRI, MRA, PET scans and nuclear imaging Mammogram No copayment for one baseline for women age 35 through 39, one every year for women age 40 and over or more frequently based on physician's recommendation. Mastectomy Covered as any other eligible service, based on place of service. NHP POS HSA 9/10 Rev2-6- XV2 $30/$60/$200/$1,000/80% R
Services & Supplies Maternity care, including pre- and post-natal care and delivery* Physician office services include one OB ultrasound between weeks 13 and 24 of pregnancy. Mental Health (Services must be provided by NHP s behavioral health network) Neurobiological Disorder Services Autism Spectrum Disorder Newborn Children* (birth 30 days) Organ Transplant Inpatient Services Osteoporosis Outpatient Therapies limited to 20 visits per calendar year per modality except 36 visits for cardiac therapy. These limits do not apply to Autism Spectrum Disorder for Large Employer Groups. Your Responsibility for HMO Benefits Covered as any other eligible service, based on place of service. Note: any office visit copayment applies only to the initial visit. Outpatient: $60 copayment per visit Limited to a maximum of 20 visits per calendar year. PCP referral not required. Inpatient: $250 copayment per admission and 20% after deductible Limited to a maximum of 30 days per calendar year. Outpatient: $60 copayment per visit Limited to a maximum of 20 visits per calendar year. PCP referral not required. Your Responsibility for POS Benefits Benefits accessed only through HMO Benefit Level Benefits accessed only through HMO Benefit Level Inpatient: $250 copayment per admission and 20% after deductible Limited to a maximum of 30 days per calendar year. No copayment per visit for well baby care and treatment of Illness or Injury. Covered as any other eligible service, based on place of service. Must be pre-certified by NHP Medical Director. Covered as any other eligible service, based on place of service. Limited to diagnosis and treatment of highrisk individuals. $50 copayment per visit NHP POS HSA 9/10 Rev2-7- XV2 $30/$60/$200/$1,000/80% R
Services & Supplies Physical Rehabilitation Inpatient Care limited to 60 days per calendar year for restorative physical therapy. Physician Services Podiatry Preventive Health Services Prosthetic Devices limited to one prosthetic per loss of limb or eye during the entire period of time you are covered. Skilled Nursing Facility limited to 120 days per calendar year. Your Responsibility for HMO Benefits Your Responsibility for POS Benefits 20% after deductible 20% after deductible for inpatient care or outpatient surgical services when performed in an inpatient setting or an outpatient facility. $60 copayment per visit PCP referral not required. No copayment 20% after deductible 20% after deductible Custodial care is not covered. Specialist Office Visits Sterilization $60 copayment per visit PCP referral required unless direct access is allowed, as indicated. Covered as any other eligible service, based on place of service. Reversals are not covered. NHP POS HSA 9/10 Rev2-8- XV2 $30/$60/$200/$1,000/80% R
Services & Supplies Substance Use Disorders (Services must be provided by NHP s behavioral health network) Your Responsibility for HMO Benefits Outpatient: $60 copayment per visit Limited to a maximum of 44 visits per calendar year. PCP referral not required. Inpatient: $250 copayment per admission and 20% after deductible Limited to crisis intervention for medical detoxification only. Your Responsibility for POS Benefits Benefits accessed only through HMO Benefit Level Urgent Care Center $50 copayment per visit Vision Screening (children through age 21) No copayment when performed by PCP. Limited to services necessary to determine need for vision correction and to one exam per calendar year. Benefits accessed only through HMO Benefit Level * For coverage to begin at the date of birth for newborn children, a completed and signed enrollment form must be received by NHP. When received within 30 days of birth, no additional premium will be charged for this 30 day period. When notice is received within 60 days from the date of birth, premium will be charged from the date of birth. If the enrollment form is not received within 60 days of birth, the newborn child will be considered a Late Enrollee by NHP. You must enroll your newborn within these time periods regardless of whether your coverage is family coverage. A full list and description of benefits are in your Handbook and POS Rider. Your Handbook and POS Rider also list the Exclusions, Limitations and Restrictions which apply. You have coverage for Prescription Drugs only if your Group has elected to obtain a Prescription Drug Rider. Benefit levels when accessing services through your POS plan. Plan payment when accessing services without PCP referral is as follows: When accessing a Plan Provider, plan will pay based on plan s contracted rate; when accessing a Non-Plan Provider, plan will pay based on plan s usual, customary and reasonable rate. Please note that if you access a Non-Plan Provider under your POS plan, the difference between the plan s payment of the usual, reasonable, and customary charge and the Non-Plan Provider s charge will be your responsibility. PRE-CERTIFICATION REQUIREMENTS NHP POS HSA 9/10 Rev2-9- XV2 $30/$60/$200/$1,000/80% R
Certain services require pre-certification by NHP. You are responsible for assuring that your treating physicians (Plan Providers and Non-Plan Providers) obtain the necessary pre-certifications for services and that they otherwise comply with applicable UR requirements. FAILURE TO OBTAIN PRE-CERTIFICATIONS WILL RESULT IN A 20% DECREASE IN YOUR POS BENEFIT LEVEL Pre-certification is required for any of the following services: 1. Inpatient: hospital (including observation), psychiatric, rehabilitation facility and skilled nursing facility 2. Surgery and invasive procedures: performed in an outpatient hospital or ambulatory facility (with the exception of Colonoscopies for customers 50 years of age and older and Sigmoidoscopies). 3. Implantable cardiac defibrillators, ventricular assist devices, and lung volume reduction surgery procedures, even if the inpatient admission has been authorized 4. All out of network and out of area services, except for emergencies. 5. MRI, MRA, CT Scans, PET scans 6. Sleep studies 7. Nuclear stress tests, including without limitation thallium, technetium, Cardiolite, Myoview, sestamibi; and myocardial perfusion and ejection fraction, and wall motion studies. Nuclear stress tests encompass nonpharmacological (exercise) and pharmacological stress tests, including without limitation, adenosine, persantine and dobutamine. 8. Invasive vascular studies and procedures/ep studies 9. Durable medical equipment, including insulin pumps and supplies 10. Prosthetic and orthotic devices 11. Home health care 12. Outpatient therapy: physical, occupational, speech, cardiac, and respiratory 13. Hyperbaric oxygen treatment 14. Wound care 15. Mental Health, Substance Use Disorders and Neurobiological Disorders - Autism Spectrum Disorder Services 16. Dialysis 17. Chemotherapy (chemotherapeutic agents regardless of indication), radiation therapy, transfusions, infusions 18. Chronic specialist care 19. Pain management 20. Hospice 21. Biophysical profiles and amniocentesis 22. Laboratory services 23. Ambulance service, other than emergencies 24. Genetic Testing 25. Drugs: Botox, Epogen, Procrit, Lupron 11.25 mg, Prolastin, Remicaid, Synvisc/Hyalgan, Growth Hormone, Alferon, and Mifeprex NHP POS HSA 9/10 Rev2-10- XV2 $30/$60/$200/$1,000/80% R
www.mynhp.com or call Customer Services at the phone number on your NHP ID Card NHP POS HSA 9/10 Rev2-11- XV2 $30/$60/$200/$1,000/80% R
DIRECT ACCESS RIDER As of the Effective Date, and notwithstanding anything in the Group Service Agreement ( Agreement ) to the contrary, the following Direct Access Rider is hereby made a part of the Agreement if elected by the Group and such election is evidenced in the Group s Application for Group Service Agreement. The terms used in this Rider shall have the same meaning ascribed thereto or used in the Agreement, unless otherwise stated herein. DIRECT ACCESS PROGRAM A Member with a Direct Access Rider has the right to elect to visit an NHP Specialist without a referral from the Primary Care Physician or Plan ( Direct Access Visit(s) ). Direct Access Visits are subject to the terms and conditions of the Agreement and this Direct Access Rider. All services and treatment rendered to the Member by a NHP Specialist during or in connection with a Direct Access Visit are subject to NHP s Utilization Review (UR) requirements and the Agreement, except as may be stated otherwise in this Rider. A Direct Access Visit includes services and treatment received from an NHP Specialist, so long as such services do not require pre-certification from NHP. Those services which require pre-certification under the Plan s UR requirements require pre-certification on a Direct Access Visit. NEIGHBORHOOD HEALTH PARTNERSHIP, INC. NHP POS HSA 9/10 Rev2-12- XV2 $30/$60/$200/$1,000/80% R