Louisiana Administrative Code › Title 32 - EMPLOYEE BENEFITS › Part V - Additional Plans and Operations › Chapter 5 - PPO/Consumer-Driven Health Plan Structure-Pelican HRA 1000 Plan › Section V-505 - Schedule of Benefits

Current through Register Vol. 50, No. 6, June 20, 2024
A. Benefits and
				Coinsurance
Coinsurance
Network Providers
Non-Network
							 Providers
Physician's Office Visits including surgery performed
							 in an office setting:
* General Practice
* Family Practice
* Internal Medicine
* OB/GYN
* Pediatrics
80% - 20%1
60% - 40%1
Allied Health/Other Office Visits:
* Chiropractors
* Federally Funded Qualified Rural Health
							 Clinics
* Retail Health Clinics
* Nurse Practitioners
* Physician's Assistants
80% - 20%1
60% - 40%1
Specialist Office Visits including surgery performed
							 in an office setting:
* Physician
* Podiatrist
* Optometrist
* Midwife
* Audiologist
* Registered Dietician
* Sleep Disorder Clinic
80% - 20%1
60% - 40%1
Ambulance Services - Ground (
for Emergency
							 Medical Transportation Only
)
80% - 20%1
80% - 20%1
Ambulance Services Air (for Emergency Medical
							 Transportation only)
Non-emergency requires prior
							 authorization2
80% - 20%1
80% - 20%1
Ambulatory Surgical Center and Outpatient Surgical
							 Facility
80% - 20%1
60% - 40%1
Bariatric Surgery Services Facility
							 Services4
$2,500.00
							 Copayment2,3
No Coverage
Bariatric Surgery Services Professional
							 Services4
90% - 10%2,3
No Coverage
Bariatric Surgery Services Preoperative and
							 Postoperative Medical Services4
80% - 20%2,3
No Coverage
Birth Control Devices - Insertion and Removal
							 (
as listed in the Preventive and Wellness Article in the Benefit
							 Plan
)
100% - 0%
60% - 40%1
Cardiac Rehabilitation
(
limited to 36 visits per Plan
							 Year
)
80% - 20%1,2
60% - 40%1,2
Chemotherapy/Radiation Therapy (
Authorization
							 not required when performed in Physician's office
)
80% - 20%1,2
60% - 40%1,2
Diabetes Treatment
80% - 20%1
60% - 40%1
Diabetic/Nutritional Counseling Clinics and
							 Outpatient Facilities
80% - 20%1
Not Covered
Dialysis
80% - 20%1
60% - 40%1
Durable Medical Equipment (DME), Prosthetic
							 Appliances and Orthotic Devices
80% - 20%1,2
60% - 40%1,2
Emergency Room (
Facility
							 Charge
)
80% - 20%1
80% - 20%1
Emergency Medical Services (
Non-Facility
							 Charge
)
80% - 20%1
80% - 20%1
Eyeglass Frames and One Pair of Eyeglass Lenses or
							 One Pair of Contact Lenses (
purchased within six months following
							 cataract surgery)
Eyeglass Frames Limited to a Maximum Benefit of
							 $501
No Coverage
Emergency Ground Ambulance Services; In-State
80% - 20%1
80% - 20%1
Emergency Ground Ambulance Services;
							 Out-of-State
80% - 20%1
80% - 20%1
Flu Shots and H1N1 vaccines (
administered at
							 Network Providers, Non-Network Providers, Pharmacy, Job Site or Health
							 Fair
)
100% - 0%
100% - 0%
Hearing Aids (
Hearing Aids are not covered
							 for individuals age eighteen (18) and older
)
80% - 20%1,3
Not Covered
Hearing Impaired Interpreter Expense
100%-0%
100%-0%
High-Tech Imaging - Outpatient
* CT Scans
* MRA/MRI
* Nuclear Cardiology
* PET Scans
80% - 20%1,2
60% - 40%1,2
Home Health Care (
limit of 60 Visits per Plan
							 Year)
80% - 20%1,2
60% - 40%1,2
Hospice Care (
limit of 180 Days per Plan
							 Year)
80% - 20%1,2
60% - 40%1,2
Injections Received in a Physician's Office
							 (
when no other health service is received
)
80% - 20%1
60% - 40%1
Inpatient Hospital Admission (
all Inpatient
							 Hospital services included
)
80% - 20%1,2
60% - 40%1,2
Inpatient and Outpatient Professional Services
80% - 20%1
60% - 40%1
Mastectomy Bras (
limited to three (3) per
							 Plan Year
)
80% - 20%1
60% - 40%1
Mental Health/Substance Abuse -Inpatient Treatment
							 and Intensive Outpatient Programs
80% - 20%1,2
60% - 40%1,2
Mental Health/Substance Abuse Office Visit and
							 Outpatient Treatment (Other than Intensive Outpatient Programs)
80% - 20%1
60% - 40%1
Newborn - Sick, Services excluding Facility
80% - 20%1
60% - 40%1
Newborn - Sick, Facility
80% - 20%1,2
60% - 40%1,2
Oral Surgery
80% - 20%1,2
60% - 40%1,2
Pregnancy Care - Physician Services
80% - 20%1
60% - 40%1
Preventive Care - Services include screening to
							 detect illness or health risks during a Physician office visit. The Covered
							 Services are based on prevailing medical standards and may vary according to
							 age and family history. (
For a complete list of benefits, refer to the
							 Preventive and Wellness/Routine Care Article in the Benefit
							 Plan
.)
100% - 0%3
100% - 0%3
Rehabilitation Services - Outpatient:
* Speech
* Physical/Occupational
(
Limited to 50 Visits combined PT/OT per
							 Plan Year. Authorization required for visits over the combined limit of
							 50.)
*
(Visit limits do not apply when services
							 are provided for Autism Spectrum Disorders.)
80% - 20%1
60% - 40%1
Skilled Nursing Facility (
limit 90 Days per
							 Plan Year
)
80% - 20%1,2
60% - 40%1,2
Sonograms and Ultrasounds - Outpatient
80% - 20%1
60% - 40%1
Urgent Care Center
80% - 20%1
60% - 40%1
Vision Care (Non-Routine) Exam
80% - 20%1
60% - 40%1
X-Ray and Laboratory Services (
low-tech
							 imaging
)
80% - 20%1
60% - 40%1
1Subject to Plan Year
							 Deductible, if applicable
2Pre-Authorization
							 Required, if applicable. Not applicable for Medicare primary.
3Age and/or Time
							 Restrictions Apply
4No Benefits will be
							 payable unless Prior Authorization is obtained, including Plan Participants
							 with Medicare as the Primary Plan.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  42:801(C) and
				  802(B)(1).