Louisiana Administrative Code › Title 32 - EMPLOYEE BENEFITS › Part V - Additional Plans and Operations › Chapter 3 - Narrow Network HMO Plan Structure-Magnolia Local Plan (in certain geographical areas) › Section V-305 - Schedule of Benefits

Current through Register Vol. 50, No. 6, June 20, 2024
A. Benefits,
				Copayments, and Coinsurance
Copayments and
							 Coinsurance
Network Providers
Non-Network
							 Providers
Physician Office
* General Practice
* Family Practice
* Internal Medicine
* OB/GYN
* Pediatrics
$25 Copayment per Visit
No Coverage
Allied Health/Other Professional
Visits:
* Chiropractors
* Federally Funded Qualified Rural
* Health Clinics
* Nurse Practitioners
* Retail Health Clinics
* Physician Assistants
$25
Copayment per Visit
No Coverage
Specialist Office Visits including surgery performed
							 in an office setting:
* Physician
* Podiatrist
* Optometrist
* Midwife
* Audiologist
* Registered Dietician
* Sleep Disorder Clinic
$50
Copayment per Visit
No Coverage
Ambulance Services - Ground (
for Emergency
							 Medical Transportation only
)
$50 Copayment
$50 Copayment
Ambulance Services - Air (
for Emergency
							 Medical Transportation only
) Non-emergency requires prior
							 authorization2
$250 Copayment
No Coverage
Ambulatory Surgical Center and Outpatient Surgical
							 Facility
$100 Copayment
No Coverage
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%
No Coverage
Cardiac Rehabilitation (
limit of 36visits per
							 Plan Year
)
$25/$50
Copayment per day depending on Provider
							 Type2
$50
Copayment-Outpatient
							 Facility2
No Coverage
Chemotherapy/Radiation Therapy (
Authorization
							 not required when performed in Physician's office
)
Office $25
Copayment per Visit Outpatient Facility 100% -
							 0%1,2
No Coverage
Diabetes Treatment
80% - 20%1
No Coverage
Diabetic/Nutritional Counseling -Clinics and
							 Outpatient Facilities
$25 Copayment
No Coverage
Dialysis
100% - 0%1
No Coverage
Durable Medical Equipment (DME), Prosthetic
							 Appliances and Orthotic Devices
80% - 20%1,2 of first
							 $5,000
Allowable per Plan Year;
100% - 0% of Allowable in Excess of $5,000 per Plan
							 Year
No Coverage
Emergency Room (
Facility
							 Charge
)
$200 Copayment; Waived if admitted to the same
							 facility
Emergency Medical Services (
Non-Facility
							 Charges
)
100% - 0%1
100% - 0%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
$50 Copayment
$50 Copayment
Emergency Ground Ambulance Services;
							 Out-of-State
$50 Copayment
$50 Copayment
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
No Coverage
Hearing Impaired Interpreter Expense
100% - 0%
No Coverage
High-Tech Imaging - Outpatient
* CT Scans
* MRA/MRI
* Nuclear Cardiology
* PET Scans
$50
Copayment2
No Coverage
Home Health Care
(
limit of 60 Visits per Plan
							 Year
)
100% - 0%1,2
No Coverage
Hospice Care
(
limit of 180 Days per Plan
							 Year
)
100% - 0%1,2
No Coverage
Injections Received in a Physician's Office
							 (
when no other health service is received
)
100% - 0%1
No Coverage
Inpatient Hospital Admission, All Inpatient Hospital
							 Services Included
$100
Copayment per day2,
							 maximum of $300 per Admission
No Coverage
Inpatient and Outpatient Professional Services for
							 which a Copayment is Not Applicable
100% - 0%1
No Coverage
Mastectomy Bras (
limited to three (3) per
							 Plan Year
)
80% - 20%1 of first $5,000
							 Allowable per Plan Year;
100% - 0% of Allowable in Excess of $5,000 per Plan
							 Year
No Coverage
Mental Health/Substance Abuse -Inpatient Treatment
							 and Intensive Outpatient Programs
$100
Copayment per day2,
							 maximum of $300 per Admission
No Coverage
Mental Health/Substance Abuse Office Visit and
							 Outpatient Treatment (Other than Intensive Outpatient Programs)
$25 Copayment per Visit
No Coverage
Newborn - Sick, Services excluding Facility
100% - 0%1
No Coverage
Newborn - Sick, Facility
$100
Copayment per day2,
							 maximum of $300 per Admission
No Coverage
Oral Surgery
100% - 0%1,2
No Coverage
Pregnancy Care - Physician Services
$90 Copayment per pregnancy
No Coverage
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 Article in the Benefit Plan.
)
100% - 0%3
No Coverage
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.)
$25 Copayment per Visit
No Coverage
Skilled Nursing Facility (
limit of 90 days
							 per Plan Year
)
$100 Copayment per day2,
							 maximum of $300 per Admission
No Coverage
Sonograms and Ultrasounds
							 (
Outpatient
)
$50 Copayment
No Coverage
Urgent Care Center
$50 Copayment
No Coverage
Vision Care (Non-Routine) Exam
$25/$50
Copayment depending on Provider Type
No Coverage
X-ray and Laboratory Services (
low-tech
							 imaging
)
Hospital Facility
100% - 0%1
Office or Independent Lab 100% - 0%
No Coverage
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).