HomeMy WebLinkAboutRESPONSE - RFP - P682 BENEFITS (4)IN -NETWORK
OUT -OF -NETWORK
15. EMERGENCY CARE'
Emergency room setting inside
80%
the service area: $50
copayment per visit.
Copayment waived if admitted
to the hospital.
16. AMBULANCE
90%
80%
17. URGENT, NON -ROUTINE,
$10 copayment per visit.
70%
AFTER HOURS CARE
18. BIOLOGICALLY -BASED
Coverage is no less extensive
Coverage is no less extensive than the
MENTAL ILLNESS° CARE
than the coverage provided for
coverage provided for any other
any other physical illness.
physical illness.
19. OTHER MENTAL HEALTH CARE
a) Inpatient care
90%; coverage for maximum of
70% facility charges, 50% doctor's
45 full or 90 partial days per
charges; coverage for maximum of 45 full
calendar year.
or 90 partial days per calendar year.
b) Outpatient care
$10 copayment per visit;
50%; limited to 20 visits per calendar
limited to 20 visits per calendar
year.
year.
20. ALCOHOL & SUBSTANCE
Inpatient: 90%; Doctor's
Inpatient: 70% for facility charges; 50%
ABUSE
charges are limited to $1,000
for doctor charges (doctor's charges are
per calendar year for
limited to $1,000 per calendar year for
alcoholism and substance abuse
alcoholism and substance abuse
combined; coverage for
combined); coverage for maximum of
maximum of 45 full or 90
45 full or 90 partial days per calendar
partial days per calendar year
year for mental health, substance abuse
for mental health, substance
and alcoholism combined.
abuse and alcoholism
Outpatient: 50%; limited to $1,000 per
combined.
calendar year.
Outpatient: $10 copayment per
visit; limited to $1,000 per
calendar year.
21. PHYSICAL, OCCUPATIONAL, &
$10 copayment per visit,
70% up to $2,000 per calendar year for
SPEECH THERAPY
limited to $2,000 per calendar
in- and out -of -network charges
year for in- and out -of -network
combined (including biofeedback
charges combined (including
therapy).
biofeedback therapy).
22. DURABLE MEDICAL
90%; see plan booklet for types
70%; see plan booklet for types and
EQUIPMENT
and circumstances of coverage.
circumstances of coverage.
23. OXYGEN
90%; covered as durable
70%; covered as durable medical
medical equipment (see #22).
equipment (see #22).
24. ORGAN TRANSPLANTS
Cornea, heart, heart/lung
Cornea, heart, heart/lung (combined),
(combined), kidney,
kidney, kidney/pancreas (combined),
kidney/pancreas (combined),
bone marrow (for certain conditions),
bone marrow (for certain
heart valve replacements, liver, artery or
conditions), heart valve
vein transplants, and breast cancer in
replacements, liver, artery or
stages 2 or 3 are covered according to
vein transplants, and breast
criteria.
cancer in stages 2 or 3 are
covered according to criteria.
' "Emergency care" means services delivered by an emergency care facility which are necessary to screen and stabilize a covered person.
The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably
would have believed that an emergency medical condition or life or limb threatening emergency existed.
"Biologically based mental illnesses" means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive
disorder, specific obsessive -compulsive disorder, and panic disorder.