Louisiana Administrative Code › Title 32 - EMPLOYEE BENEFITS › Part V - Additional Plans and Operations › Chapter 4 - PPO/Consumer-Driven Health Plan Structure-Pelican HSA 775 Plan › Section V-405 - Schedule of Benefits

Current through Register Vol. 50, No. 6, June 20, 2024
A. Benefits and
				Coinsurance
Coinsurance
Network Providers
Non-Network Providers
Physicians 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
*Physicians 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
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 Physicians 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 Physicians 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 Visits 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
Non-Emergency Ground Ambulance Services
80% - 20%1
80% - 20%1
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
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  42:801(C) and
				  802(B)(1).