Common use of Other Than In-Patient-Hospital Benefits Clause in Contracts

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 fifty dollar ($50.00) 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). For non-network physicians, benefits shall be paid after the thirty dollar ($30.00) co-pay, or fifty dollar ($50.00) co-pay effective July 1, 2020, 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 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 pre-natal outreach program to encourage pre-natal 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 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 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 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 contracted allowable 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.

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 fifty fifty-dollar ($50.00) 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. In Vitro fertilization and embryo transplantation, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and any costs associated with the collection, preparation or storage of sperm for artificial insemination (including donor fees) coverage applicable to the cost sharing as referenced in Section 55.03 B, Cost Sharing, not to exceed a twenty thousand dollar ($20,000) lifetime benefit. f. Preventive health care services, as recommended by the United States preventive services task force (USPSTF) guidelines shall be covered with no co-paycopay, co-insurance or deductible if provided by a network physician and shall include at least the following: (1) Screening colonoscopy beginning at age 5045. (2) Routine physical examinations including routine lab profiles (including but not limited to cholesterol and other lab screenings). For non-network physicians, benefits shall be paid after the thirty dollar ($30.00) co-pay, or fifty dollar ($50.00) co-pay effective July 1, 2020copay, with no deductible or co-insurance: one (1) every two (2) years for ages 40- 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 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 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 pre-natal outreach program to encourage pre-natal 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 Centers for disease control Disease Control and prevention Prevention guidelines. (8) PSA Testing Prostate Specific Antigen (PSA) Testing PSA screening. One (1) screening test per 12 months for men age 40 and over. (9) Skin Cancer Screening. One (1) screening test per twelve (12) months. 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 contracted allowable amount and not subject to deductibles and co-payscopays. Additional days of coverage for medically necessary care at sixty percent (60%) of the 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 contracted allowable 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 six (26) visits per patient per condition member per year. k. Physical therapy. l. Occupational therapy. m. Speech therapy.