On This Page: Physician Services, Hospital Services, Vision, Wellness, Mental and Substance Abuse, Prescription Drugs |
|
| Low Option (Plan L) Coverage Option
| With the cost of health care being what it is, no one should be without coverage if at all possible. Therefore, if you meet the requirements described below, you may be offered the opportunity to pay for the Low Option Plan, a limited insurance coverage option.
The Low Option plan is only available to participants on COBRA or those in the Extended Coverage program. This option is a self-pay option and provides medical and hospital coverage only. The plan does not provide coverage for: life insurance, accidental death and dismemberment (AD&D) insurance, prescription drug, dental, vision or wellness benefits.
Under this option, you have the choice between receiving services through a Preferred Provider Organization (PPO) or providers you choose on your own. When you use a PPO provider, you not only help the Fund control expenses, but you pay a lesser percentage of a negotiated rate. You receive the advantages of assignment of benefits (provider bills the Fund directly) and that the provider should not charge more than the negotiated rate.
Blue Cross provides the California Hospital and Physician network effective 01/01/2004. |
| |
|
| PPO
Provider | Non-PPO
Provider
|
| |
|
|
| LIFETIME MAXIMUM
| $5,000,000
| $5,000,000
|
| |
|
|
| CALENDAR YEAR DEDUCTIBLE
| $750/ person
$2250/ family
| $750/ person
$2250/ family
|
| |
|
|
|
OUT-OF-POCKET EXPENSE
LIMITATIONS (after deductible) 1 | $4,500 2
|
$4,500 2 |
| |
|
|
| PHYSICIAN SERVICES
|
|
| Office Visit (including x-ray & laboratory)
| 70%
| 60%
|
| |
|
|
| Periodic Health Assessment 3 | Not Covered | Not Covered |
| |
|
|
| Well Baby Care 3 | Not Covered | Not Covered |
| |
|
|
| Immunizations3 | Not Covered | Not Covered |
| |
|
|
| In-Hospital Visits Maternity Care (Pre-natal, delivery, post-natal) | 70% | 60% |
| |
|
|
HOME HEALTH CARE
HOME INFUSION THERAPY
& SKILLED HOME NURSING
(All treatment must be reviewed for medical necessity through case-management .)
|
| Mandatory Case
Management
Authorization
| Mandatory
Case
Management
Authorization
|
| |
|
|
HOSPICE CARE
All treatment must be reviewed for medical necessity through case-management .
|
|
Mandatory
Case
Management
Authorization
|
Mandatory
Case
Management
Authorization
|
| |
|
|
|
HEARING AIDS
|
One device per ear every three years, reimbursed @ 50% up to an allowable charge of $2,000 per device, after satisfaction of plan deductible.
|
One device per ear every three years, reimbursed @ 50% up to an allowable charge of $2,000 per device, after satisfaction of plan deductible.
|
| |
|
|
| HOSPITAL SERVICES
|
|
|
PPO Provider
|
Non-PPO Provider
|
| |
|
|
|
Inpatient (Room and Board, within Plan limits, and Ancillary Services)
| 70% after a $100 per admission co-pay | 60% after a $100 per admission co-pay |
| |
|
|
Outpatient
Outpatient Surgery
| 70%
70% | 60%
60% |
| |
|
|
| Outpatient Lab or X-Ray | 70% | 60% |
| |
|
|
| Emergency Room | 70% after $50 co-pay (waived if admitted) | 60% after $50 co-pay (waived if admitted) |
| |
|
|
| Ambulatory Surgery Center | 70% | $1,500 incident maximum |
| |
|
|
| ACUPUNCTURE, BIOFEEDBACK, MANIPULATIONS OF THE MUSCULOSKELETAL SYSTEM,
OCCUPATIONAL THERAPY, OSTEOPATHIC MANIPULATIVE TREATMENT AND OUTPATIENT
PHYSICAL THERAPY
| 70% of up to $60 per visit, to a maximum of 50 visits per Calendar Year | 60% of up to $60 per visit, to a maximum of 50 visits per Calendar Year |
| |
|
|
|
INFERTILITY
|
Not Covered
|
Not Covered
|
| |
|
|
CHILD IMMUNIZATION & ALL ASSOCIATED
|
Through age 6
|
| Age 7 and above (see Wellness Plan) |
|
|
|
| |
|
|
|
VISION PLAN
| Not covered.
| Not covered. |
| |
|
|
|
WELLNESS PLAN
| Not covered. | Not covered. |
| |
|
|
| MENTAL AND NERVOUS AND SUBSTANCE ABUSE 4
PBH and Non-PBH provider visits are integrated for purposes of the annual visit limits, meaning they cross accumulate. |
|
| Non-PBH Provider |
|
| Inpatient | 70% of reasonable and customary charges after a $200 inpatient co-payment per admission, up to a maximum of 14 days per lifetime. Regular plan deductible applies.
|
| |
|
| Outpatient | 70% of reasonable & customary up to a maximum of 20 visits per Calendar Year
(Regular plan deductible applies.) |
| |
|
| PBH PROVIDER
|
|
| Inpatient | 100% after a $200 inpatient co-pay per confinement for a maximum of 45 days
per Calendar Year |
| |
|
| Outpatient | 100% after a $15 co-pay up to a maximum of 45 visits/ year for non-SMI or
70 visits/ year for SMI (Serious Mental Illness) |
| |
|
| PRESCRIPTION DRUGS | Not covered. |
| |
|
|
|
| 1 | When reached, benefits (other than Mental and Nervous and Substance Abuse)
are payable at 100% of usual and customary allowance, for the rest of the Calendar
Year. |
| |
|
| 2 | For those Medicare Eligible Certified Retirees and their Medicare eligible
dependents/same-sex domestic partners having benefits paid on a "carve-out"
basis, in the Out-of-Pocket Expense Benefit (after deductible) is $400 for PPO
providers and $600 for non-PPO providers. |
| |
|
| 3 |
Limited coverage as defined in SPD is
extended for dependents age 6 and under.
|
| |
|
| 4 |
PBH and Non-PBH provider visits are integrated for purposes of the annual visit
limits, meaning they cross accumulate.
|
| |
|
|
|
| Disclaimer | NOTE: This is only a brief summary of your benefits. All benefit descriptions contained herein are governed by the limitations and other information contained in your SPD.
|
| |
|
