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Section
5(c). Services provided by a hospital or
other facility, and ambulance services |
 |
| Important
things you should keep in mind about these
benefits: |
- Please
remember that all benefits are
subject to the definitions,
limitations, and exclusions in this
brochure and are payable only when
we determine they are medically
necessary.
- In this
Section, unlike Sections 5(a)
and 5(b),
the calendar year
deductible applies to only a
few benefits. We added
"(calendar year deductible
applies)". The calendar
year deductible is: $250 per person
($500 per family) under the High
Option and $300 per person ($600 per
family) under the Standard Option.
- The
non-PPO benefits are the regular
benefits of this Plan. PPO benefits
apply only when you use a PPO
provider. When no PPO provider is
available, non-PPO benefits apply.
- Be sure
to read Section
4, Your costs for covered
services for valuable information
about how cost sharing works, with
special sections for members who are
age 65 or over. Also read Section
9 about coordinating benefits
with other coverage, including with
Medicare.
- The
amounts listed below are for the
charges billed by the facility
(i.e., hospital or surgical center)
or ambulance service for your
surgery or care. Any costs
associated with the professional
charge (i.e., physicians, etc.) are
in Sections 5(a)
or (b).
- YOU
MUST GET PRECERTIFICATION FOR
HOSPITAL STAYS; FAILURE TO DO SO
WILL RESULT IN A MINIMUM $500
PENALTY.
Please refer to the
precertification information
shown in Section
3 to be sure which services
require precertification.
|
| Benefit
Description |
You
Pay |
| Note:
The calendar year deductible applies ONLY
when we say below: "(calendar year
deductible applies)". |
| Inpatient
hospital |
High
Option |
Standard
Option |
Room
and board, such as
- ward,
semiprivate, or intensive care
accommodations;
- general
nursing care; and
- meals
and special diets.
Note: We only
cover a private room when you must be
isolated to prevent contagion. Otherwise, we
will pay the hospital's average charge for
semiprivate accommodations. If the hospital
only has private rooms, we base our payment
on the lowest rate for a private room.
Note: When the non-PPO hospital bills a flat
rate, we prorate the charges to determine
how to pay them, as follows: 30% room and
board and 70% other charges.
|
PPO:
Nothing after a $200 copayment per
confinement
Non-PPO: $300 copayment per confinement and
30% of the Plan allowance
Note: A confinement is defined in Section
10, page 72.
|
PPO:
Nothing after a $200 copayment per
confinement
Non-PPO: $300 copayment per confinement and
30% of the Plan allowance
Note: A confinement is defined in Section
10, page 72.
|
Other
hospital services and supplies, such as:
- Operating,
recovery, maternity, and other
treatment rooms
- Prescribed
drugs and medicines
- Diagnostic
laboratory tests and X-rays
- Blood
or blood plasma, if not donated or
replaced
- Dressings,
splints, casts,
and sterile tray services
- Medical
supplies and equipment, including oxygen
- Anesthetics
Note: We base payment on whether the
facility or a health care professional
bills for the services or supplies. For
example, when the hospital bills for
anesthetics services, we pay Hospital
benefits and when the anesthesiologist
bills, we pay Anesthesia benefits.
|
PPO:
10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
Note: If you use a PPO facility, we pay PPO
benefits if you receive treatment from a
radiologist, pathologist, anesthesiologist,
or assistant surgeon who is not a PPO
provider.
|
PPO:
15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
Note: If you use a PPO facility, we pay PPO
benefits if you receive treatment from a
radiologist, pathologist, anesthesiologist,
or assistant surgeon who is not a PPO
provider.
|
Not
covered:
- Any
part of a hospital admission that is
not medically necessary (see
definition), such as when you do not
need acute hospital inpatient
(overnight) care, but could receive
care in some other setting without
adversely affecting your condition
or the quality of your medical care.
Note: In this event, we pay benefits
for services and supplies other than
room and board and in-hospital
physician care at the level they
would have been covered if provided
in an alternative setting
- Custodial
care; see definition
- Non-covered
facilities or any facility used
principally for convalescence, for
rest, for a nursing home, for the
aged, for domiciliary or custodial
care, or as a school
- Personal
comfort items, such as telephone,
television, barber services, guest
meals and beds
|
All
charges
|
All
charges
|
| Outpatient
hospital or ambulatory surgical center |
|
| |
- Operating,
recovery, and other treatment rooms
- Prescribed
drugs and medicines
- Diagnostic
laboratory tests, X-rays,
and pathology services
- Administration
of blood, blood plasma, and other
biologicals
- Blood
and blood plasma, if not donated or
replaced
- Pre-surgical
testing
- Dressings,
casts, and sterile tray services
- Medical
supplies, including oxygen
- Anesthetics
and anesthesia service
Note: We cover
hospital services and supplies related to
dental procedures when necessitated by a
non-dental physical impairment. |
PPO:
$100 copayment per outpatient
facility charge and 10% of the Plan
allowance
Non-PPO: $150 copayment per outpatient
facility charge and 30% of the Plan
allowance and any difference between our
allowance and the billed amount (calendar
year deductible applies)
Note: You pay the copayment per facility per
occurrence.
|
PPO:
15% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount (calendar year deductible
applies)
|
| Extended
care benefits/Skilled nursing care facility
benefits |
|
|
No
benefit
|
All
charges
|
All
charges
|
| Hospice
care |
|
|
Hospice is
a coordinated program of maintenance and
supportive care for the terminally ill
provided by a medically supervised team
under the direction of a Plan-approved
independent hospice administration.
Note: A terminally ill person is a covered
family member whose life expectancy is six
months or less, as certified by the primary
doctor.
|
See
below
|
See
below
|
Benefits
are limited to $10,000 under High Option and
$5,000 under Standard Option per person, per
calendar year for a combination of inpatient
and outpatient services.
|
PPO:
10% of the Plan allowance and all charges
after the Plan has paid $10,000
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount and all charges after the Plan
has paid $10,000
|
PPO:
15% of the Plan allowance and all charges
after the Plan has paid $5,000
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount and all charges after the Plan
has paid $5,000
|
Not
covered:
- Any
charges in excess of the $10,000
High Option or $5,000 Standard
Option plan limitation for covered
hospice care
- Charges
incurred during a period of
remission
Definition:
A remission is a halt or actual reduction in
the progression of illness resulting in
discharge from a hospice care program with
no further expenses incurred. A re-admission
within 3 months of a prior discharge is
considered the same period of care. A new
period begins 3 months after a prior
discharge, with maximum benefits available.
|
All
charges
|
All
charges
|
| Ambulance |
|
|
- Local
professional ambulance service
only to and from a hospital, when
medically appropriate
|
PPO:
10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
|
PPO:
15% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
|
- All
other local ambulance service when
medically appropriate
- Air
ambulance to nearest facility where
necessary treatment is available if
no emergency ground transportation
is available or suitable and the
patient's condition warrants
immediate evacuation
|
PPO:
10% of the Plan allowance (calendar year
deductible applies)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount (calendar year deductible
applies)
|
PPO:
15% of the Plan allowance (calendar year
deductible applies)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount (calendar year deductible
applies)
|
Not
covered
- Ambulance
transport for you or your family's
convenience
- Air
ambulance if transport is beyond the
nearest available suitable facility,
but is requested by the patient or
physician for continuity of care or
other reasons
|
All
charges
|
All
charges
|
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