Immunizations and Lead Screening for Children NONE NONE Second Surgical opinion Pre-natal visits NONE NONE NONE NONE Prescription Drugs [Generic Drugs] [Preferred Drugs] [Non-Preferred Drugs] [$250] [$50] [$100] [$150] [All other Covered Charges Per Covered Person Per Covered Family (Use above deductible for separate accumulation..) [All other Covered Charges Per Covered Person Per Covered Family (Use above if Tier 1 deductible can be satisfied independently; Tier 1 accumulates toward Tier 2) Copayment applies after the Cash Deductible is satisfied $500 $1,000 $1,000 $2,000 $1,500 $3,000] $2,000 $4,000 Preventive Care Primary Care Physician Visits [when care is provided by the pre-selected PCP] Specialist Visits [and PCP visits if the PCP was not Pre-natal visits All Other Practitioner Visits Hospital Confinement NONE N/A See Tier 2 $30 NONE N/A See Tier 2 $300 per day up to $1500 per confinement; up to $3000 per year NONE $30 $50 NONE $30 $500 per day up to $3000 per confinement; up to $5000 per year
Behavior management – for additional time required to provide services to a child with special needs that requires more time than generally required to provide a dental service. Request must indicate specific medical diagnosis and clinical appearance. One unit equals 15 minutes of additional time Utilization thresholds are based on place of service as follows. Prior authorization is required when thresholds are exceeded. Office or Clinic maximum – 2 units Inpatient/Outpatient hospital – 4 units Skilled Nursing/Long Term Care – 2 units Consultation by specialist or non-primary care provider Professional visits House or facility visit – for a single visit to a facility regardless of the number of members seen on that day. Hospital or ambulatory surgical center call For cases that are treated in a facility. For cases taken to the operating room –dental services are provided for patient with a medical condition covered by this Policy which requires this admission as in-patient or out-patient. Prior authorization is required. General anesthesia and outpatient facility charges for dental services are covered Dental services rendered in these settings by a dentist not on staff are considered separately Office visit for observation – (during regular hours) no other service performed Drugs Therapeutic parenteral drug Single administration Two or more administrations - not to be combined with single administration Other drugs and/or medicaments – by report Application of desensitizing medicament – per visit Occlusal guard – for treatment of bruxism, clenching or grinding Athletic mouthguard covered once per year Occlusal adjustment Limited - (per visit) Complete (regardless of the number of visits), once in a lifetime Odontoplasty Internal bleaching ] Note to carriers: the above Dental benefits provision is variable and may be deleted as explained in the Explanation of Brackets. If the provision is deleted include the following heading such that the under age 6 provision would be part of the Dental Care and Treatment provision. [Additional benefits for a Child under age 6]
the requirements of this section [Carrier] reduces what it pays for covered Hospital charges as a penalty. Pre-Hospital Review All non-Emergency Hospital admissions must be reviewed by [ABC] before they occur. The Covered Person or the Covered Person's Practitioner must notify [ABC] and request a pre-hospital review. [ABC] must receive the notice and request as soon as possible before the admission is scheduled to occur. [For a maternity admission, a Covered Person or his or her Practitioner must notify [ABC] and request a pre-hospital review at least [60 days] before the expected date of delivery, or as soon as reasonably possible.] When [ABC] receives the notice and request, [they] evaluate: the Medical Necessity and Appropriateness of the Hospital admission the anticipated length of stay and the appropriateness of health care alternatives, like home health care or other care. [ABC] notifies the Covered Person's Practitioner [by phone, of the outcome of their review. And [they] confirm the outcome of [their] review in writing.] If [ABC] authorizes a Hospital admission, the authorization is valid for: the specified Hospital; the named attending Practitioner; and the authorized length of stay. The authorization becomes invalid and the Covered Person's admission must be reviewed by [ABC] again if: he or she enters a Facility other than the specified Facility he or she changes attending Practitioners; or more than [60 days] elapse between the time he or she obtains authorization and the time he or she enters the Hospital, except in the case of a maternity admission. Emergency Admission [ABC] must be notified of all Emergency admissions by phone. This must be done by the Covered Person or the Covered Person's Practitioner no later than the end of the next regular working day or as soon as possible after the admission occurs. When [ABC] is notified [by phone,] they require the following information: the Covered Person's name, social security number and date of birth; the Covered Person group plan number; the reason for the admission the name and location of the Hospital when the admission occurred; and the name of the Covered Person's Practitioner. Continued Stay Review
If an Employee's group health benefits end due to his or her termination of employment or reduction of work hours, he or she may elect to continue such benefits for up to 18 months, unless he or she was terminated due to gross misconduct. A Qualified Continuee may elect to continue coverage under COBRA even if the Qualified Continuee: is covered under another group plan on or before the date of the COBRA election; or is entitled to Medicare on or before the date of the COBRA election. The continuation: may cover the Employee and any other Qualified Continuee; and is subject to the When Continuation Ends section. Extra Continuation for Disabled Qualified Continuees If a Qualified Continuee is determined to be disabled under Title II or Title XVI of the United States Social Security Act on the date his or her group health benefits would otherwise end due to the Employee's termination of employment or reduction of work hours or during the first 60 days of continuation coverage, he or she and any Qualified Continuee who is not disabled may elect to extend his or her 18 month continuation period above for up to an extra 11 months. To elect the extra 11 months of continuation, the Qualified Continuee or other person acting on his or her behalf must give the Employer written proof of Social Security's determination of his or her disability within 60 days measured from the latest of: the date on which the Social Security Administration issues the disability determination; the date the group health benefits would have otherwise ended; or the date the Qualified Continuee receives the notice of COBRA continuation rights. If, during this extra 11 month continuation period, the Qualified Continuee is determined to be no longer disabled under the Social Security Act, he or she must notify the Employer within 30 days of such determination, and continuation will end, as explained in the When Continuation Ends section. An additional 50% of the total premium charge also may be required from the Qualified Continuee by the Employer during this extra 11 month continuation period. If An Employee Dies While Insured If an Employee dies while insured, any Qualified Continuee whose group health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to 36 months, subject to the When Continuation Ends section. If An Employee's Marriage Ends If an Employee's marriage ends due to legal divorce or legal separation any Qualified Continuee whose group health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to 36 months, subject to the When Continuation Ends section.
[CONVERSION RIGHTS FOR DIVORCED SPOUSES IF AN EMPLOYEE'S MARRIAGE OR CIVIL [OR DOMESTIC PARTNERSHIP] ENDS If an Employee's marriage ends by legal divorce or annulment or the employee’s civil union is dissolved [or termination of the domestic partnership], the group health benefits for his or her former spouse ends. The former spouse may convert to an individual major medical policy during the conversion period. The former spouse may insure under his or her individual policy any of his or her Dependent children who were insured under this Policy on the date the group health benefits ends. See exceptions below. Exceptions No former spouse may use this conversion right: if he or she is eligible for Medicare; or if it would cause him or her to be overinsured. This may happen if the spouse is covered or eligible for coverage providing similar benefits provided by any other plan, insured or not insured. [Carrier] will determine if overinsurance exists using its standards for overinsurance. HOW AND WHEN TO CONVERT The conversion period means the 31 days after the date group health benefits ends. The former spouse must apply for the individual policy in writing and pay the first premium for such policy during the conversion period. Evidence of insurability will not be required. THE CONVERTED POLICY The individual policy will provide the medical benefits that [Carrier] is required to offer in the state where the Employer is located. The individual policy will take effect on the day after group health benefits under this Policy ends. After group health benefits under this Policy ends, the former spouse and any children covered under the individual policy may still be paid benefits under this Policy. If so, benefits to be paid under the individual policy will be reduced by the amount paid under this Policy.] EFFECT OF INTERACTION WITH A HEALTH MAINTENANCE ORGANIZATION PLAN HEALTH MAINTENANCE ORGANIZATION ("HMO") means a prepaid alternative health care delivery system.