TN Insurance Bulletin (1993-07-08)
TN Insurance Bulletin (1993-07-08): Basic and Standard Health Care Plans
NED McWHERTER
QOVEIINOII
TO:
FROM:
RE:
DATE:
STATE OF TENNESSEE
DEPARTMENT OF COMMERCE AND INSURANCE
LEGAL SERVICES
500 JAMES ROBERTSON PARKWAY
VOLUNTEER PLAZA BUILDING. FIFTH FLOOR
NASHVILLE, TENNESSEE 37243
B U L L E T I N
All Tennessee Small Employer Carriers
Elaine A. McReynolds
f1 11 .. v1
Commissioner
'{j()/VYI
Basic and Standard Health Care Plans
July 8, 1993
ELAINE A. McREYNOLDS
COMMISSIONER
Enclosed is a copy of the July 1, 1993 Order approving the
basic and standard health care plans for insurance and for HMOs.
Also enclosed are the plans including modifications specified in
the Order.
Pursuant to Tennessee Code Annotated Section 56-7-
2208 every small employer carrier shall offer at least one (1)
basic and one (1) standard health care plan by January 1, 1994 . .
Based on both oral and written comments received by the
Department some clarification is necessary.
Neither the basic
nor the standard benefit plans (non-HMO) list benefits for inhospital
items
such
as
physician
charges,
in-patient
miscellaneous hospital charges and prescription drugs.
However,
these plans are basically major medical plans with certain
specified limitations and exceptions.
It is not possible to list
all the covered in-hospital charges in a major medical policy.
It is intended that these plans pay the ordinary in-hospital
charges up to the coverage limits.
The Department is concerned that there not be abuses in the
area of the usual and customary charges and we will require that
all small employer carriers file, along with their rates, the
bases used for determining their usual and customary charges.
In
addition, the Department will also be requiring that carriers
file
the
bases
used
for
their
setting
of
standards
for
experimental treatments.
The goal of these additional filings is
the standardization of procedures used by the Department in the
evaluation of complaints under the Unfair Trade Practices Act.
Further bulletins or notices may be issued from time to
time if the need arises to clarify other aspects of the plans.
Please direct questions regarding the plans to the Actuarial
Section.
EAM:JL:MC
Enclosures
. .
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NED McWHIIITlll
OOVI~MOII
STATI OP: T!NNISSII
DEPARTMENT OF COMMERCE AND INSURANCE
LEGAL SERVICES
500 JAMIS AOI!JIITSON PAIIKWAY
VOlUNTE!II PUlA IUILDINO. Fl~ ftLOOII
NASHVILLE. T£NNISSll 312~
IN THE MATTER OF:
I!LAINI A. McRIYNOLOS
:OMMIUIONI"
TENNESSEE SMALL EMPLOYER GROUP
HEALTH COVERAGE REFORM ACT
CONSIDERATION OF BASIC AND
STANDARD HEALTH CARE PLANS
Docket No.:
93-19
Pursuant to Tennessee Code Annotated Section 56-7-2208(b) a
public hearinq was held by the Commissioner of the Department of
Commerce ana Insurance to consider whether to either approve,
modify or disapprove the basic ana standard health care plans
submitted ana recommended by the Tennessee Small Employer Carrier
Committee in accordance with Tenneasee Code Annotated Section-56-
7-2208(a).
Under
consideration
at
the
follow in; a
hearinq
were
the
1.
The proposed basic health care plan as contained in
the report of the basic plan sub-committee~
2.
The proposed standard health care plan as contained
in the report of the standard plan sub-committee~
3.
The proposed HMO plans as contained in the report
of the HMO sub-committee.
Based on a careful review of the plans submitted and the
comments presented both at the hearinq and followinq the hearing
it is decided that the plans should be approved with the
tollovinq DOdificationsa
1.
In both the basic and standard insurance plans
number 8 of the listed exclusions shall read, "for experimental
treatment, includinq treatment with nev druqs or technological
medical device• which are experimental in natura~·
2.
In the standard insurance plan number 19 of the
listed exclusions shall read, ·for inpatient private duty nursinq
care;·
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3.
In both the basic and standard insurance plans
number 21 .of the listed exclusions shall read, "in connection
with the care of a pre-existing condition as defined in t he
contract; •
It is
therefore
ORDERED
that
the
health care
plans
submitted pursuant to Tennessee Code Annotated Section 56-7-
2208(a) are APPROVED as modified herein.
This fd:.. day ofs~~~~~--
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Beneflts
Overall ~tuimum
Benefit Percenta1e
• Non·PPO
• PPO
Note: Son-PPO Plan !-tius1
Be Offe~ Bven I!
Insur=r Offers PPO Plan
in the Area.
Dcduaible
• Benefit Perio<l
• Comprehensive Limit
• !mcr1ency Room
• Canyover Credit
• Family LinUt
• Waiver
Out-of·Pocket Limics
• Insured
• Family
Basic Plan
Standarcl PlAn
Annual: SlOO,OOO per
Lifetime: Sl,OOO,CCO
Insured
~r I.ruured
• 601
• In-Network: Not Oreater
than 60~
Out.of-Netv.'ork: Not
Oreater than SO" Nor Less
than 40 ~
• Calendar Year
• 5300 per Insured
• S$0 pet Visit, Waived
When Admitted
• Not Covered
• 3 Oeductiblea per family
• No Deductible and 100 95
Payme& on Pint Pren&W
Visit if Within 3 Montbs
after Conc~on
• $6,000 per Year (Plus
5300 Oe.ductible)
• Sl2,000 per Year (Plus
Oeductibles to 5900)
• PPO: Out-of-Necwork u
Dbcmion of IDaurer,
Subject to Dep&mnent ot
Insurance's Approval.
• 80,
• ln·NtrNork: Not
Gxuter than SO~
Out-of-Netv.'ork: Sot
:
Greater than 70%
'
Nor Less than 50%
1
• Same u Basic Plan
• S$ 00 per Insured
• Same as Basic Plan
• Same u Basic Plm
• Same u Buic Pl&n
• Same II lute Plan
'
• Sl,500 per Yw (Ptus \
$500 Deductible)
,
• S5 ,000 per Year (Plus 1
Otductiblas to S 1 ,SCO) 1
• PPO: Same as Basic
PliA
•
~entive Care
• Annual Maximum Umic
• Well Baby Clio and
Immunizatloaa
• Routine Phy sie&l ·
Examination
• Routine
Diarnosti~
Procedures
·Pap Smears
• Mammornphy
· ~ .
-
. 1. ·
..
. ~-
·.:~
•
~,.. 4
•
•
~.:_ ... _.
...
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Hospital Room. and Board
Intensive Cm Ua.ic
Extended Care FacwLy
• Payment R.uo
• Maximum Limit
Maternity
.
. . . .
. .
...
. .
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~:i.k;i>ll-'f.!.lli< ..:-· . -
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Not Covereci
I
• 5100 per Insured
I
• 1 00 " of Providu' s
I
R.auoD&blo Cba:Jo
\
• 100' of Provider's
I
Reasonable Cbuae:
i
Limited to Geneftl Hwth
j
Cb~kupt, X·R&ys, Blood
I
Pressure Checks, Urine
I
Tuu, Tubcrculcw Teats,
!
Routine Di&rnottic Tests,
Coloa Etxams, Proswe
I
E.xams, and Rectal Exams
l
• A&o 0·39: Oace Bvery
' I
· Tbree Years
I
Aao 4()..54: Once Evuy
I
Two Yeua
Age SS+: Once/Year
I
·One per Insuroe per Year
i
-Limited to Female
Insureds:
Ago 35·39: 0Dce
Aae 40-49: ODcc/Year or
Aa ~mmen<1ed by
Ooctor
Aao SO+: Once/Yw
i
A. veraae Semi·Privue Rate
Same u Buic Plan
i
l
Raasonable &c Customary
S&me u Buic Plan
I
l
• SO~ of A venae Semi·
• Samt u Bast; Plan
I
Privace Rate &l Hospital
I
ot Prior Confltlemeat
l
• 100 Days
• Same 11 Buk Plan
i
Len thaD 10 2mployeca:
Same u Basic Pl.a.n
I
51,500
I
10 or More Employees: AJ
I
Any Other IllDeu
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Meatal/Nervous/ Alcoholism/DNI Abuae
• uted.me MaXimum
• Iaparient
• Outpatient
• Maximum CharaoiVisit
• Number of Visits/Yea:
Private Duty Nunin1
• Inpatient
• Outpatient
• Calead&r Year L.iznit
• Lifetime Maximum
OrpA Transplant
• Lifetime Maximum for
Same Type of Orpn
• Coveted Cha.r1es
Ouq,uilnt Physical
Ther&py
• Maximum Chi:JeiVisil
• I of Treacmenu/Ycu
Skelew Adjusunea&/
AdjUAC:tive Tbenpy/
Venlb~ Ma.nipulauoa/
Dislocation·Subluxaaoo
Services
Not Covered
Not Covereci
• $.50,000
• Initial TMtinl & Oiagno'is
• Immunosuppressant Dru1
Therapy before & after
suraery
• Complicatiooa Resultinl
from Suraery, Orptl
R.ej ec:tionl P lilure
• Any R.tpat Transpl&Ats of
same~ ot Orau
Noc Covered
Not Covered
I
I
I
• $10,000 per Insured
I
• Paid at ~0'1, Subject
I
only to Lifetime
I
Maximum on
I
Mont&l/Nervous
• Covered
I
• '0' \\lith I
!
Muimwn Covered
I
Chuae of $60
I
(530 Maximum
I
BeaefiO
I
• 30
I
I
'
• Not Covered
\
• Covcrec:1
• S2.~00 per Insure4
\
• SlO,OOO per Insurw
• $100,000
• S arne u Basic Pla.n
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I
I
I
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• 50 I 'lt'ith a Muimum I
Covered Cb&rae of
I
S40 ($20 Mu.imum
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BeGd\0
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• 20
Llmitld???
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TENNESSEE BASIC PLAN
LIMITATIONS
Benefits for expenses for care or treatment related to an organ
transplant are limited.
The benefits are limited to the extent
shown in the Schedule of Insurance.
The limit applies to all
Covered
Expenses
relating to
the
organ
being
transplanted
including charges for:
1.
initial testing and diagnosis;
2.
immunosuppressant drug therapy before and subsequent to the
surgery, no matter how long after the surgery;
3.
complications resulting from the surgery, organ rejection
or failure, whether current or anticipated; and
4.
any repeat transplants of the same type of organ.
(The following limitation applies to employers with less than 10
employees).
Benefits
for
expenses
for care or treatment related to
a
pregnancy, other than expenses for complications of pregnancy,
are limited.
The benefits are limited to the extent shown in the
Schedule of Insurance.
Services or supplies obtained through the laws or regulations of
a government will be deemed Covered Expenses only to the extent
that a charge is made that the patient is legally required to
pay.
Government
includes
the
government
of
a
state,
commonwealth, territory, province or a political division of
them.
It also includes an agency of a state or local government.
Only certain charges for, or related to, treatment or operations
to improve appearance will be Covered Expenses.
They will be
deemed to be Covered Expenses only if they are for:
1.
repair of disfigurement due to an accident which occurs
while the patient is insured and the treatment begins
within ninety days after the accident; or
2.
correction of a birth defect.
EXCLUSIONS
Benefits will not be paid for charges:
1.
for, or in connection with, the care or treatment of an
injury or sickneaa due to war or an act of war, declared or
undeclared;
2.
for medical services or supplies if no charge would have
been made if the patient did not have this insurance;
3.
for
the
care
or
treatment
of
an
injury
that
is
intentionally self-inflicted, while sane or insane;
l
...
4 .
5 •
6.
7 •
8 .
9.
10.
11.
12.
13.
14.
15.
16.
17.
.
. .. .
for the care or treatment of
an injury due to the
commission of, or an attempt to commit, an assault or a
felony or an injury or sickness incurred while engaging in
an illegal act or occupation;
for the care or treatment of an injury or sickness due to
voluntary participation in a riot;
for custodial or sanitarium care or rest cures;
for treatment in a facility, or part of a facility, that is
mainly a
place for:
(a) rest;
(b)
convalescense;
(c)
custodial care; (d) the aged; (e) rehabilitation; or (f)
training, schooling or occupational therapy;
for experimental treatment, including treatment with new
drugs
or
technological
medical
devices
which
are
experimental in nature;
for testing eyesight or purchase or fitting of glasses,
contact lenses (except following cataract surgery), hearing
aids, corrective shoes, or other corrective devices or
appliances;
for exams or tests for check-up purposes that are not for
the treatment of injury or sickness except as provided for
in the Schedule of Benefits;
for dental work or treatment which includes hospital or
professional care in connection witht
(a)
an operation or treatment for the fitting or
wearing of dentures;
(b)
orthodontic care or treatment of malocclusion; and
(c)
operations on or treatment of or to the teeth or
supporting tissues of the teeth except for:
(1)
removal of malignant tumors and cysts; or
(2)
treatment of an injury to natural teeth due
to an accident (other than an accident
occurring while, and as a result of eating
or chewing) if the accident occurs while
the patient is insured and the treatment is
received within twelve months after the
accident;
for treatment or surgery for obesity, weight reduction or
weight control;
for orthomolecular therapy including nutrients, vitamins
and food supplements;
for radial keratotomy,
myoptic
keratomileusis
and
any
surgery which involves corneal tissue for the purpose of
altering, modifying or correcting · myopia,
hyperopia or
stigmatic error;
for treatment of weak, strained or flat feet, including
orthopedic shoes or other supportive devices,
or for
cutting, removal or treatment of corns, callouses or nails,
other than with corrective surgery, or for metabolic or
peripheral vascular disease;
for lifestyle improvements, including smoking cessation,
nutrition counsellinq or physical fitness programs;
for speech therapy, except to restore speech abilities
which were lost due to injury or sickness;
2
. . -
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· . '
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18.
for, or in connection with, home health care;
19.
for inpatient or outpatient private duty nursing care;
20.
for the correction of, or complications arising from,
trea~ment or an operation to improve appearance if the
original treatment or operation either was not a Covered
Expense under the group policy or would not have been a
Covered Expense if the patient had been insured;
21.
in connection with the care of a pre-existing condition as
defined in the contract;
22.
due to
a
sickness for which the patient can receive
benefits under a workers' compensation act or similar law;
23.
due to an injury that arises out of or in the course of a
job or employment for pay or profit;
24.
for
pre-conception
testing
or
genetic
testing;
for
artificial insemination or an implant procedure to induce
pregnancy; for in vitro fertilization; for a procedure to
reverse a surgically performed sterilization; or for a sex
change;
25.
for treatment that is not medically necessary for the care
of an injury or sickness except as provided in the Schedule
of Benefits; or
26.
to the extent that they are more than either: (a) the
customary charge made by the provider for the treatment
furnished, or (b) the general level of charges made by
others in the same locality for such treatment.
If the
amount of the customary charges or the general level of
charges for a service cannot be determined due to the
unusual nature of the service,
XYZ will determine the
amount.
XYZ will take into account:
(a) the complexity
involved; (b) the degree of professional skill required;
and (c) other pertinent factors;
27.
for inpatient and outpatient psychiatric care, alcoholism
and drug addiction;
28.
for physical therapy if treatment is received while the
patient is not confined to a hospital as a bed patient;
29.
for skeletal adjustments,
adjunctive therapy, vertebral
manipulation and services for the care or treatment of
dislocations or subluxation& of a vertebrae;
30.
for treatment for Temporomandibular Joint Dysfunction (TMJ)
and Crainiomandibular Pain Syndrome (CPS), except surgical
services for TMJ and CPS are covered, but only if medically
nece11ary and there is clearly demonstrable radiographic
evidence of joint abnormality due to illness or injury.
3
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. ·~ .
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TENNESSEE STANDARD PLAN
LIMITATIONS
Benefits payable for the charges for the care of mental or
nervous conditions and alcoholism and drug addiction are limited.
They are limited to the extent
shown
in the Schedule of
Insurance.
Charges for physical therapy that are Covered Expenses may be
limited.
They will be limited if they are made for treatment
received while the patient is not confined to a hospital as a bed
patient.
The charges will be deemed Covered Expenses only to the
limited extent shown in the Schedule of Insurance.
Charges of a doctor for skeletal adjustment, adjunctive therapy,
vertebral manipulation and services for the care or treatment of
dislocations of subluxations of the vertebrae that are Covered
Expenses may be limited.
They will be limited if they are made
for treatment received while the patient is not confined to a
hospital as a bed patient.
The charges will be deemed Covered
Expenses only to the limited extent shown in the Schedule of
Insurance.
Benefits for expenses for care or treatment related to an organ
transplant are limited.
The benefits are limited to the exten~
shown in the Schedule of Insurance.
The limit applies to all
Covered
Expenses
relating to
the
organ
being
transplanted
including charges for:
1.
initial testing and diagnosis~
.
2.
immunosuppressant drug therapy before and subsequent to the
surgery, no matter how long after the surgery~
3.
complications resulting from the surgery, organ rejection
or failure, whether current or anticipated~ and
4.
any repeat transplants of the same type of organ.
(The following limitation applies to employers with less than 10
employees. )
Benefits
for
expenses
for care or treatment related to
a
pregnancy, other than expenses for complications of pregnancy,
are limited.
The benefits are limited to the extent shown in the
Schedule of Insurance.
Services or supplies obtained through the laws or regulations of
a government will be deemed Covered Expenses only to the extent
that a charge is made that the patient is legally required to
pay.
Government
includes
the
government
of
a
state,
commonwealth, territory, province or a political division of
them.
It also includes an agency of a state or local government.
-~
Only certain charges for, or related to, treatment or operations
to improve appearance will be Covered Expenses.
They will be
deemed to be Covered Expenses only if they are for:
1.
2 .
repair of disfigurement due to an accident which occurs
while the patient is insured and the treatment begins
within ninety days after the accident; or
correction of a birth defect.
EXCLUSIONS
Benefits will not be paid for charges:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
for, or in connection with, the care or treatment of an
injury or sickness due to war or an act of war, declared or
undeclared;
for medical services or supplies if no charge would have
been made if the patient did not have this insurance;
for
the
care
or
treatment
of
an
injury
that
is
intentionally self-inflicted, while sane or insane;
for
the care or treatment of
an
injury due
to the
commission of, or an attempt to commit, an assault or a
felony or an injury or sickness incurred while engaging in
an illegal act or occupation;
for the care or treatment of an injury or sickness due to
voluntary participation in a riot;
for custodial or sanitarium care or rest cures;
for treatment in a facility, or part of a facility, that is
mainly
a
place for:
(a)
rest;
(b)
convalescence;
(c)
custodial care; (d) the aged; (e) rehabilitation; or (f)
training, schooling or occupational therapy;
for experimental treatment, including treatment with new
drugs
or
technological
medical
devices
which
are
experimental in nature;
for testing eyesight or purchase or fitting of glasses,
contact lenses (except following cataract surgery), hearing
aids, corrective shoes, or other corrective devices or
appliances;
for exams or tests for check-up purposes that are not for
the treatment of injury or sickness;
for dental work or treatment which includes hospital or
professional care in connection with&
(a)
an operation or treatment
for the fitting or
wearing of dentures;
(b)
orthodontic care or treatment of malocclusion; and
(c)
operations on or treatment of or to the teeth or
supporting tissues of the teeth except for:
(l)
removal of malignant tumors and cysts; or
(2)
treatment of an injury to natural teeth due
to an accident
(other than an accident
occurring while, and as a result of eating
or chewing) if the accident occurs while
-. ·:·- .
-
. :
.
.
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- .• I
.~: ..
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the patient is insured and the treatment is
received within twelve months after the
accident;
12.
for treatment or surgery for obesity, weight reduction or
weight control;
13.
for orthomolecular therapy including nutrients, vitamins
and food supplements;
14.
for radial
keratotomy,
myoptic
keratomileusis
and
any
surgery which involves corneal tissue for the purpose of
altering, modifying or correcting myopia,
hyperopia or
stigmatic error;
15.
for treatment of weak, strained or flat feet, including
orthopedic
shoes or other supportive devices,
or for
cutting, removal or treatment of corns, callouses or nails,
other than with corrective surgery, or for metabolic or
peripheral vascular disease;
16.
for lifestyle improvements, including smoking cessation,
nutrition counselling or physical fitness programs;
17.
for speech therapy, except to restore speech abilities
which were lost due to an injury or sickness;
18.
for, or in connection with, home health care;
19.
for inpatient private duty nursing care;
20.
for the correction of, or complications arising from,
treatement or an operation to improve appearance if the
original treatment or operation either was not a Covered
Expense under the group pol icy or would not have been a
Covered Expense if the patient had been insured;
21.
in connection with the care of a pre-existing condition as
defined in the contract;
22.
due to
a
sickness
for which the patient can receive
benefits under a workers' compensation act or similar law;
23.
due to an injury that arises out of or in the course of a
job or employment for pay or profit;
24.
for
pre-conception
testing
or
genetic
testing;
for
artificial insemination or an implant procedure to induce
pregnancy; for in vitro fertilization; for a procedure to
reverse a surgically performed sterilization; or for a sex
change;
25.
for treatment that is not medically necessary for the care
of an injury or sickness; or
26.
to the extent that they are more than either: (a) the
customary charge made by the provider for the treatment
furnished, or (b) the general level of charges made by
others in the same locality for such treatment.
If the
amount of customary charges or the general level of charges
for a
service cannot be determined due to the unusual
nature of the service, XYZ will determine the amount.
XYZ
will take into account: (a) the complexity involved, (b)
the degree of professional skill required, and (c) other
pertinent factors.
3
; ~ ;-:~:c - ·. ' - ~_-_'it:;
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~:
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for treatment for Temporomandibular Joint Dysfunction (TMJ)
and Crainiomandibular Pain Syndrome (CPS), except surgical
s~rvices for TMJ and CPS are covered, buy only if medically
necessary and there is clearly demonstrable radiographic
evidence of joint abnormality due to illness or injury .
- • ..... 1
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BASIC
SCOPE OF BENEFITS ·
I
ALL CARE MOST BE RENDERED OR REFERRED BY THB PRIMARY CARE PHYSICIAN FOR
THE CHARGES TO BE PAID BY THIS HEALTH CARE PLAN.
~~~~~~1r~ (subject to conaitiona & exclusion•
listed elaewhere)
INPATIENT HOSPITAL SEaVICZS
SSOO deductible per aamiasion not to exceed SO\ of chargee
PLAN PAYS
Room ana Boara •............•......•......... . ..••........ •SO\ Semi-Privat•
Len;th of Stay .•.....•...••.......... . ..•••••.••.•.•..•.. Unlimited
Chargee other than room ana boara ..•..•..•....•...•..••.. *80\
INPATIENT HOSPITAL PHYSICIAN SEaVICES
Any eervicee renaerea by the Primary Care
Phyeician or by a Consultant when referred
by the Primary care Physic ian. . . . . . . . . . • . . . . • • • . . . • . . . • • • 100\
OUTPATIENT SUKOEaY PHYSICIAN SEaVICZS ......•.•.•.....•..... 100\
EMERGENCY aOOM SBaVICZS •........•.•..•.••.•••••••••••••••.. *80\ after SSO.OO Copay
INPATIENT PRIVAr. DUTY KUaSING
When medically neceeeary ana authorized
by thia Plan•• Medical Oirector .•.•••.•..•..••.•..•...•.. •SO\
OU'l'PATIEN'l' HOSPITAL SEJt.VI CKS •.••...•••.•••••...••••.•••.••. * 80\
Incluain; Ambulatory Surgical Center•
MEDICAL OFFICB VISITS ......•••.•.••.....•..•....•.••..•.•.. 100\ after $15.00 Copay
PREVENTIVW BEALTB szaviczs
Well-baby care, routine exam1, family
planning, routine gynecological exame,
viaion and hearin; screenin; throu;h age 17 ••••••••••.••• 100\ after $15.00 copay
IJiOCUNI ZA~IOJIS. • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 100\
ALLERGY TESTING ••......•.•••.•......••••.•.••••••....•.••.• 100\ after $15.00 Copay
Allergy injection• and allergen•························· 100\
MATEJUfi'n' CAD
Hospital Service• •••••••••••••••••••••••..•.•.•.•.••••••• •Paid a• any other condition
Phylician Servicee •••••••••••••••.••••.•..•.•••..•••.•.•• 100\ after $15.00 Copay
HOIG IEALft CAD
service• are covered when medically nece••ary •••.•.••.••• 100\ after $15.00 Copay
OU'l'PATI Elft' IGDI'IAL DAI.ft SDVI c&l
Up to 20 vilitl per calendar year ••.••.••••.•.•..•.•.•••. 100\ after $50.00 Copay
REBABILITATIOW SIRVICII
Short-term therapy when pre1cribed by
the Primary Care Phy8ician •••••.•.•..••.••. •.••....•.••.• •80\
SERVICES roa ALCOIOL aDd DRUG A8US8
Acute Detoxification Stage Only ••.•.•.•.••..•..•....•.•.. •80\
SKILLED NURSING FACILITY
SSOO deductible per admi••ion not to exceed 50\ of charge•
Up to 60 dayl per calendar year •••••..•..........•.•..... •80\
AMBULAHCI SllVICII
Ground service for emergency ..•.......................•.. •80\ after S50.00 C=~ay
.,
%-Ray aud Laboratory Teat .....•....•••...•..•.... •BO\
Includinq pap teat and mammoqr&ms
Hospice care .•...................•........••..... • 80\
BASIC
SCOPE OF BE.~FITS
Physical, Occupatioual 6 Speech Therapy ...•..•... $10 per viait up to 2 months
When neceasary and authorized by this
Plan's Medical Director
•For these services the employee pay• 20\ of the first $25,000 ($5,000) per member
per calendar year.
For the remainder of that year, benefit• are paid at 100\.
!n
addition, hospital and skilled nurainq facility admiaaions are aub)ect to a ssoo
deductible per admiaaion.
WHAT IS NOT COVERED
A. Service• of non-participatinq provider•, except in an emerqency or for out-of-area
benefite, or when authorized in advance in writinq by thia plan.
I
a. Service• and treatment of mental retardation and other mental health service~ except
ae otherwiae provided in Part V (J).
c. Eyeqla••••• contact len•••• hearinq aide and other vieion care aervic••• except
medical aervice• required for diaqnoeie and treatment of di••a••• of, or injury to,
the •Y•• or ear•, and Preventive Health Service• tor children throuqh aqe 17.
D. Coemetic or reconatructive aurqery, unl••• deemed medically neceeaary by a
participatinq phy•ician with the prior approval of this plan to re•tore normal
phyaioloqical tunctioninq, or to correct a conqenital condition.
!. Outpatient private duty nureinq.
F. Non-preecription druq•, medication• and contraceptive devicee, includinq birth
control pill•.
G. Peraonal comfort iteme (auch ae radio, televi•ion, telephone and queet meala);
private roome, unlee• neceeeary durinq inpatient hoepitalization.
H. Custodial or domiciliary care, or convaleecent care not requirinq akilled nurainq in
the opinion of the participatinq phy•ician.
r. All dental aervicee, except oral aurqery.
J. Ambulance aervice, unle•• medically nec•••ary.
K. Lonq-term phyaical therapy and rehabilitation eervic••·
L. Medical, aurqical, or other health care procedure• deemed to be experimental by the
Department of Health and Human Servic••·
H. Rever1al1 of voluntarily induced infertility and in vitro fertilization procedures.
N. Elective &bortionl.
o. Procedure•, 1ervice1, and 1upplie1 related to ••• tranttormatione.
P. Care tor military tervice•connected diaabilitiel tor which the member il leqally
entitled to 1ervice1 and for which facilitiel are rea1onably acce11ible to the
mei!IDer.
Q. service• on which claim il baaed from care which i1 received in a veteran·•, mar~n•
or other federal hoapital.
R. Non-medical ancillary ••rvice• and lonq-term rehabilitative eervicet for the
treatment of alcoholi•m or druq abule,includinq rehabilitation eervicea in a
specialized inpatient or retidential facility •
. ~ . •'
. -· .. ··
.
. i •,{
BASIC
SCOPE OF BENEFITS
\VHAT IS NOT COVERED ccont'd)
s. Examination• apecifically for the purpose of obtaininq employment or ~nsurance or
examination precedent to enqaqinq in recreational activitiea unless obtained in t he
context of periodic exam.
T. Care for condition• that federal, •tate or local law require• be treated in a publi:
facility.
u. Service• which in the judgment of a partricipatinq phyaician are not reasonably or
medically neceaaary or not required in accordance with accepted 1tandarda of medical
practice.
v. Eductation therapy and lonq-term speech therapy.
w. Routine foot care •.
X. Vision care benefit• or orthoptica, viaion traininq, low v~•~on aida, and any
service• or auppliea determined by the plan to be 1pecial or unuaual.
Y. Any typea of ••rvicea, auppliea or treatment not •pecif1cally provided herein.
z. Service• rendered prior to your effective date of coveraqe or after your coverage
terminate•.
AA. Illn••••• or injuriea that are a reault of war, declared or undeclared, or any act of
war.
AI. Rental or purehaae of durable medical equipment.
c. Proathetic and orthopedic appliancaa.
?. Service• that would have been payable under other eontracta had the peraon followed
the other contract'• preecribed procedure for obtainin9 health care eervicee or
coveraqe.
AE. service• received from a member of the ~iate family or rendered by a phyaician or
another provider to himaelf or heraelf.
.
AF. Any service to the extent payment haa been made under Medicare, or would have been
made if the member had applied for Medicare and claimed Medicare benefita.
AG. Service• that are for any illn••• or injury occurrinq in the couree of •mployment ~t
whole or partial eompenaation i.e available under Worker'• compeneation law• or the
lawa of any qovernmental entity.
(Thia doea not apply where a aole propr~•tor or
partner hal elected not to be covered by the proviaiona of the Worker•• compentations
Act.)
AH. Any service for which the member haa no leqal obli9ation to pay in the abaence of
thia or aimilar covera9e.
AI. Treatment of obeaity or for wei9ht reduction•.
AJ. outpatient preecription druq1.
IMPOR'l'AN'l' NO'l'ICII
Althouqh a apecitie service may be lilted u
a benefit, it will
not be provided unl••• in the judqment of the Plan doctor, it ia medically neceaeary
for the prevention, diaqnolil, or treatment of illneaa, injury or condition.
Thi~ document doe~ not alter any oL the te~ or conditions ot the
subscriber contract.
.
/
,_ '
STANDARD
SCOPE OF BENEFITS
ALL CARE MUST BE RENDERED OR REFERRED BY TBB PRIMARY CARE PHYSICIAN FOR
THZ CHARGES TO BE PAID BY TBIS BEALTB CARB PLAN.
~~~~J411LS. (subject to condition• & exclu•ion•
listeci elsewhere)
PLAN PAYS
IHPA%IENT HOSPITAL SERVICES
Room ana Board ............•••••..•..••....••..•••.••..... *80\ Semi-Private
Lenqth ot Stay •........•...•.....•.•••..•....•.•...••.... Unlimited
Charqe• other than room ana boara •............•..•..•••.. •SO\
IHPA%IEHT BOSPITAL PBYSICIAM SERVICES
Any •ervice• renciereci by the Primary Care
Phy•ician or by a con•ultant when reterreci
by the Primary Care Phy•ician ..•.•............. • ..•..•..• 100\
OUTPATIENT SURGERY PBYSICIAM SERVICES ..••...••.••.•••••••. • 100\
EMERGENCY ROOM SERVICES .........•.••...........•...•.••.•.. *80\ after $25.00 Copay
IHPA%IENT PRIVATS DUTY NURSIHG
When medically nece••ary ana authorized
by thi• Plan•• Medical Director ••••••....•••••••••••••••• •SO\
,OUTPA1'IENT BOIPI%A1. SERVICES •••••••••••.•....••••••••••••.. •80\
Includinq Ambulatory Surqical Center•
MEDICAL OPPIC. VISITS .........•.•••..••.••..••••.•.•...•... 100\ after $10.00 Copay
PRIVENTIVI ~TB SERVICES
Well-baby care, routine exam•, family
planninq, routine qynecoloqical exam•,
vision and hearinq 1creening through aqe 17 ••••••••••••.• 100\ after 510.00 copay
ItDCtJ'HI ZA~IONS. • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 100\
ALtZROY TESTIHG ••.......•••.••••••••••.••••••.••.•••..•.•.• 100\ after $10.00 Copay
Allerqy injection• and allergen•· ..•...•••..•..•.•••.•..• 100\
MA1'EJUflT! CU.
: i
Holpital Service•········································*Paid a• any other condition
Phyaician Servicee •••••••••••••••.•..•...••••.•.••...••.• 100\ after $10 . 00 Copay
IONS BEAL%11 CAD
service• are covered when medically nece••ary •.•••.•••••• 100\ after $10.00 Copay
OUTPA1'IIM'l' MEJI'rAL DALft SIAVtCZI
Up to 20 vilit• per calendar year ••.....••...•.•••..••..• 100\ after $50.00 Copay
REBAIILI1'ATION SERVICES
Short-term therapy when prelcribed by
the Primary Care Phylician ••.....••.•..•.•..•••....•..... •80\
SERVICES POA ALCOIOL aDd DRUG AIUS8
Acute Detoxification Stage Only ••..••.......•..••.••...•. •80\
SKILLED HURSIHG FACILITY
Up to 60 dayl per calendar year •.•..........••..•..•.•... •80\
AMBULAHC. SERVICES
Ground service for emerqency •............................ •80\
STANDARD
SCOPE OF BENEFITS
Preacriptioa Druqa ...........•.••••...•..•...•... SO\ copay per 30 day aupply
1-Rar aad Laboratory Teat ...............••..•.... •BO\
Includinq pap teat and mammoqr&ml
Boapice care ..•....................•.....•.•..... •80\
Pbyaical, OccupatioDal l Speech Tberapr·········· $15 per visit up to 2 montha
When neceaaary and authorized by thia
Plan'• Medical Director
•ror th••• aervicea the employ•• pay• 20\ of the firat $10,000 ($2,000)
per member per calendar year.
For the remainder of that year, benefitl
are paid at 100\.
WHAT IS NOT COVERED
\
I
A. Service• of non-participating provider•, except in an emergency or for out-of-area
benefit•, or when authori&ed in advance in writing by thil plan.
8. Service• and treatment of mental retardation and other mental health 1ervice1,· except
a1 otherwi1e provided in Part V (J).
!. !yegla11e1, contact len1e1, hearing aidl and other vilion care aervicea, except
medical aervice• required for diagnoail and treatment ot diaeaaea of, or injury to,
the •Y•• or earl, and Preventive Health Service• for children through age 17.
o. Coametic or reconatructive 1urgery, unle11 deemed medically nece11ary by a
participating phylician with the prior approval of thi1 plan to reatore normal
phyaiological functioning, or to correct a congenital condition.
!. outpatient private duty nuraing.
r. ~on-prelcription drug•, medication• and contraceptive devicea, including birth
control pilll.
G. Peraonal comfort itema (auch aa radio, televiaion, telephone and que•t meala);
private rooma, unle•• nece11ary during inpatient hoapitali&ation.
H. Cultodial or domiciliary care, or convaleacent care not requiring akilled nurainq in
the opinion of the participating phy1ician.
I. All dental aervice•, except oral aurgery.
J. Ambulance aervice, unl••• medically neceaaary.
x. Long-term phylical therapy and rehabilitation 1ervicea.
L. Medical, aurqical, or other health care procedure• deemed to be experimental by the
Department of Health and Huaan Servicea.
M. Rever•ala of voluntarily induced infertility and in vitro fertilization procedure•.
N. Elective &bortiona.
o. Procedurea, aer.icel, and auppliea related to 1ex tranlformationa.
P. Care for military aervice•connected diaabilitiea tor which the member ia legally
entitled to aervice• and for which facilitiea are reaaonably acc•••ible to the
member.
Q. service• on which cla~ il baaed from care which ia received in a veteran·•, marine
or other federal hoapital.
R. Non-medical ancillary 1ervice1 and long-term rehabilitative aervicea for the
trlatment ot alcoholilm or drug abuae,includinq rehabilitation aervic•• in a
apecialized inpatient or reaidential facility.
•
\VHAT IS NOT COVERED ccont'd)
STANDARD
SCOPE OF B&~FITS
s. Examination• apecitically for the purpoae of obtaininq employment or insurance or
examination precedent to enqaqinq in recreational activitiea unle11 obtained in the
context of periodic exam.
I
I
T. Care tor condition• that federal, 1tate or local law require• be treated in a public
facility.
u. Service• which in the judqment of a partricipatinq phy•ician are not rea•onably or
medically n•c••••ry or not required in accordance with accepted standards ot medical
practice.
v. Eductation therapy and lonq-term 1peech therapy.
w. Routine foot care.
X. Viaion care benefits or orthoptica, viaion traininq, low viaion aida, and any
••rvicea or auppliea determined by the plan to be apecial or unu1ual.
Y. Any type• of aervicea, •uppli•• or treatment not apecifically provided herein.
z. Service• rendered prior to your effective date of coverage or after your coveraqe
terminate•.
AA. Illn••••• or injurie• that are a reault of war, declared or undeclared, or any act ot
war.
AI. Rental or purchaae of durable medical equipment.
c. Prolthetic and orthopedic appliance•.
• service• that would have been payable under other contract• had the peraon followed
the other contract•• pre•cribed procedure for obtaining health care ••rvicea or
coveraqe.
AI. service• received from a member of the Lmmediate family or rendered by a phyaician or
another provider to himaelf or her•elf.
·
AF. Any service to the extent payment ha• been made under Medicare, or would have been
made if the member had applied for Medicare and claimed Medicare benetitl.
AG. service• that are tor any illne•• or injury occurrinq in the cour•e of employment if
whole or partial compen•ation i• available under Worker•• Compenaation lawa or the
law• of any qovernmental entity.
(Thi• doe• not apply where a 1ole proprietor or
partner hal elected not to be covered by the proviaion• of the Worker•• Compenaations
Act.)
AH. Any aervice for which the member ha• no leqal obligation to pay in the absence ot
thi• or eimilar coverage.
AI. Treatment of obe•ity or for weight reduction•.
IMPORTAH'l' NO'fiC•a
Although a apecit ic ••rvice may be Hated u
a benefit, it will
not be provided unle•• in the judgment of the Plan doctor, it ie medically necea1ary
for the prevention, diaqno•i•, or treatment of illne••• injury or condition.
Th1~ docuaent doe• not alter any o~ the tera8 or conditions oL the
subscriber contract.
.,