Connected Care California (CA) High Deductible Health Plan (HDHP) Details*

Transcription

1 Connected Care California (CA) High Health (HDHP) Details* The chart below provide key features (e.g., copayments, coinsurance, and deductibles) for the Connected Care CA HDHP option effective January 1, Please contact your Connected Care Concierge at for more information. The Concierge Center is open Monday-Friday, 8 a.m. - 6 p.m. Pacific Time. Additionally, your Connected Care member portal has your latest information about claims, balances and more. * The information provided here is a summary of your benefits and is not intended to take the place of or change official plan documents in any way. In the event of any discrepancy between the information in this guide and the 2019 Pay, Stock and Benefits Handbook (PSBH), the 2019 PSBH will prevail. What s included: Connected Care CA Overview page 2 Connected Care CA Medical Benefits pages 3-4 Connected Care CA Medical s - Mental Health Benefits page 5 Connected Care CA Medical s - Chemical Dependency Benefits page 5 Connected Care CA Medical s - Prescription Benefits page 6

2 Connected Care CA Overview s Provisions In-Network 1 Out-of-Network 1, 2 Where Available How the plan works Whenever coinsurance percentages are payable by you, you must first meet the deductible before coinsurance begins Optional Health Savings Account (HSA) Out-of-pocket Maximum Northern California Must use Connected Care network providers designated for your plan to receive the maximum benefit $1,350 individual $2,700 you and your children $3,375 you and your spouse or you, your spouse and your children May use any covered licensed practitioner of your choice You may use HSA funds to pay for eligible out-of-pocket medical expenses (i.e., deductible or coinsurance). Participants in the Connected Care HDHP may be eligible to fund an account with pre-tax dollars to cover outof-pocket expenses related to the plan. The account may be funded up to an annual maximum amount of $3,500 if you have single coverage or $7,000 if you have family coverage. There is no limit on rollover amounts. $2,100 individual $4,200 you and your children $5,000 you and your spouse or you, your spouse and your children Coinsurance and deductible are applied toward the out-of-pocket maximum Pre-existing conditional limitation Lifetime maximum per covered member Does not apply There is no lifetime limit on the dollar value of benefits. Specific coverage provisions may be subject to a lifetime maximum. In-hospital Preadmission Certification, Continued Stay Review (CSR), or Surgical Precertification Prior authorization/pre-certification is required

3 Connected Care CA Medical Benefits Provisions In-Network 1 Out-of-Network 1, 2 Unless otherwise indicated, your coinsurance is based on discounted fees after you have paid the deductible. Unless otherwise indicated, your coinsurance is based on MAA after you have paid the deductible. Primary Care - Office visit services Preventive Care Services Covered at 100% 40% coinsurance Specialist Physician Services Acupuncture Acupuncture limited to 30 visits per year; combined in- and out-of-network Naturopath Chiropractic Services Limited to 30 visits per year; combined in- and out-of-network Second Surgical Opinions No charge No charge Outpatient Laboratory and X-ray Services Outpatient Hospital Surgical Services. Inpatient Hospital Services - Semiprivate Room and Board Inpatient Hospital Services Hospital Emergency Room 5% coinsurance 5% of billed charges Urgent care facility Ambulance Emergency services: 5% coinsurance Emergency services: 5% coinsurance Coinsurance based on billed charges 40% coinsurance for non-emergencies 40% coinsurance for non-emergencies Maternity Services -Pre/Post Delivery Exams -Professional Services (physician charges) Maternity Services -Facility charges Prenatal covered at no charge before deductible. Other maternity services: No charge after you have paid the deductible See inpatient schedule 40% coinsurance See inpatient schedule Newborn care No charge after you have paid the deductible 40% coinsurance Birthing centers Same as inpatient hospital Same as inpatient hospital Home Birth No charge after you have paid the deductible 40% coinsurance Nurse midwife (covered if services performed in licensed medical facility) Services for infertility -Office visit and diagnosis -Inpatient Corrective Surgical Treatment (ICST) No charge after you have paid the deductible 40% coinsurance

4 Services for infertility - Assisted Reproductive Technology (ART) Outpatient physical, occupational, and speech therapy for short-term rehabilitative therapy Outpatient physical, Occupational, and speech therapy for developmental delay diagnosis ART combined in- and out-of-network lifetime maximum $40,000 Medical and $20,000 Pharmacy Unlimited visits combined in- and out-of network. Cardiac rehabilitation outpatient therapy Pulmonary therapy Dialysis treatment Family planning services - Physician office visit - Vasectomy - Tubal Ligation - Abortion (elective or spontaneous) Hearing services - Hearing exam - Hearing Aid (analog/digital) 5% coinsurance Batteries also covered 40% coinsurance Batteries also covered Nutritional counseling TMJ services Transplant services Travel and living expenses $10,000 lifetime maximum for expenses incurred in conjunction with authorized medical services or a transplant See Covered Services Weight reduction services Tobacco cessation services Orthotics Durable medical equipment External prosthetic appliances Other healthcare facilities (e.g., skilled nursing facilities, inpatient physical rehabilitation facilities) Home health care (noncustodial) Hospice 100% covered after deductible 40% coinsurance 1 Prior authorization may be required. 2 For the out-of-network provisions under the plans, once you meet the deductible you will be responsible for paying amounts in excess of the MAA which are not included when calculating the out-of-pocket maximum

5 Connected Care CA Medical s - Mental Health Benefits Provisions In-Network 1 Out-of-Network 1, 2 Unless otherwise indicated, your coinsurance is based on discounted fees after you have paid the deductible Unless otherwise indicated, your coinsurance is based on MAA after you have paid the deductible Inpatient or Alternate Care No separate deductible; plan deductible applies Outpatient Care 1 Prior authorization may be required. 2 For the out-of-network provisions under the plans, once you meet the deductible you will be responsible for paying amounts in excess of the MAA which are not included when calculating the out-of-pocket maximum Connected Care CA Medical s - Chemical Dependency Benefits Provisions In-Network 1 Out-of-Network 1,2 Unless otherwise indicated, your coinsurance is based on discounted fees after you have paid the deductible Unless otherwise indicated, your coinsurance is based on MAA after you have paid the deductible Inpatient or Alternate Care No separate deductible; plan deductible applies Outpatient care 1 Prior authorization may be required. 2 For the out-of-network provisions under the plans, once you meet the deductible you will be responsible for paying amounts in excess of the MAA which are not included when calculating the out-of-pocket maximum.

6 Connected Care CA Medical s - Prescription Benefits Provisions In-Network Out-of-Network No separate deductible; plan deductible applies Network Retail Pharmacy Program 30-day supply Mail Service Program 5% coinsurance Not available Limited to a 90-day supply Certain medications are covered at 100%. These drugs are used to treat conditions such as high blood pressure, high cholesterol, and diabetes. For a list of medications covered at 100%, contact your medical coverage option. Dispensing Limitation: If you request a brand-name drug when a generic is available and Dispense as Written (DAW) is not specified by your doctor, you will be responsible for paying the generic copayment plus the difference in cost between the brand-name drug and the generic medication. For information regarding medication coverage and cost estimates you can go to: Express-Scripts.com/inteloe (follow the link to the Connected Care California plan options)