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 women as mandated by PPACA. No deviations will be considered. Allergy Testing 100% $15 copay – PCP; $25 copay – Specialist 80% of allowed benefit after deductible EMERGENCY TREATMENT Urgent Care Office Visit $20 copay 80% of allowed benefit after deductible Emergency Room (ER) Services –In and Out of Network 100% of allowed benefit $50 facility copay and $50 physician copay 100% of allowed benefit after $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 $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
Ambulance Services – Non-Emergency Transport 100% of allowed benefit 80% of allowed benefit MATERNITY BENEFITS Maternity Benefits 100% of allowed benefit 80% of allowed benefit after deductible Prenatal Care 100% of allowed benefit 80% of allowed benefit after deductible Newborn Care 100% of allowed benefit 80% of allowed benefit after deductible Breastfeeding Support and Counseling 100% of allowed benefit 80% of allowed benefit after deductible Breastfeeding Supplies (per birth) 100% of allowed benefit Not Covered Covers the cost of rental/purchase of certain breastfeeding equipment pumps through Carrier’s DME partner(s). No deviations will be considered. SERVICES AND SUPPLIES Acupuncture Services for Chronic Pain Management 100% after $20 copay 80% of allowed benefit after deductible Chiropractic Services 100% after $20 copay 80% of allowed benefit after deductible Cardiac Rehabilitation 100% of allowed benefit 80% of allowed benefit after deductible Dental Services Not covered except as a result of accident or injury or as mandated by Maryland or federal law. No deviations will be considered. Nutritional Counseling 100% of allowed benefit 80% of allowed benefit after deductible Durable Medical Equipment 100% of allowed benefit 80% of allowed benefit after deductible Must be medically necessary as determined by the attending physician No deviations will be considered. Extended Care Facilities 100% of allowed benefit 80% of allowed benefit deductible Skilled nursing care and extended care facility benefits are limited to 180 days per calendar year as long as skilled nursing care is medically necessary. No deviations will be considered.
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 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 $15 copay 80% of allowed benefit 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
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 which standard is measured: Quarter Report Card - Vendor to maintain log and system generated reports for review by the contract auditor. Frequency of report: Quarterly 0.20% of fees for each percentage point, or fraction thereof, under 98%. Contractor attendance at 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 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 State's 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: 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
develop the projected costs. Disclosure of supporting data used in the calculations, including monthly paid claims and enrollment, large claims analysis, trend analysis, demographic analysis, etc. Substantiation of any proposed increase in fixed costs via a thorough analysis of activities and costs covered by those fees. Explanations for any unusual results (high relative to the market, low relative to the market). Claims Standards Financial Accuracy Measures the gross dollars paid incorrectly (overpayments plus underpayments) subtracted from total paid claim dollars, divided by total paid claim dollars within the audit sample 99% of dollars processed accurately. 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. 2.00% of fees if below 99% but at least 97%. 4.00% of fees if less than 97%. Claims Standards Payment Accuracy Measures the number of incorrect drafts of payments made on behalf of the State, subtracted from the total draft or payment 97% of claims with benefit payments are processed accurately. Measured by the State's independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured 2.00% of fees if below 97% but at least 95%. 4.00% of fees if less than 95%.
Measured annually. Provision of Draft Plan Documents Certificate/ Evidence of Coverage Document Draft Plan Document including all required updates provided to the State at least three months prior to the first day of the plan year. Receipt date as documented by vendor and confirmed by State. $500 per calendar day for the three days the document is not received. $1,000 per calendar day for each day the document is not received for the fourth day and beyond. Provision of Final Plan Documents Final Plan Document including all required edits and in a format ready for posting to State intranet is returned to the State no later than 45 days prior to the start of the plan year. Receipt date as documented by vendor and confirmed by State. $500 per calendar day for the three days the document is not received. $1,000 per calendar day for each day the document is not received for the fourth day and beyond. DBM Claims Eligibility Audits Plan will provide response files to Department’s Audit Unit within 14 business days of receipt of error report from Department. Receipt date as documented by vendor and confirmed by $500 per calendar day for the first three days the document is not received. $1,000 per calendar day for each day the document is not received for the fourth day and beyond. *Determination of results and any applicable damages will be conducted by the contract auditor. Note: If due date for any PG falls on a state / vendor holiday or a weekend, document is due on the next business day.