special situations (e.g., trauma, brain injury) for additional visits. COMMON AND PREVENTIVE SERVICES Physician Office Visits - Primary Care 100% after $15 copay 80% of allowed benefit after deductible Physician Office Visits – Specialist 100% after $25 copay 80% of allowed benefit deductible Preventive Health Office Visit and Associated Lab (Adult and Child) 100% of allowed benefit 80% of allowed benefit after deductible Routine annual GYN Exam (including PAP test) 100% of allowed benefit 80% of allowed benefit after deductible Hearing Examinations and Hearing Aids 100% after $15 copay – PCP or $25 copay – Specialist 80% of allowed benefit after deductible 100% of allowed benefit for Model Hearing Aid 80% of allowed benefit deductible for Basic Model Hearing Aid A model hearing aid is a hearing aid worn on the exterior of the ear and is used primarily for hearing amplification. It does not include implant devices. The basic model hearing aid will not require prior authorization. Limited to once every three years per ear. Includes Maryland mandated benefit for hearing aids for children (ages 0-18), including hearing aids per each impaired ear for minor children. No deviations will be considered. Immunizations 100% of allowed benefit 80% of allowed benefit after deductible Immunizations are only covered as recommended by the U.S. Preventive Services Task Force. The immunization benefit covers immunizations required for participation in school athletics and Lyme Disease immunizations when medically necessary. No deviations will be considered. Flu Shots 100% of Allowed Benefit 80% of allowed benefit after deductible Mammography Preventive 100% of allowed benefit 80% of allowed benefit deductible
Screening: One each year 35+. No deviations will be considered. Mammography Diagnostic 100% of allowed benefit 80% of allowed benefit after deductible No age/frequency limitation on diagnostic mammogram. No deviations will be considered. Physical Exams 100% of allowed benefit 80% of allowed benefit after deductible One exam per plan year for all members and their dependents age three (3) and older. No deviations will be considered. Well Baby Care 100% of allowed benefit 80% of allowed benefit after deductible Birth – 3036 months: 13 visits total No deviations will be considered. STI Screening and Counseling (Including HPV DNA and HIV) 100% of allowed benefit 80% of allowed benefit after deductible Counseling and screening for sexually active as mandated by PPACA. No deviations will be considered. Allergy Testing 100% after $15 copay – PCP; $25 copay – Specialist 80% of allowed benefit after deductible EMERGENCY TREATMENT Urgent Care Office Visit $20 copay 80% of allowed benefit deductible Emergency Room (ER) Services –In and Out of Network 100% of allowed benefit after $50 facility copay and $50 physician copay 100% of allowed benefit $50 facility copay and $50 physician copay Copays are waived if admitted. No deviations will be considered. If criteria are not met for a medical emergency, plan coverage is 50% of allowed amount, plus the two $50 copays. Observation – up to 23 hours and 59 minutes - presented via Emergency Department 100% of allowed benefit after $50 facility copay and $50 physician copay 80% of allowed benefit after deductible Observation – 24 hours or more - presented via Emergency Department 100% of allowed benefit 80% of allowed benefit after deductible Ambulance Services – Emergency Transport 100% of allowed benefit 100% of allowed benefit
Residential Crisis Services 100% of allowed benefit 80% of allowed benefit after deductible VISION SERVICES - ADULT Vision - Medical (services related to the medical health of the eye) 100% after $15 copay (PCP) or $25 copay (specialist) 80% of allowed benefit after deductible Vision - Routine Exam (per year) 100% after $15 copay (PCP) or $25 copay (specialist) 80% of allowed benefit after deductible Prescription Lenses, frames and/or contacts. One pair per plan year. Frames/lenses or contacts, not both. Plan pays up to noted allowed amounts, remainder is participant responsibility. Prescription Lenses Single Vision $29.00 Bifocal, single $49.00 Bifocal, double $89.00 Trifocal $71.00 Aphakic, glass $54.00 Aphakic, plastic $126.00 Aphakic, aspheric $162.00 Frames $45.00 Contacts Medically Necessary $202.00 Cosmetic $51.00 Obtain vision services from provider of your choice. Pay entire cost up front, then submit claim to carrier for reimbursement up to the above allowed amounts. VISION SERVICES - PEDIATRIC Vision – Medical “sick” visit 100% of allowed benefit after $15 copay 80% of allowed benefit after deductible Vision – Routine exam 100% of allowed benefit 100% of allowed benefit (member may still be balance billed) Vision Supplies – Frames/Lenses or Contacts. 100% of allowed benefit 80% of allowed benefit after deductible Limited to dependent children age 18 and under. Medically necessary Frames/Lenses or Contacts. Contacts in lieu of Frames/Lenses. No deviations will be considered
FA1 Attachment S-8: Access to Hospitals Instructions: Provide access two ways: (1) all employees currently in PPO and (2) all employees. Matches must be determined based on criteria outlined in Section III Participants Access to Providers in "Attachment S-1: Plan Information.” A. For Response Attachment S-1: GeoAccess® GeoNetworks® Report, provide the following report format for Access to Hospitals: Zip Code Average Distance to Adult PCPs Total Number of Employees Employees Matched Employees Not Matched Number Percent Number Percent B. Provide subtotals for all employees currently in PPO by County of residence and by region of residence as shown in the table below: Metropolitan/ Geographic Area Average Distance to Adult PCPs Total Number of Employees Employees Matched Employees Not Matched Number Percent Number Percent Anne Arundel County Baltimore City Baltimore County Carroll County Harford County Howard County Central Maryland Caroline County Cecil County Dorchester County Kent County Queen Anne's County Somerset County Talbot County Wicomico County Worcester County Eastern Shore Calvert County Charles County St. Mary's County Southern Maryland District of Columbia Montgomery County Prince George's County Washington Metro Allegany County Frederick County Garrett County Washington County Western Maryland
Describe your organization’s experience in managing web educational media for clients, including the technology used and content developed. Describe your ability to support emerging technologies in particular mobile applications. SUBCONTRACTORS Provide a complete listing of all services which are subcontracted and the subcontractor used. (Complete "FA1 PPO-SF Attachment S-13: Subcontractor Questionnaire" for each of the subcontractors used.)
handling the SLEOLA account. Frequency of report: Quarterly Processing of Enrollment Eligibility Update Information Plan will process electronic interchange of SLEOLA enrollment information by 5:00PM of the second business day after receipt. If information is received after 12:00PM, record as having been received as of the next business day. Time over which standard is measured: Quarter Report Card - Vendor to maintain log for review by the State's contract auditor. Frequency of report: Quarterly 0.20% of fees for each calendar day, or portion thereof, of Accuracy of Processing Enrollment Eligibility Information Plan will process electronic interchange of SLEOLA enrollment with at least 98% accuracy. Time over standard is measured: Quarter Report Card - Vendor to maintain log and system generated reports for review by the State's contract auditor. Frequency of report: Quarterly 0.20% of fees for each percentage point, or fraction thereof, under 98%. Contractor attendance at State-sponsored Open Enrollment meetings Attendance by plan representatives trained on SLEOLA plan benefits at 100% of meetings scheduled by the State, for 100% of the meeting's duration. Representative must arrive early enough to have their table set-up prior to meeting start time. Display must be organized and include appropriate covering of table. Representative must have detailed plan knowledge, interact with members, and exhibit professional Sign-in sheets at meetings or minutes of State meetings. Frequency of report: Annually 0.05% of fees for each scheduled meeting date vendor fails to attend.
appearance and behavior. Time over which standard is measured: Annual Delivery of Quarterly Utilization, Case Management, and Disease Management Data Reports to Consultant Delivery to the State by 6:00PM on the following dates**: Documentation of receipt by Benefit Consultant, i.e., date-stamp of mailing package for data information and verification of completeness. (All required fields must be filled in correctly.) Frequency of report: Quarterly 0.20% of fees for each week, or fraction thereof, the data report is not received or is incomplete. First Quarter (Jan – Mar) Due: May 1st Second Quarter (Apr – Jun) Due: August 1st Third Quarter (Jul – Sep) Due: November 1st Fourth Quarter (Oct – Dec) Due: February 1st Delivery of Rate Renewal Reports Delivery to the State and to the State's actuarial consultant of reports required for annual rate renewal process by 6:00PM March 1 of each contract year. At a minimum, the renewal reports must include (but not be limited to) the following: Date-stamp of receipt by the State and verification of completeness of required documentation. Frequency of report: Annually Projection of incurred claim costs for renewal year. Estimate of IBNR reserves at end of current year; including the most recent 36 months of incurred/paid triangular reports. Complete documentation of the methodology and assumptions utilized to
transactions, divided by the total draft or payment transactions. to two (2) decimal places. Claims Standards Processing Time 95% of all claims are adjudicated within 10 business days; and 98% of all claims are adjudicated within 20 business days. Measured by the State's independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal places. 3.00% of fees if performance is less than standard. Provision of claims and eligibility data to third party vendors. Delivery of agreed-upon claims and eligibility data to third party vendors in the format and frequency required by the applicable vendor(s). Date-stamp of receipt by the third-party vendor and verification of completeness of required documentation. 0.05% for each calendar day the data is not received or is incomplete. Annual Hospital Records Claims Audit Conduct hospital records (including clinical and billing issues) audits for admission with paid claims in excess of $25,000, subject to a minimum of 2% of all hospital claims. Audits are to be conducted to ensure accuracy of billed charges in relation to the clinical services delivered. Provide quarterly reporting of the number of audits conducted, the amount of recoveries to the SLEOLA Plan. 3.00% of fees if performance is less than standards. SLEOLA Member Satisfaction Satisfactory or better results from an annual State-conducted Participant satisfaction survey. 90% of members indicate satisfied or very satisfied. Survey results. 1.00% of fees if less than 90% of members indicate satisfied or very satisfied.