Louisiana Administrative Code › Title 32 - EMPLOYEE BENEFITS › Part V - Additional Plans and Operations › Chapter 2 - PPO Plan Structure-Magnolia Open Access Plan › Section V-205 - Schedule of Benefits

Current through Register Vol. 50, No. 6, June 20, 2024
A. Benefits and
				Coinsurance
Coinsurance
Active Employees/ Non-Medicare
							 Retirees (regardless of retire date)
Retirees with Medicare
							 (regardless of retire date)
Network Providers
Non-Network
Network Providers
Physician Office Visits including surgery performed
							 in an office setting:
* General Practice
* Family Practice
* Internal Medicine
* OB/GYN * Pediatrics
90% - 10%1
70% - 30%1
80% - 20%1
Allied Health/Other Professional Visits:
* Chiropractors
* Federally Funded Qualified Rural Health
							 Clinics
* Nurse Practitioners
* Retail Health Clinics
* Physician Assistants
90% - 10%1
70% - 30%1
80% - 20%1
Specialist (Physician) Office Visits including
							 surgery performed in an office setting:
* Physician
* Podiatrist
* Optometrist
* Midwife
* Audiologist
* Registered Dietician
* Sleep Disorder Clinic
90% - 10%1
70% - 30%1
80% - 20%1
Ambulance Services - Ground (
for Emergency
							 Medical Transportation only
)
90% - 10%1
70% - 30%1
80% - 20%1
Ambulance Services - Air (
for Emergency
							 Medical Transportation only
) Non-emergency requires prior
							 authorization2
90% - 10%1
70% - 30%1
80% - 20%1
Ambulatory Surgical Center and Outpatient Surgical
							 Facility
90% - 10%1
70% - 30%1
80% - 20%1
Bariatric Surgery Services - Facility
							 Services4
$2,500.00
							 Copayment2,3
Not Covered
Network Providers $2,500.00
							 Copayment2,3
Non-Network Providers Not Covered
Bariatric Surgery Services - Professional
							 Services4
90% - 10%2,3
Not Covered
Network Providers 90% -
							 10%2,3
Non-Network Providers Not Covered
Bariatric Surgery Services - Preoperative and
							 Postoperative Medical Services4
80% - 20%2,3
Not Covered
Network Providers 80% -
							 20%2,3
Non-Network Providers Not Covered
Birth Control Devices -Insertion and Removal
							 (
as listed in the Preventive and Wellness Care Article in the Benefit
							 Plan)
100% - 0%
70% - 30%1
Network Providers 100% - 0%
Non-Network Providers 80% -
							 20%1
Cardiac Rehabilitation (
limit of 36 visits
							 per Plan Year)
90% - 10%1,2
70% - 30%1,2
80% - 20%12
Chemotherapy/Radiation Therapy (Authorization not
							 required when performed in Physician's office)
90% - 10%1,
														2
70% - 30%1,
														2
80% - 20%1,2
Diabetes Treatment
90% - 10%1
70% - 30%1
80% - 20%1
Diabetic/Nutritional Counseling - Clinics and
							 Outpatient Facilities
90% - 10%1
Not Covered
80% - 20%1
Dialysis
90% - 10%1
70% - 30%1
80% - 20%1
Durable Medical Equipment (DME), Prosthetic
							 Appliances and Orthotic Devices
90% - 10%1,2
70% - 30%1,2
80% - 20%1,2
Emergency Ground Ambulance Services; In-State
90% - 10%1
90% - 10%1
80% - 20%1
Emergency Ground Ambulance Services;
							 Out-of-State
90% - 10%1
70% - 30%1
80% - 20%1
Emergency Room (
Facility
							 Charge
)
$200 Copayment1; Waived if
							 admitted to the same facility
Emergency Medical Services (
Non-Facility
							 Charges
)
90% - 10%1
90% - 10%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
Flu shots and H1N1 vaccines (
administered at
							 Network Providers, Non-Network Providers, Pharmacy, Job Site or Health
							 Fair
)
100% - 0%
100% - 0%
100% - 0%
Hearing Aids (
Hearing Aids are not covered
							 for individuals age eighteen (18) and older
)
90% - 10%1,3
70% - 30%1,3
80% - 20%1,3
Hearing Impaired Interpreter Expense
100% - 0%
100% - 0%
100% - 0%
High-Tech Imaging -Outpatient
* CT Scans
* MRA/MRI
* Nuclear Cardiology
* PET Scans
90% - 10%1,2
70% - 30%1,2
80% - 20%1,2
Home
Health Care (
limit of
							 60 Visits per Plan Year)
90% - 10%1,2
70% - 30%1
														,2
Not Covered
Hospice Care (
limit of 180 Days per Plan
							 Year)
80% - 20%1,2
70% - 30%1
														,2
Not Covered
Injections
Received in a Physician's
							 Office (
when no other health service is received
)
90% -10%1
70% - 30%1
80% - 20%1
Inpatient Hospital Admission, All Inpatient Hospital
							 Services Included
Per Day Copayment Day Maximum
							 Coinsurance
$0
Not Applicable
90% - 10%1,2
$50
5 Days
70% - 30%1,2
$0
Not Applicable
80% - 20%1,2
Inpatient and Outpatient
Professional
Services
90% - 10%1
70% - 30%1
80% - 20%1
Mastectomy Bras - Ortho-Mammary Surgical
							 (
limit of three (3) per Plan Year
)
90% - 10%1
70% - 30%1
80% - 20%1
Mental Health/Substance
Abuse - Inpatient Treatment and Intensive Outpatient
							 Programs
Per Day Copayment Day Maximum Coinsurance
$0
Not Applicable
90% - 10%1,2
$50
5 Days
70% - 30%1,2
$0
Not Applicable
80% - 20%1,2
Mental Health/Substance Abuse - Office Visit and
							 Outpatient Treatment (Other than Intensive Outpatient Programs)
90% - 10%1
70% - 30%1
80% - 20%1
Newborn - Sick, Services Excluding Facility
90% - 10%1
70% - 30%1
80% - 20%1
Newborn - Sick, Facility
Per Day Copayment
							 Day Maximum Coinsurance
$0
Not Applicable
90% - 10%1,2
$50
5 Days
70% - 30%1,2
$0
Not Applicable
80% - 20%1,2
Non-Emergency Ground Ambulance Services
90% - 10%1
70% - 30%1
80% - 20%1
Oral Surgery for Impacted Teeth
90% - 10%1,2
70% - 30%1,2
80% - 20%1,2
Pregnancy Care - Physician Services
90% - 10%1
70% - 30%1
80% - 20%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 Care Article in the Benefit Plan.
)
100% - 0%3
70% - 30%1,3
Network 100% - 03
Non-Network
80% - 20%1,3
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)
90% - 10%1
70% - 30%1
80% - 20%1
Skilled Nursing Facility (
limit 90 days per
							 Plan Year
)
90% - 10%1,2
70% - 30%1,2
80% - 20%1,
														2
Sonograms and Ultrasounds
							 (
Outpatient
)
90% - 10%1
70% - 30%1
80% - 20%1
Urgent Care Center
90% - 10%1
70% - 30%1
80% - 20%1
Vision Care (Non-Routine) Exam
90% - 10%1
70% - 30%1
80% - 20%1
X-ray and Laboratory Services (
low-tech
							 imaging
)
90% - 10%1
70% - 30%1
80% - 20%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).