Benefits and Exclusions. Only medically necessary eligible services are covered. The State, after consultation with the JHCC, may carve-out procedures and services, including but not limited to, durable medical equipment, laboratory services, and prosthetics so that carved-out procedures and services may be provided by a vendor other than the participant’s health plan. After consultation with the JHCC, the Director of DAS may require participants to use centers of excellence for designated procedures or services. Additionally, upon the recommendation of the JHCC, the Director of DAS may place limits on certain benefits. 1. In-Patient Hospital Benefits: Health plans will offer at least the following hospital services: a. Unlimited duration of eligible medically necessary services except as provided herein. b. Semi-private room. c. Hospital ancillary services. d. Emergency room services. There is a seventy-five dollar ($75.00) charge for the use of the emergency room which does not result in an admission. If there is a penalty charge established by the Department of Administrative Services for the non- emergency use of a non-network hospital, it shall be no greater than $350. e. Diagnostic imaging and laboratory tests. f. All other eligible medically necessary treatments and procedures. 2. Other Than In-Patient Hospital Benefits Benefits for all health plans offered to State employees shall minimally include: a. Physician services. Routine office visits, house calls and consultations. Office visits provided by a network physician and billed by that office shall be covered at one hundred percent (100%) with no co-insurance or deductibles after a twenty dollar ($20.00) co-payment. If such visit, house call, or consultation is covered on an out-of-network basis, the participant shall pay a thirty dollar ($30.00) co-payment with no coinsurance or deductible. b. Outpatient medical services. c. Emergency medical services. d. Diagnostic laboratory and diagnostic and therapeutic radiological services. e. Infertility services to include diagnostic services to establish cause or reason for infertility. f. Preventive health care services, as recommended by the United States Preventive Services Task Force (USPSTF) guidelines shall be covered with no co-pay, co-insurance or deductible if provided by a network physician and shall include at least the following: (1) Screening colonoscopy beginning at age 50. (2) Routine physical examinations including routine lab profiles (including but not limited to cholesterol and other lab screenings). If coverage is available for non-network physicians, benefits shall be paid up to one hundred fifty ($150) maximum after the thirty dollar ($30.00) co-pay with no deductible or co- insurance: one (1) every two (2) years for ages 40-59; one (1) each year for ages 60 and over. (3) Cervical cancer screening, which at a minimum shall include annual gynecological physical examinations, including screenings and rescreenings for cervical cancer for women age 18 and over, and for women younger than 18 who are sexually active. Adjunctive technologies approved by the U.S. Food and Drug Administration in addition to traditional papanicolaou smears shall be covered. Additional testing for cervical cancer is covered when medically necessary. (4) Mammographies to detect the presence of breast cancer shall be covered as follows: Routine or screening mammography (age 35-39) one (1) in five (5) years, one (1) screening or diagnostic mammography during that five (5) year period; age 40 and older, annually covered; high risk individuals as needed, regardless of age. Mammography coverage will include both males and females; any additional mammogram(s) shall be covered subject to deductibles or co-payments. (5) Pre-natal obstetrical care and pre-natal care outreach. A prenatal outreach program to encourage prenatal care beginning in the first trimester. (6) Well child care. This includes the initial inpatient examination of a newborn infant. The plans cover annual physical exams including hearing examinations, developmental assessments, anticipatory guidance, immunizations (including, but not limited to meningococcal) and laboratory tests in accordance with the recommendations of the preventive care task force guidelines (or other recommending body as determined to be appropriate by the JHCC. (7) Immunizations as recommended by the centers for disease control and prevention guidelines. (8) PSA Testing Prostate Specific Antigen (PSA) screening. One (1) screening test per twelve (12) months for men age 40 and over. g. Skilled Nursing Facility, including Extended Care is covered at eighty percent (80%) for up to one hundred eighty (180) days for each confinement provided that the benefit must immediately follow a hospital confinement, or provided that the confinement will avoid a hospitalization which would otherwise be necessary. Coverage is at eighty percent (80%) of the UCR/allowed amount and not subject to deductibles and co-pays. Additional days of coverage for medically necessary care at sixty percent (60%) of the UCR/allowed amount and are not subject to deductibles. h. Allergy injections. i. Home Health Care Services: Home Health Care (noncustodial) services prescribed by a physician to treat a medical condition for which the patient was or would otherwise have been hospitalized shall be covered at eighty percent (80%) if provided by a network provider, and at sixty percent (60%) of UCR/allowed amount if provided by a non-network provider in plans that permit use of non-network providers. Such benefit shall not exceed one hundred eighty (180) days. j. Registered dietitian services for medically necessary conditions and obesity management up to two (2) visits per patient per condition per year. k. Physical therapy. l. Occupational therapy. m. Speech therapy.
Appears in 3 contracts
Samples: Collective Bargaining Agreement, Collective Bargaining Agreement, Collective Bargaining Agreement
Benefits and Exclusions. Only medically necessary eligible services are covered. The State, after consultation with the JHCC, may carve-out procedures and services, including but not limited to, durable medical equipment, laboratory services, and prosthetics so that carved-out procedures and services may be provided by a vendor other than the participant’s health plan. After consultation with the JHCC, the Director of DAS may require participants to use centers of excellence for designated procedures or services. Additionally, upon the recommendation of the JHCC, the Director of DAS may place limits on certain benefits.
1. In-Patient Hospital Benefits: Health plans will offer at least the following hospital services:
a. Unlimited duration of eligible medically necessary services except as provided herein.
b. Semi-private room.
c. Hospital ancillary services.
d. Emergency room services. There is a seventy-five one hundred dollar ($75.00100.00) charge for the use of the emergency room which does not result in an admission. For the plan year beginning July 1, 2020, there is a one-hundred and fifty dollar ($150.00) charge for the use of the emergency room which does not result in an admission. If there is a penalty charge established by the Department of Administrative Services for the non- emergency use of a non-network hospital, it shall be no greater than $350.
e. Diagnostic imaging and laboratory tests.
f. All other eligible medically necessary treatments and procedures.
2. Other Than In-Patient Hospital Benefits Benefits for all health plans offered to State employees shall minimally include:
a. Physician services. Routine office visits, house calls and consultations. Office visits provided by a network physician and billed by that office shall be covered at one hundred percent (100%) with no co-insurance or deductibles after a twenty dollar ($20.00) co-payment. Effective July 1, 2020, visits provided by a network physician and billed by that office shall be covered at one hundred percent (100%) with no co-insurance or deductibles after a thirty-dollar ($30.00) co-payment. If such visit, house call, or consultation is covered on an out- of-network basis, the participant shall pay a thirty dollar ($30.00) co-payment with no coinsurance or deductible. Effective July 1, 2020, if such visit, house call, or consultation is covered on an out-of-network basis, the participant shall pay a thirty fifty dollar ($30.0050.00) co-payment with no coinsurance or deductible.
b. Outpatient medical services.
c. Emergency medical services.
d. Diagnostic laboratory and diagnostic and therapeutic radiological services.
e. Infertility services to include diagnostic services to establish cause or reason for infertility.
f. Preventive health care services, as recommended by the United States Preventive Services Task Force (USPSTF) guidelines shall be covered with no co-pay, co-insurance or deductible if provided by a network physician and shall include at least the following:
(1) Screening colonoscopy beginning at age 50.
(2) Routine physical examinations including routine lab profiles (including but not limited to cholesterol and other lab screenings). If coverage is available for non-network physicians, benefits shall be paid up to one hundred fifty ($150) maximum after the thirty dollar ($30.00) co-pay with no deductible or co- insurance: one (1) every two (2) years for ages 40-59; one (1) each year for ages 60 and over.
(3) Cervical cancer screening, which at a minimum shall include annual gynecological physical examinations, including screenings and rescreenings for cervical cancer for women age 18 and over, and for women younger than 18 who are sexually active. Adjunctive technologies approved by the U.S. Food and Drug Administration in addition to traditional papanicolaou smears shall be covered. Additional testing for cervical cancer is covered when medically necessary.
(4) Mammographies to detect the presence of breast cancer shall be covered as follows: Routine or screening mammography (age 35-39) one (1) in five (5) years, one (1) screening or diagnostic mammography during that five (5) year period; age 40 and older, annually covered; high risk individuals as needed, regardless of age. Mammography coverage will include both males and females; any additional mammogram(s) shall be covered subject to deductibles or co-payments.
(5) Pre-natal obstetrical care and pre-natal care outreach. A prenatal outreach program to encourage prenatal care beginning in the first trimester.
(6) Well child care. This includes the initial inpatient examination of a newborn infant. The plans cover annual physical exams including hearing examinations, developmental assessments, anticipatory guidance, immunizations (including, but not limited to meningococcal) and laboratory tests in accordance with the recommendations of the preventive care task force guidelines (or other recommending body as determined to be appropriate by the JHCC.
(7) Immunizations as recommended by the centers for disease control and prevention guidelines.
(8) PSA Testing Prostate Specific Antigen (PSA) screening. One (1) screening test per twelve (12) months for men age 40 and over.
g. Skilled Nursing Facility, including Extended Care is covered at eighty percent (80%) for up to one hundred eighty (180) days for each confinement provided that the benefit must immediately follow a hospital confinement, or provided that the confinement will avoid a hospitalization which would otherwise be necessary. Coverage is at eighty percent (80%) of the UCR/allowed amount and not subject to deductibles and co-pays. Additional days of coverage for medically necessary care at sixty percent (60%) of the UCR/allowed amount and are not subject to deductibles.
h. Allergy injections.
i. Home Health Care Services: Home Health Care (noncustodial) services prescribed by a physician to treat a medical condition for which the patient was or would otherwise have been hospitalized shall be covered at eighty percent (80%) if provided by a network provider, and at sixty percent (60%) of UCR/allowed amount if provided by a non-network provider in plans that permit use of non-network providers. Such benefit shall not exceed one hundred eighty (180) days.
j. Registered dietitian services for medically necessary conditions and obesity management up to two (2) visits per patient per condition per year.
k. Physical therapy.
l. Occupational therapy.
m. Speech therapy.
Appears in 1 contract
Samples: Collective Bargaining Agreement
Benefits and Exclusions. Only medically necessary eligible services are covered. The State, after consultation with the JHCC, may carve-out procedures and services, including but not limited to, durable medical equipment, laboratory services, and prosthetics so that carved-out procedures and services may be provided by a vendor other than the participant’s health plan. After consultation with the JHCC, the Director of DAS may require participants to use centers of excellence for designated procedures or services. Additionally, upon the recommendation of the JHCC, the Director of DAS may place limits on certain benefits.
1. In-Patient Hospital Benefits: Health plans will offer at least the following hospital services:
a. Unlimited duration of eligible medically necessary services except as provided herein.
b. Semi-private room.
c. Hospital ancillary services.
d. Emergency room services. There is a seventy-five one hundred dollar ($75.00100.00) charge for the use of the emergency room which does not result in an admission. For the plan year beginning July 1, 2020, there is a one-hundred and fifty dollar ($150.00) charge for the use of the emergency room which does not result in an admission. If there is a penalty charge established by the Department of Administrative Services for the non- emergency use of a non-network hospital, it shall be no greater than $350.
e. Diagnostic imaging and laboratory tests.
f. All other eligible medically necessary treatments and procedures.
2. Other Than In-Patient Hospital Benefits Benefits for all health plans offered to State employees shall minimally include:
a. Physician services. Routine Xxxxxxx office visits, house calls and consultations. Office visits provided by a network physician and billed by that office shall be covered at one hundred percent (100%) with no co-insurance or deductibles after a twenty dollar ($20.00) co-payment. Effective July 1, 2020, visits provided by a network physician and billed by that office shall be covered at one hundred percent (100%) with no co-insurance or deductibles after a thirty-dollar ($30.00) co-payment. If such visit, house call, or consultation is covered on an out- of-network basis, the participant shall pay a thirty dollar ($30.00) co-payment with no coinsurance or deductible. Effective July 1, 2020, if such visit, house call, or consultation is covered on an out-of-network basis, the participant shall pay a thirty fifty dollar ($30.0050.00) co-payment with no coinsurance or deductible.
b. Outpatient medical services.
c. Emergency medical services.
d. Diagnostic laboratory and diagnostic and therapeutic radiological services.
e. Infertility services to include diagnostic services to establish cause or reason for infertility.
f. Preventive health care services, as recommended by the United States Preventive Services Task Force (USPSTF) guidelines shall be covered with no co-pay, co-insurance or deductible if provided by a network physician and shall include at least the following:
(1) Screening colonoscopy beginning at age 50.
(2) Routine physical examinations including routine lab profiles (including but not limited to cholesterol and other lab screenings). If coverage is available for For non-network physicians, benefits shall be paid up to one hundred fifty ($150) maximum after the thirty dollar ($30.00) co-pay, or fifty dollar ($50.00) co-pay effective July 1, 2020, with no deductible or co- co-insurance: one (1) every two (2) years for ages 40-59; one (1) each year for ages 60 and over.
(3) Cervical cancer screening, which at a minimum shall include annual gynecological physical examinations, including screenings and rescreenings for cervical cancer for women age 18 and over, and for women younger than 18 who are sexually active. Adjunctive technologies approved by the U.S. Food and Drug Administration in addition to traditional papanicolaou smears shall be covered. Additional testing for cervical cancer is covered when medically necessary.
(4) Mammographies to detect the presence of breast cancer shall be covered as follows: Routine or screening mammography (age 35-39) one (1) in five (5) years, one (1) screening or diagnostic mammography during that five (5) year period; age 40 and older, annually covered; high risk individuals as needed, regardless of age. Mammography coverage will include both males and females; any additional mammogram(s) shall be covered subject to deductibles or co-payments.
(5) Pre-natal obstetrical care and pre-natal care outreach. A prenatal outreach program to encourage prenatal care beginning in the first trimester.
(6) Well child care. This includes the initial inpatient examination of a newborn infant. The plans cover annual physical exams including hearing examinations, developmental assessments, anticipatory guidance, immunizations (including, but not limited to meningococcal) and laboratory tests in accordance with the recommendations of the preventive care task force guidelines (or other recommending body as determined to be appropriate by the JHCC).
(7) Immunizations as recommended by the centers for disease control and prevention guidelines.
(8) PSA Testing Prostate Specific Antigen (PSA) screening. One (1) screening test per twelve (12) months for men age 40 and over.
g. Skilled Nursing Facility, including Extended Care is covered at eighty percent (80%) for up to one hundred eighty (180) days for each confinement provided that the benefit must immediately follow a hospital confinement, or provided that the confinement will avoid a hospitalization which would otherwise be necessary. Coverage is at eighty percent (80%) of the UCR/allowed contracted allowable amount and not subject to deductibles and co-pays. Additional days of coverage for medically necessary care at sixty percent (60%) of the UCR/allowed contracted allowable amount and are not subject to deductibles.
h. Allergy injections.
i. Home Health Care Services: Home Health Care (noncustodial) services prescribed by a physician to treat a medical condition for which the patient was or would otherwise have been hospitalized shall be covered at eighty percent (80%) if provided by a network provider, and at sixty percent (60%) of UCR/allowed contracted allowable amount if provided by a non-network provider in plans that permit use of non-network providers. Such benefit shall not exceed one hundred eighty (180) days.
j. Registered dietitian services for medically necessary conditions and obesity management up to two (2) visits per patient per condition per year.
k. Physical therapy.
l. Occupational therapy.
m. Speech therapy.
Appears in 1 contract
Samples: Collective Bargaining Agreement