Surgical Benefits. The Contractor shall cover Behavioral Health Benefits in a manner that is no more restrictive than the coverage for Medical/Surgical Benefits. Attachment A, “Schedule of In-Plan Benefits” identifies the types and amount, duration, and scope of services and is consistent with EOHHS’ parity analysis. The Contractor may cover additional services necessary to comply with the requirements for parity in Behavioral Health Benefits in 42 C.F.R. Part 438, Subpart K; however, the Contractor must provide advance written notice to and receive prior written approval from the EOHHS Managed Care Director when it believes this requirement is triggered. The Contractor shall not:
Surgical Benefits. Major medical benefits. The Board reserves the right to change the carrier. However, the benefits under a new carrier must be at least equal to those of the State Health Benefit Program. The Board shall provide a Prescription Drug Program covering employee, spouse and family. Such program shall be with a $10.00 deductible co-insurance feature for non-generic drugs and a $5.00 deductible co-insurance feature for generic drugs, and a $0 feature for mail-in refills. The Board shall provide a Dental Program with coverage equal to or better than coverage under the prior agreement. The coverage shall include 90/10 co-insurance provision with a zero deductible. This program shall cover employee and dependents. Orthodontic coverage shall continue a 50-50 split, but to a maximum of Two Thousand Dollars ($2,000.00). Orthodontic shall include adult coverage.
Surgical Benefits. (a) Doctor's bill will be paid fo gical operations according to a standard "Sched ule of Operations" as set forth in the insurance certificate, maximum payment $350.00.
(b) Obstetrical benefits will be pay able as follows after nine (9) months of coverage, as provided in the policy: Normal delivery $125.00, Caesarean section $225.00, Miscarriage $62.50.
(c) Anesthesia benefits payable when anesthesia is administered by other than a hos pital employee in accordance with the following schedule: Surgical Payment Anesthesia Benefit Less than $50.00 $10.00 $50.00 but less than $75.00 15.00 $75.00 and over 20% of the amount of the Surgical Payment Anesthesia payment for maternity cases is $15.00, payment for caudal anesthesia for obstetrical de liveries is $25.00.
Surgical Benefits. The Plan pays charges for surgery by a Physician, including medical and surgical benefits in connection with a mastectomy. In addition, in compliance with federal law, the Plan provides benefits for certain reconstructive surgery the same as other medical and surgical benefits. This covers reconstruction of the breast on which the mastectomy was performed, surgery on the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of all stages of mastectomy, including lymphedemas. The Plan pays charges for Physician visits, including Physician office visits, subject to any required copayments. The Plan pays for the following medical services: • Local ambulance service; • Blood and blood plasma; • Appliances; • X-rays; • Laboratory tests; • Anesthesia and its administration; • Use of radium and radioactive isotopes; and • Oxygen. The Plan complies with federal law that prohibits restricting benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section. Health care providers are not required to obtain authorization from the Plan for hospital stays within these guidelines. Federal law does not prohibit the physician, after consultation with the mother, from discharging the mother and/or her newborn earlier than 48 (or 96) hours. The Plan pays surgical benefits performed by non-PPO Providers based on the Allowable Charge. The Plan pays benefits up to the amounts listed on the Summary of Benefits insert for the Program under which you are covered. Benefits are paid for both the organ donor and the organ recipient, provided both are eligible under this Plan. No benefits are payable for any expenses incurred for Experimental or Investigative procedures. The following organ procurement expenses will be paid when the transplant is performed in an in-network facility: • Hospital expenses incurred by a donor(s) as related to the transplant; • Testing to identify suitable donor(s) • The expense of life support of a donor pending the removal of a usable organ; and • Transportation of organ(s) or a donor on a life support system. You must call the Plan’s UR provider for preauthorization before receiving any transplant services. If you do not call for preauthorization, benefits paid by the Plan will be reduced by 50%. Any additional amounts you pay when preauthorization is not obtai...
Surgical Benefits. (a) Doctor’s bill will be paid for surgical operations according to a standard “ Schedule of Operations” as set forth in the insurance certi ficate; maximum payment $350.00.
(b) Obstetrical benefits will be payable as fol lows after nine (9) months of coverage, as pro vided in the policy: Normal delivery $125.00; Caesarean section $225.00; Miscarriage $62.50.
(c) Anesthesia benefits payable when anesthesia is administered by other than a hospital employee in accordance with the following schedule: Surgical Payment Anesthesia Benefit Less than $50.00 $10.00 $50.00 but less than $75.00 $15.00 $75.00 and over 20% of the amount of the Surgical Payment. Anesthesia payment for maternity cases is $15.00; payment for caudal anesthesia for obste trical deliveries is $25.00.
