CAPE COD MUNICIPAL HEALTH GROUP IMPORTANT - PLEASE READ The attached benefit comparison chart is a high level overview of the plans offered by CCMHG. The plan documents available to registered users on the carrier websites are the documents that describe full and complete The carrier documents are the only documents that coverage is based on. Should you have a question about specific coverage, you will need to contact the Member Service number on your ID card for detail or visit the carrier website.
Deductible - applies to: In-patient Admission; Out-patient Surgery; ER, High Tech Imaging (MRI, CT, & PET) and Diagnostic Tests & Procedures. Does not apply to routine office visits or pharmacy. Per plan year (July 1 to June 30) - See plan document for full details $250 per member $250 per member $400 per member $250 per member $250 per member $250 per member $400 per member $750 per family $750 per family $800 per family $750 per family $750 per family $750 per family $800 per family Out-of-Pocket (OOP) $2,000 per member $2,000 per member $3,000 per member $2,000 per member $2,000 per member $2,000 per member $3,000 per member Maximum - Once your out-ofpocket $4,000 per family $4,000 per family $4,000 per family $4,000 per family $4,000 per family expenses for applicable services reaches this amount, you pay $0 for remainder of plan year. NOTE: Prescription co-pays do not count towards the coinsurance maximum. Lifetime Benefit Maximum INPATIENT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY General Hospital/Mental Hospital/Substance Abuse Facility (semi-private room and board and special services) - for emergency/accident s $700 per Physician Services for emergency/accident s Skilled Nursing Facility to 100 days to 100 days to 100 days per calendar year benefit maximum Limit to 100 days per per Limit to 100 days per per Rehabilitation Hospital to 60 days to 60 days to 60 days per calendar year benefit maximum Limit to 60 days per per Limit to 60 days per per 2
OUTPATIENT HOSPITAL YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Emergency Room Visits for Emergency or Accident Care - $100 (waived if for first treatment of accident; $100 for emergency medical care Emergency Room Visits for Medical Care - $100 (waived if $100, waived if admitted Surgery - $150 $150 $150 $150 $150 Radiation and Chemotherapy Deductible Applies Diagnostic X-ray and Lab - Routine Colonoscopy (without surgery) $0 $0 $0 $0 $0 High Cost Radiology (MRI, CT & PET) - $100 $100 $100 $100 $100 Hemodialysis - $0 $0 $0 $0 $0 Physical Therapy to 60 visits to 100 visits per calendar year to 100 visits per calendar year $20 Physician Office $20 Hospital Setting Copay Level 1 : $20 per visit, 30 visits per Plan Year Copay Level 1 : $20 per visit, 30 visits per Plan Year PHYSICIAN'S OFFICE YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Surgery - $20/35 co-pay $20/35co-pay $20 co-pay NO DEDUCTIBLE Copay Level 1 provider : per visit Copay Level 2 provider : $35 per visit Copay Level 1 provider : per visit Copay Level 2 provider : $35 per visit 3
PHYSICIAN'S OFFICE YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Adult Preventative Exam $0 $0 $0 $0 $0 (includes preventative lab tests) PCP Medical Care/ Mental Health Care/ Substance Abuse Care Well Child Care $0 $0 $0 (includes preventative lab tests) Routine GYN Exam ( one per calendar year, includes preventative lab tests) $0 $0 $0 Copay Level 1 :$20 $0 (including routine physical exams, immunizations, school, camp, sports) $0 $0 Copay Level 1 :$20 $0 (including routine physical exams, immunizations, school, camp, sports) Routine Mammogram $0 $0 $0 $0 $0 Routine Vision Exam year) Charge Charge Specialist Office Visit $35 $35 Copay Level 2 : $35 Copay Level 2 : $35 OTHER OUTPATIENT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Visiting Nurse Home Health Care Durable Medical Equipment - $0 (once every 12 months), plan pays 80% with $0 (once per calendar year), plan pays 80% with (once per calendar member pays 40%, plan pays 60% with $0 ( once every 24 months) Limited 1 visit per Plan Year - No until member has paid $1,000 out of pocket, then plan pays in full. Wigs are covered in full when needed as a result of any form of cancer, leukemia, alopecia areata, alopecia totalis, or permanent hair loss due to injury. Limited 1 visit per Plan Year - No until member has paid $1,000 out of pocket, then plan pays in full. Wigs are covered in full when needed as a result of any form of cancer, leukemia, alopecia areata, alopecia totalis, or permanent hair loss due to injury. coinsurance. Ambulance- for accident or emergency; 20% coinsurance* other medically necessary ambulance transport 4
NETWORK BLUE HMO In-Network Out-of-Network Indemnity Plan HPHC HMO Routine Pediatric Dental (through age 11) Covered in full: Preventive care for children under age 12 2 visits per member per plan year including exam, cleaning, x-rays, & flouride treatment. Covered in full: Preventive care for children under age 12 2 visits per member per plan year including exam, cleaning, x-rays, & flouride treatment. Chiropractor Visits Prescription Drugs Retail: (30 day supply) Retail: (30 day supply) Retail: (30 day supply) Retail: (30 day supply) Retail: (30 day supply) Retail: (30 day supply) Retail: (30 day supply) Tier 1: $10.00 Tier 1: $10.00 Tier 1: $10.00 Tier 1: $10.00 Tier 1: $10.00 Tier 1: $10.00 Tier 1: $10.00 Tier 2: $25.00 Tier 2: $25.00 Tier 2: $25.00 Tier 2: $25.00 Tier 2: $25.00 Tier 2: $25.00 Tier 2: $25.00 Tier 3: $50.00 Tier 3: $50.00 Tier 3: $50.00 Tier 3: $50.00 Tier 3: $50.00 Tier 3: $50.00 Tier 3: $50.00 Tier 1: $20.00 Tier 1: $20.00 Tier 1: $20.00 Tier 1: $20.00 Tier 1: $20.00 Tier 1: $20.00 Tier 1: $20.00 Tier 2: $50.00 Tier 2: $50.00 Tier 2: $50.00 Tier 2: $50.00 Tier 2: $50.00 Tier 2: $50.00 Tier 2: $50.00 Tier 3: $110.00 Tier 3: $110.00 Tier 3: $110.00 Tier 3: $110.00 Tier 3: $110.00 Tier 3: $110.00 Tier 3: $110.00 Fitness Benefit reimbursement toward membership or exercise classes at a health club. See plan details. receive up to $150 per calendar year toward your program fees. reimbursement toward membership or exercise classes at a health club. See receive up to $150 per calendar year toward your program fees. reimbursement toward membership or exercise classes at a health club. See receive up to $150 toward your program fees. Non-formulary drugs No Fitness Benefit calendar year. Must be an active member of HPHC for at least 4 months and a member of any qualified health & calendar year. Must be an active member of HPHC for at least 4 months and a member of any qualified health & calendar year. Must be an active member of HPHC for at least 4 months and a member of any qualified health & *After Deductible 5