Benefit Maximums. Some of the Authorized Benefits and Services described in this Certificate are covered for a limited number of days or visits per Contract Year. This is known as a benefit maximum. The Schedule of Out-of-Pocket Expense attached to this Certificate lists the maximums that apply to certain benefits. Once you have reached a maximum for a Covered Service, you will be responsible for the cost of additional services received during that Contract Year even when continued care is Medically/Clinically Necessary.
Benefit Maximums. Annual Deductible and Out‐of‐Pocket Maximums Deductible and Out‐of‐ Pocket Maximums In‐Network Out‐of‐Network Annual Deductible (per Calendar Year) Individual $2,000 $5,000 Family $4,000 $10,000 Coinsurance (plan pays) 70% 50% Annual Out‐of‐Pocket Maximum (per Calendar Year) Individual $6,350 N/A Family $12,700 N/A SCHEDULE OF MEDICAL BENEFITS COMMUNITY HEALTHESSENTIALS Benefit Copay Applies to Deductible In‐Network Providers (plan pays) Out‐of‐Network Providers (plan pays) Acupuncture 12 visits per Calendar Year (except when provided for Chemical Dependency treatment). No Yes 70% 50% Ambulance Services No Yes 70% 50% Anesthesia No Yes 70% 50% Autologous Blood Donation/Blood Transfusion No Yes 70% 50% Chemical Dependency (inpatient, residential and partial hospitalization services) Pre‐authorization is required. Inpatient (facility and professional) No Yes 70% 50% Outpatient (facility) No Yes 70% 50% Outpatient (professional) No Yes 70% 50% Acupuncture (when provided for Chemical Dependency conditions, services do not apply to the overall acupuncture maximum benefit) No Yes 70% 50% Diabetic Education and Diabetic Nutrition Education In Office (Primary Care Provider) $0 In‐Network Providers only Out‐of‐ Network Providers only 100% after Copay 50% In Office (Specialist) $0 In‐Network Providers only Out‐of‐ Network Providers only 100% after Copay 50% COMMUNITY HEALTHESSENTIALS Benefit Copay Applies to Deductible In‐Network Providers (plan pays) Out‐of‐Network Providers (plan pays) All other places of Out‐of‐ service No Network Providers 100% 50% only Durable Medical Equipment Pre‐authorization required if purchases exceed $2,000 or $500 per month rental. Breast Pumps No Out‐of‐ Network Providers only 100% 50% Durable Medical Equipment No Yes 70% 50% Medical Supplies No Yes 70% 50% Orthopedic Appliances No Yes 70% 50% Prosthetic Devices No Yes 70% 50% Emergency Care Services Emergency Care Services Copay waived if admitted as an inpatient within 24 hours $250 No 100% after Copay 100% after Copay Urgent Care $55 Out‐of‐ In‐Network Providers Network Providers 100% after Copay 50% only only Family Planning Office visits $0 Out‐of‐ In‐Network Providers Network Providers 100% after Copay 50% only only Devices, implants and $0 Out‐of‐ injections In‐Network Providers Network Providers 100% after Copay 50% only only COMMUNITY HEALTHESSENTIALS Benefit Copay Applies to Deductible In‐Network Providers (plan pays) Out‐of‐Network Providers (...
Benefit Maximums. The Plan pays up to the annual benefit maximum amounts (listed on the Summary of Benefits insert for the Program under which you are covered) per person each year.
Benefit Maximums. Effective January 1, 2010 medically necessary inpatient alcohol and substance abuse treatment shall be unlimited.
Benefit Maximums. Members must continue to pay any applicable copayments, Prescription Drug copayments and penalty amounts after meeting their Out-of- Pocket Maximum. Maximum Benefit Unlimited per Member per lifetime OUTPATIENT BENEFITS Benefit Copayment Primary Care Physician Services Adult Physical Examination including Immunizations Visits are subject to the following visit maximum Adults 18-65 years old 1 visit per 12 month period Adults over 65 years old 1 visit per 12 month period Well Child Physical Examination including Immunizations Office Hours Visits After-Office Hours Visits E-visit by a Primary Care Physician $0 per visit $0 per visit $40 per visit $40 per visit $30 per visit Specialist Physician Services Office Visits (Non-surgical E-visit by a Specialist $60 per visit $30 per visit Walk In Clinic Visit $40 per visit Routine Gynecological Exam(s) 1 visit(s) per Calendar Year $0 per visit Prenatal Visits by the attending Obstetrician $0 per visit OUTPATIENT BENEFITS (continued) Benefit Copayment Outpatient Physical, Occupational and Speech Therapy 30 combined Physical, Occupational and Speech Therapy visits per Calendar Year; 30% (of the contracted rate) after Deductible per visit Outpatient Facility Visits 30% (of the contracted rate) after Deductible per visit Diagnostic X-Ray Testing Performed at a Hospital Outpatient Facility Complex Imaging Services, including, but not limited to: Magnetic Resonance Imaging (MRI); Computerized Axial Tomography (CAT); and Positron Emission Tomography (PET); and any other outpatient diagnostic imaging service costing over $500. Performed at a facility other than a Hospital Outpatient Facility Complex Imaging Services, including, but not limited to: Magnetic Resonance Imaging (MRI); Computerized Axial Tomography (CAT); and Positron Emission Tomography (PET); and any other outpatient diagnostic imaging service costing over $500. $100 per visit 30% (of the contracted rate) after Deductible per visit $100 per visit 30% (of the contracted rate) after Deductible per visit Mammography (Diagnostic) $100 per visit Diagnostic Laboratory Testing Performed at a Hospital Outpatient Facility Performed at a facility other than a Hospital Outpatient Facility $40 per visit $40 per visit OUTPATIENT BENEFITS (continued) Benefit Copayment Colorectal Cancer Screening Services Fecal Occult Blood Test Age 50 and over 1 test per calendar year Sigmoidoscopy Age 50 and over 1 test per 5 consecutive year period Double Contrast Barium Enema (DCBE) Age ...
