RULES FOR NETWORK USE. A member is considered to have access to the network based on the type of services required, if there are: • Primary Care -Two primary care physicians (PCP) within 15 miles; • Specialty Care -Two specialty care physicians (SCP) within 20 miles; and • Hospital - One hospital within 25 miles. The distance between the member and provider is the center-point of one zip code to the center-point of the other. Member Costs Associated with In-Network or Out-of-Network Use Deductible In-Network $200/individual Out-of-Network $500/individual $400/family $1,000/family Effective January 1, 2009 $300/individual $600/family $600/individual $1,200/family Co-payments Effective October 1, 2008 Office Visits $10 Office Visits $15 Most services 10% Services 0% or 10% (See 2. below) Effective October 1, 2008 Emergency 0% Emergency room visit Emergency room visit $50 co-pay if not admitted $50 co-pay if not admitted Preventive Services Covered at 100%; limited to $1,500 per calendar year per person. Not covered Out-of-Pocket Maximum $1,000/individual $2,000/family $2,000/individual $4,000/family
RULES FOR NETWORK USE. A member is considered to have access to the network based on the type of services required, if there are: • Primary care -two primary care physicians (PCP) within 15 miles; • Specialty care -two specialty care physicians (SCP) within 20 miles; and • Hospital - one hospital within 25 miles. The distance between the member and provider is the center-point of one zip code to the center-point of the other. Member Costs Associated with In-Network or Out-of-Network Use Deductible In-Network $200/individual Out-of-Network $500/individual $400/family $1,000/family Co-payments Office Visits $10 Services 0% or 10% Emergency 0% Most services 10% (See 2. below) Preventive Services Covered at 100% Limited to $750 per calendar year per Not covered person. In January 2007, limit increases to $1,500 Out-of-Pocket Maximum $1,000/individual $2,000/individual $2,000/family $4,000/family
RULES FOR NETWORK USE. See Appendix E-2 for member costs. A member is considered to have access to the network based on the type of services required, if there are: • Primary Care -Two Primary Care Physicians (PCP) within 15 miles; • Specialty Care -Two Specialty Care Physicians (SCP) within 20 miles; and • Hospital - One hospital within 25 miles. The distance between the member and provider is the center-point of one zip code to the center-point of the other.
RULES FOR NETWORK USE. 34 A member is considered to have access to the network based on the type of services 35 required, if there are: 37 • Primary care -two primary care physicians (PCP) within 15 miles; 39 • Specialty care -two specialty care physicians (SCP) within 20 miles; and 41 • Hospital - one hospital within 25 miles. 42 43 The distance between the member and provider is the center-point of one zip code to 44 the center-point of the other.
RULES FOR NETWORK USE. The Rules for Network Use will be used by the parties in determining in and out-of- network benefits. In addition, the parties agree to set up a joint committee for the purpose of creating any additional guidelines and reviewing implementation. The committee will also be charged with identifying situations in which access to non- participating providers may be necessary and developing procedures to avoid balance billing in these situations. The parties have also discussed the fact that there are some state employees who do not live in Michigan. The following are procedures in place for persons living or traveling outside Michigan: Members who need medical care when away from Michigan can take advantage of the Third Party Administrator’s National PPO program. There is a toll-free number for members to call in order to be directed to the nearest PPO provider. The member is not required to pay the physician or hospital at the time of service if he/she presents the PPO identification card to the network provider. If a member is traveling he/she must seek services from a PPO provider. Failure to seek such services from a PPO provider will result in a member being treated as out-of-network unless the member was seeking services as the result of an emergency. If a member resides out of state and seeks non-emergency services from a non- PPO provider, he/she will be treated as out-of-network. If there is not adequate access to a PPO provider, exceptions will be handled on a per case basis.
