Download annual open enrollment - health insurance only

This booklet has been developed to assist you in evaluating your health care options and to help guide you through
the complexities of the benefits program. We have attempted to give you as much information as possible in the
limited space available, but we could not include every detail of every plan. Actual benefits are determined by each
of the plan contracts and those will prevail with any misinterpretations. This guide does not express all of the terms
or conditions of those contracts. Therefore, if you have any questions concerning your benefits, please consult your
contract, call the Health Plan directly, or call the Benefits Division at (608) 663-1746.
YOUR CHOICES
The Madison Metropolitan School District (MMSD) offers a choice of health insurance plans to you.
You may choose from Dean Health Plan PPO, Group Health Cooperative of South Central Wisconsin PPO (GHCSCW PPO) or Unity Health Insurance PPO.
SELECTION PROCESS
To assist you in your selection process, the Benefit Comparison Guide was developed. Refer to this section to
compare the plans for which you are eligible and choose the plan that best fits your needs. Remember that each plan
is different from the others, so you should determine whether the available physicians, premium level, benefit
coverage, and type of health care delivery system are appropriate for you. All plans have some restrictions,
exclusions, or limitations, so you should investigate all possibilities before making your choice. Feel free to call the
Member Services Department of any plan should you have specific questions:
Dean: 800-279-1301
GHC-SCW: 608-828-4853
Unity: 800-362-3310
OUT-OF-AREA EMERGENCY CARE AND COVERAGE
Out of area urgent and emergency care is covered. Services with non-plan providers are subject to reasonable and
customary charges.. Members need to contact Member Services for their provider within 48 hours of the care. NonEmergency care is not covered unless prior authorization has been approved. $50 emergency room co-pay for all
services is waived if you are admitted to the hospital.
In the event of a life-threatening emergency, visit one of the hospitals emergency rooms participating in the plan’s
network. If that is not possible, proceed immediately to the nearest hospital emergency room. In both situations, you
must contact GHC’S Care management Department at 800-605-4327 Ext. 4514, Dean Health Plan(DHP) at 1-800279-1301, Unity Health Insurance at 800-362-3310, within 48 hours when out-of-area care is received.
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WHO IS ELIGIBLE?
Any employee hired to work more than one-half time (19 or more hours per week or a 50% or more contract) is
eligible to participate in the benefit plans and to receive Board of Education contribution to those plans.
WHEN DO YOU BECOME ELIGIBLE?
Most new employees become eligible for health, dental, life and long-term care coverage on the first of the month
following one month of employment. Example: If hired on September 17th, coverage begins November 1st.
Employees who have their hours increased to more than half time become eligible the first of the month following
one month of employment at the increased level.
HOW TO ENROLL
Eligible employees (see above) must submit their applications within one month of their date of hire or date of
increased hours to participate in the insurance plans in Initial Eligibility. You and your eligible dependents will be
accepted into the plans without limitation or restriction if your application is received within that one-month time
frame. Late applications will result in delayed enrollment between 3 months and one year, depending on the plan
and may have to be approved through medical underwriting for some benefits.
Application forms are included in new employee orientation materials and some are available on the “Staff Only”
area of the District website: https:hrweb.madison.k12.wi.us/empbenefits or through the Benefits Division at
(608)663-1746.
ENROLLING DEPENDENTS
In order to be accepted eligible dependents must be enrolled under the same time-line as a new employee. These
dependents will be enrolled through the same application as the employee.
New dependents acquired through marriage or partnership must be added to your plan within 30 days of the
marriage or formation of partnership in order to avoid longer waiting periods and/or other coverage
limitations/restrictions. If applications are received in a timely manner, coverage will be effective as of the date of
the event.
New dependents acquired through birth or adoption must be added to your plan within 60 days of the date of birth or
legal adoption placement date in order to avoid longer waiting periods and/or other coverage limitations/restrictions.
If applications are received in a timely manner, coverage will be effective as of the date of the event.
SPECIAL RULES FOR MARRIED EMPLOYEES WHO BOTH WORK FOR THE DISTRICT
If two employees are married to each other, they are eligible for one family policy and one single policy under
dental insurance. They are not eligible for two family policies under health or dental.
DESIGNATED FAMILY PARTNERS
Currently, all employee groups have insurance coverage options available for designated family partners. If you are
interested in this coverage, call the Benefits Division at (608) 663-1746 for more information.
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WHAT IF YOU DON'T ENROLL DURING INITIAL ELIGIBILITY?
If you, or your dependents, do not enroll in the benefits plans during Initial Eligibility and decide to enroll later,
you and each of your dependents may have to submit health questionnaires, and/or may be subjected to longer
waiting periods. In some situations, you may be considered ineligible for coverage.
There are three exceptions to this rule: 1. If you qualify for future OPEN ENROLLMENT (see OPEN
ENROLLMENT section). 2. If you and/or your dependents are covered under another health/dental plan and that
coverage is lost, you may enroll yourself and your eligible dependents into the MMSD plans without restrictions
within 30 days of the loss of coverage. 3. If you are covered by the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), you may be accepted into the medical plan without a longer waiting period. Please contact
the Benefits Division for further information.
ANNUAL OPEN ENROLLMENT - HEALTH INSURANCE ONLY
All eligible employees may participate in Open Enrollment for health insurance each year. (There is no annual
open enrollment for dental insurance). The Open Enrollment application period is October 15 through November
15 of each year with the insurance effective date being the following January 1. During this period, eligible
employees without health insurance have the opportunity to enroll in the District group health plans just as if they
were a new employee. Employees who currently have coverage may add any eligible, uncovered dependents during
this time period. Details of the Annual Open Enrollment program are available to employees each year.
MAY I CHANGE MY INSURANCE CARRIER?
Yes. Once each year, between mid October and early November, we have our Annual Choice period. During this
time eligible employees and their families, who are currently receiving health insurance through a participating
District plan, may elect to switch to the other available option for which they are eligible. New coverage becomes
effective on January 1. Details of the Annual Choice program are available to employees each year. Should
extenuating circumstances exist, the District has the right to extend the Annual Choice deadline. Employees will be
notified of this extension should it occur.
HOW TO CANCEL COVERAGE
If, for some reason, you want to cancel your insurance coverage, you simply need to notify the Benefits Division, in
writing, indicating that you wish to cancel coverage. This should only be done after careful consideration of your
alternatives. Coverage will end the end of the month in which written request is received.
CANCELING DEPENDENTS
Should you desire to cancel dependent coverage on one or more dependents, you must complete new applications
eliminating coverage on the affected dependents.
You must notify the benefits department within 30 days of an event such as Divorce or loss of
dependent status. You must complete a new application as required by the insurance company.
DENTAL COVERAGE
The District offers dental care coverage to eligible employees. Initial Eligibility follows the same enrollment
criteria as medical insurance, see “WHO IS ELIGIBLE?”, “WHEN DO YOU BECOME ELIGIBLE?” and “HOW
TO ENROLL.”. A summary of the plan is located on page 21 of this booklet.
There is no Open Enrollment or Annual Choice with the Dental Plan. Those who apply for coverage after the
Initial Eligibility period will be subject to a three-month delay in their coverage effective date, and may apply at
anytime. Example: Initial Eligibility of September 10th. Application is received October 25, 15 days beyond the
one-month enrollment period. Coverage would be effective as of January 1 st (3 month delay).
One exception is if you and/or your dependents are covered under another dental plan and that coverage is lost, with
proof of coverage loss, you may enroll yourself and your eligible dependents into the MMSD plan without
restrictions within 30 days of the loss of coverage.
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LIFE INSURANCE
Life insurance is available through the District. Separate Life brochures and related rate schedules are available
within your new employee orientation materials or through the Benefits Division at 663-1697. Enrollment deadline
for employees to receive guaranteed issue is within one month of the first day of work or date of eligibility.
Enrollment for employees past this initial enrollment period is administered through medical underwriting.
LONG TERM CARE INSURANCE
The District offers long term care insurance to eligible employees, spouses, partners and other eligible family
members. Enrollment deadline for employees to receive guaranteed issue is within one month of the first day of
work or date of eligibility. Enrollment for employees past this initial enrollment period and for all eligible family
members is administered through medical underwriting.
LONG TERM DISABILITY
The District also covers all eligible employees with LTD coverage. A separate plan description is available
concerning this coverage. Coverage for the LTD plan is automatic on the first day of employment for all benefit
eligible employees and is fully paid by the District.
TERMINATION OF COVERAGE
Health and Dental Insurance: Coverage extends through the month following termination of employment. Teachers
who terminate at the end of a school year will have coverage through August of that year. All other employees
terminating at the end of a school year have coverage through July of that year.
Life Insurance: Coverage extends through the month of termination of employment.
SUMMER RESIGNATIONS – Any school-year employee who resigns, retires or otherwise terminates during the
summer will have their termination date backdated to the last day of work. All coverage extensions will be based on
the last day worked.
COBRA AND WISCONSIN EXTENSION RIGHTS
Under most cases of termination or resignation, you and your dependents are eligible for insurance continuation
coverage under COBRA and/or the Wisconsin Insurance Extension law. Should you or your family experience a
qualifying event you must notify the Benefits Division (663-1746) to protect your COBRA and Wisconsin Insurance
Extension rights. Insurance continuation information will be sent explaining your rights and benefits by the Benefits
Division upon timely notification.
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2013-2014 BENEFIT PLAN COSTS
July 1, 2013-June 30, 2014
Employee
Plan
Option
Monthly
Total
Non-Administrator
Contribution*
Administrator
Contribution**
$896.76
$265.84
$328.17
GHC
$647.82
$16.90
$64.32
Unity Health
Insurance
$879.20
$248.28
$311.38
Dental
$31.52
$3.15
$3.15
Dean Health Plan
Employee
Plan
Option
Dean Health
Plan
GHC
Unity Health
Insurance
Dental
*
**
Note:
SINGLE
FAMILY
Monthly
Total
Non-Administrator
Contribution*
Administrator
Contribution**
$2,358.48
$699.15
$863.08
$1,729.70
$70.37
$196.99
$2,312.30
$652.97
$818.91
$81.72
$8.17
$8.17
All employees pay a monthly premium based on the cost difference between the full monthly HMO and PPO cost
Administrators pay the cost different between the HMO and PPO in addition to 10% cost of the HMO
Rates for all medical plans are effective with June payroll deductions and rates for the dental plan are effective with July
payroll deductions.
5
7-1-2013
This benefit summary is intended only to highlight your benefits and should not be relied
upon to fully determine your coverage. Please review your Member Certificate of
Coverage for an exact description of the services and supplies that are covered, those that
are excluded or limited, and other items and conditions of coverage.
Dean Member Certificate of Coverage can be found through DeanConnect at
www.deancare.com, or to get a printed copy, call the Customer Care Center at 800-2791301.”
GHC-SCW Member Certificate of Coverage and Benefit Summary can be found at
www.ghcscw.com or through MyChart. To receive a printed copy, call the GHC-SCW
Member services at 828-4853.
Unity’s Member Certificate of Coverage can be found through MyUnity at
www.unityhealth.com . To receive a printed copy, call Unity Customer Service at 800362-3310 Monday through Friday from 7am to 5pm.
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7
BENEFIT COMPARISON GUIDE
Benefit
Medical
Reimbursement
Group Health Cooperative-SCW
Dean Health Plan
Unity Health Insurance
In Network
Out of Network
In Network
Out of Network
In Network
As long as care is
provided by an in plan
provider, GHC-SCW or
PPO Network provider,
there are no deductibles or
coinsurance unless
specified for that
particular service. No
limits in days or dollars of
coverage, except where
noted. Out-of-area
medically necessary
urgent & emergency room
care is covered. Members
need to contact GHCSCW at 800-605-4327.
Any follow-up care would
need prior authorization
then will be covered at
50% of the maximum
allowable fee.
All out of network
covered expenses are
subject to a $250 per
person, $500 limit per
family, and are then
payable at 80% of
covered expenses.
Maximum out-of-pocket
expense is $1,000 per
person, but no more than
$2,000 per family
combined in plan and out
of plan.
Services without-of -plan
providers are subject to
reasonable and
Customary charges, and
out of plan benefit levels.
Member needs to contact
GHC at 800-605-4327.
Follow-up medical care
will be covered at 50% of
eligible charges. Out-of
area care must receive
prior authorization.
Covered in full,
except co-payments
and limits in days or
dollars where noted.
No referral is needed
to any plan provider,
services with nonplan providers would
need an approved
referral prior to
services being
obtained.
Out of area urgent
and emergency care
is covered. Services
with non-plan
providers are subject
to reasonable and
customary charges.
Member needs to
contact Customer
Service at 800-2791301. Any follow-up
care would need prior
authorization, then
will be covered at
50% of the maximum
allowable fee.
Policy Lifetime
Maximum: No
Limit
Out- of-Network
subject to $250 contract
year deductible per
person, $500 per
family. After the
deductible has been
met, services are
subject to a 20% coinsurance to a
maximum out of pocket
of $1,250 per person or
$2,500 per family, per
contract year. Services
with non-plan provider
are subject to the
maximum allowable
fee, member would be
responsible for the
difference.
Covered in full, except
co-payments and limits in
days or dollars where
noted. No referrals
needed to participating
providers.
Policy Lifetime
Maximum: No Limit
Policy Lifetime
Maximum : No Limit
Policy Lifetime
Maximum: No Limit
If You receive Urgent or
Emergency Services from
a non-participating
provider, you must notify
Unity at 800-362-3310
within 48 hours or as soon
as is medically feasible.
Policy Lifetime
Maximum: No Limit
Out of Network
Subject to a $250 calendar
year deductible per person,
$500 per family. After the
deductible has been met,
services are subject to a 20%
co-insurance to a maximum
out-of-pocket of $1,000 per
person or $2,000 per family,
per calendar year.
Benefits are limited to the
usual, customary and
reasonable charge. Member
is responsible for amounts
above the usual, customary
and reasonable charge.
If You receive Urgent or
Emergency Services from a
non-participating provider,
you must notify Unity at
800-362-3310 within 48
hours or as soon as is
medically feasible.
Prior authorization is
required for some services.
For details, please visit
unityhealth.com.
Prescription drug
copayments are not counted
toward deductible or out of
pocket maximum.
Policy Lifetime Maximum:
No limit
8
Benefit
Group Health Cooperative-SCW
In Network
Hospitalization
Covered in full.
Prior authorization is
required.
Call GHC at 800-6054327 Ext. 4514 within 48
hours of any out-of-area
emergency hospital
admission.
Any out of area follow-up
care must be Prior
authorized to be covered
and will be covered at
50% of reasonable and
customary.
Out of Network
Unity Health Insurance
Dean Health Plan
In Network
Subject to deductible and
co-insurance.
Prior authorization is
required.
Call GHC at 800-6054327 Ext. 4515 within 48
hours of any out-of –
area emergency hospital
admittance.
Covered in full.
Call DHP at 800279-1301 within 48
hours of any out-ofarea emergency
hospital admission.
Any follow-up care
must be
preauthorized to be
covered and will be
covered at 50% of
reasonable and
customary
Out of Network
In Network
Subject to deductible
and co-insurance.
Call DHP at 800-2791301 within 48 hours
of any out-of-area
emergency hospital
admission.
Any follow-up care
must be
preauthorized to be
covered and will be
covered at 50% of
reasonable and
customary
Preauthorization is
required.
Covered in full.
Call Unity at 800-362-3310
within 48 hours of any outof-area emergency hospital
admission. Benefits will be
limited to the usual,
customary and reasonable
charge.
Prior authorization is
required.
Out of Network
Subject to deductible and coinsurance. Benefits will be
limited to the usual,
customary and reasonable
charge.
Call Unity at 800-362-3310
within 48 hours of any out-ofarea emergency hospital
admission. Benefits will be
limited to the usual,
customary and reasonable
charge.
Prior authorization is
required.
Radiation
Therapy/
Chemotherapy
Covered in full.
Subject to deductible and
co-insurance.
Covered in full
Subject to deductible
and co-insurance.
Covered in full.
Emergency Care
$50 co-pay waived if
admitted as Inpatient, life
threatening emergencies
covered in full, contact
GHC-SCW within 48
hours. Please refer to
reference card in Provider
Directory for examples.
Members need to contact
GHC-SCW at 800-6054327. Follow-up care
would need prior
authorization, then will be
covered at 50% of the
maximum allowable fee.
$50 co-pay waived if
admitted as Inpatient, life
threatening emergencies
covered in full. Contact
GHC-SCW within 48
hours. Please refer to
reference card in
Provider Directory for
examples. Members need
to contact GHC-SCW at
800-605-4327. Followup care would need prior
authorization, then will
be covered at 50% of the
maximum allowable fee.
Subject to a $50
copay. $50 copay
waived if admitted to
the hospital from the
emergency room
$50 copay. After
copay covered in full
for the emergency
room, ancillary services
are subject to the
deductible and coinsurance.
Subject to a $50 copay.
$50 copay waived if
admitted to the hospital
from the emergency room
Subject to deductible and coinsurance. Benefits will be
limited to the usual,
customary and reasonable
charge.
Subject to a $50 copay. $50
copay waived if admitted to
the hospital from the
emergency room
Call Unity at 800-362-3310
within 48 hours of any outof-area care.
Call Unity at 800-362-3310
within 48 hours of any out-ofarea care.
Call DHP at 800-2791301 within 48 hours of
any out-of-area care.
Follow up care out of
area is covered at
50% of usual and
customary with preauthorization
9
Call DHP at 800-2791301 within 48 hours
of any out-of-area
care.
Follow up care out of
area is covered at
50% of usual and
customary with preauthorization
Benefit
Group Health Cooperative-SCW
Unity Health Insurance
Dean Health Plan
In Network
Out of Network
In Network
Out of Network
In Network
Out of Network
Dependent
Definition
Legally married spouse.
Designated family partner
meeting the definition
outlined in District policy.
Unmarried or married
natural child, stepchild, or
adopted child; or eligible
partner’s natural child,
stepchild, or adopted child
to the end of the calendar
year in which age 26 is
attained. Grandchild
eligible if dependent child
is under the age of 18
years. Dependent child
over limiting age is eligible
if unable to provide own
support due to physical or
mental handicap, subject to
GHC-SCW approval.
Legally married spouse.
Designated family partner
meeting the definition
outlined in District policy.
Unmarried or married
natural child, stepchild, or
adopted child; or eligible
partner’s natural child,
stepchild, or adopted
child to the end of the
calendar year in which
age 26 is attained.
Grandchild eligible if
dependent child is under
the age of 18 years.
Dependent child over
limiting age is eligible if
unable to provide own
support due to physical or
mental handicap, subject
to GHC-SCW approval.
Legally married
spouse. Designated
family partner
meeting the definition
outlined in District
policy. Unmarried or
married natural child,
stepchild, or adopted
child; or eligible
partner’s natural child,
stepchild, or adopted
child to the end of the
calendar year in which
age 26 is attained.
Grandchild eligible if
dependent child is
under the age of 18
years. Dependent
child over limiting age
is eligible if unable to
provide own support
due to physical or
mental handicap,
subject to Dean
approval.
Legally married
spouse. Designated
family partner meeting
the definition outlined
in District policy.
Unmarried or married
natural child, stepchild,
or adopted child; or
eligible partner’s
natural child, stepchild,
or adopted child to the
end of the calendar
year in which age 26 is
attained. Grandchild
eligible if dependent
child is under the age
of 18 years. Dependent
child over limiting age
is eligible if unable to
provide own support
due to physical or
mental handicap,
subject to Dean
approval.
Legally married spouse.
Designated family partner
meeting the definition
outlined in District policy
Unmarried or married natural
child, stepchild, or adopted
child; or eligible partner’s
natural child, stepchild, or
adopted child to the end of
the calendar year in which
age 26 is attained.
Grandchild eligible if
dependent child is under the
age of 18 years. Dependent
child over limiting age is
eligible if unable to provide
own support due to physical
or mental handicap, subject to
Unity approval.
Legally married spouse.
Designated family partner
meeting the definition outlined
in District policy Unmarried or
married natural child, stepchild,
or adopted child; or eligible
partner’s natural child,
stepchild, or adopted child to the
end of the calendar year in
which age 26 is attained.
Grandchild eligible if dependent
child is under the age of 18
years. Dependent child over
limiting age is eligible if unable
to provide own support due to
physical or mental handicap,
subject to Unity approval.
Physicians Office
Visits
Covered in full.
Subject to deductible and
co-insurance.
Covered in full.
Subject to deductible
and co-insurance
Covered in full.
Regular
Examinations
Covered in full
Subject to deductible and
co-insurance.
Covered in full.
Subject to deductible
and co-insurance
Covered in full.
Pediatric Care
Covered in full.
Subject to deductible and
co-insurance.
Covered in full.
Subject to deductible
and co-insurance
Covered in full.
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
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Benefit
Immunizations
Group Health Cooperative-SCW
In Network
Out of Network
In Network
Covered in full.
Travel Immunizations:
Contact GHC at 828-4853
directly for restrictions and
co-payments pertaining to
travel related drugs.
Subject to deductible and
co-insurance.
Covered in full
Travel immunizations
covered when
medically necessary.
Travel Immunizations:
Contact GHC at 828-4853
directly for restrictions
and co-payments
pertaining to travel
related drugs.
Unity Health Insurance
Dean Health Plan
Work related
immunizations are not
covered
Out of Network
In Network
Subject to deductible
and co-insurance.
Travel immunizations
covered when
medically necessary.
Covered in full.
Work related
immunizations are not
covered
Work related immunizations
are not covered.
Travel immunizations
covered when medically
necessary.
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
Travel immunizations covered
when medically necessary.
Work related immunizations are
not covered.
Injections
Covered in full
Subject to deductible and
co-insurance.
Covered in full.
Subject to deductible
and co-insurance
Covered in full.
Maternity
Covered in full.
Subject to Deductible and
co-insurance.
Covered in full.
Subject to deductible
and co-insurance
Covered in full.
Mental Health
Care / Substance
Use Disorder
Covered the same as any
other medical or surgical
benefit under the plan.
No annual or lifetime
maximum
No limit on frequency of
treatment, number of visits,
the days of coverage or
other similar limits.
If the plan allows medical
/surgical care outside of the
network it must allow
coverage for Mental Health
or Substance Use Disorder.
Plans are permitted to use
utilization review and other
authorization or medical
management practices, and
may determine the criteria
for medical necessity and
appropriateness. Benefits
are covered under the
Mental Health Parity Law
Covered the same as any
other medical or surgical
benefit under the plan.
No annual or lifetime
maximum
No limit on frequency of
treatment, number of
visits, the days of
coverage or other similar
limits.
If the plan allows medical
/surgical care outside of
the network it must allow
coverage for Mental
Health or Substance Use
Disorder. Plans are
permitted to use
utilization review and
other authorization or
medical management
practices, and may
determine the criteria for
medical necessity and
appropriateness. Benefits
are covered under the
Mental Health Parity Law
Covered the same as
any other medical or
surgical benefit under
the plan.
No annual or lifetime
maximum.
No limit on frequency
of treatment, number
of visits, the days of
coverage or other
similar limits.
If the plan allows
medical /surgical care
outside of the
Network it must allow
coverage for Mental
Health or Substance
Use Disorder. Plans
are permitted to use
utilization review and
other authorization or
medical management
practices, and may
determine the criteria
for medical necessity
and appropriateness.
Benefits are covered
Covered the same as
any other medical or
surgical benefit under
the plan.
No annual or lifetime
maximum.
No limit on frequency
of treatment, number of
visits, the days of
coverage or other
similar limits.
If the plan allows
medical /surgical care
outside of the
Network it must allow
coverage for Mental
Health or Substance
Use Disorder. Plans are
permitted to use
utilization review and
other authorization or
medical management
practices, and may
determine the criteria
for medical necessity
and appropriateness.
Benefits are covered
Covered the same as any
other medical or surgical
benefit under the plan.
No annual or lifetime
maximum.
No limit on frequency of
treatment, number of visits,
the days of coverage or other
similar limits.
If the plan allows medical
/surgical care outside of the
Network it must allow
coverage for Mental Health
or Substance Use Disorder.
Plans are permitted to use
utilization review and other
authorization or medical
management practices, and
may determine the criteria for
medical necessity and
appropriateness.
Benefits are covered under
the Mental Health Parity
Law.
11
Out of Network
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
Covered the same as any other
medical or surgical benefit
under the plan.
No annual or lifetime maximum.
No limit on frequency of
treatment, number of visits, the
days of coverage or other
similar limits.
If the plan allows medical
/surgical care outside of the
Network it must allow coverage
for Mental Health or Substance
Use Disorder. Plans are
permitted to use utilization
review and other authorization
or medical management
practices, and may determine
the criteria for medical necessity
and appropriateness.
Benefits are covered under the
Mental Health Parity Law.
Benefit
Group Health Cooperative-SCW
In Network
Out of Network
Mental Health
Care / Substance
Use Disorder
Unity Health Insurance
Dean Health Plan
In Network
Out of Network
under the Mental
Health Parity Law
under the Mental
Health Parity Law.
Subject to the
deductible and coinsurance
In Network
Out of Network
Routine Vision
Exams
Covered in full at GHCSCW Optometry Dept.
Note: Contact Lens fitting
fee is patient’s expense.
Not Covered
Covered in full with
DHP Network
provider. Contact lens
fitting fee is patient’s
expense
Subject to deductible
and co-insurance.
Contact lens fitting fee
is patient’s expense
Covered in full at
participating Unity provider.
Contact lens fitting fee,
glasses, lenses, contacts and
frames are excluded from
coverage.
Ambulance
Service
Covered in full.
Covered in full.
Covered in full
Covered in full
Covered in full.
Home Care
Benefit
Covered in full when
provided by a home health
agency and approved by
GHC-SCW.
Prior Authorization is
required.
Subject to deductible and
co-insurance.
40 visits maximum
per benefit period.
Subject to deductible
and co-insurance.
Maximum of 40 visits
per contract year.
50 visits maximum per
benefit period. Prior
authorization is required.
Surgical-Medical
Care
Covered in full.
Subject to deductible and
co-insurance.
Covered in full.
Subject to deductible
and co-insurance
Covered in full.
Preventative
Dental Care
Not Covered
Not Covered
Not covered.
Not covered.
Not covered.
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
Not covered.
Cardiac
Rehabilitation
Covered at 100%
Limited to 36 sessions per
calendar year following
hospitalization. Prior
Authorization is required.
Subject to Deductible and
co-insurance.
Limited to 36 sessions in
a 12 month period.
Prior Authorization is
required.
Covered in full.
Must be priorauthorized and
received in
approved outpatient
facility.
Subject to deductible
and co-insurance.
Must be priorauthorized and
received in an
approved outpatient
facility.
Limited to 36 supervised and
monitored exercise sessions
per covered illness in a 12consecutive-week period.
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
Prior Authorization is
required.
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
Contact lens fitting fee, glasses,
lenses, contacts and frames are
excluded from coverage.
Covered in full.
Subject to deductible and coinsurance. 50 visits maximum
per benefit period. Prior
authorization is required.
Benefits will be limited to the
usual, customary and reasonable
charge.
12
Limited to 36 supervised and
monitored exercise sessions per
covered illness in a 12consecutive-week period.
Benefit
Group Health Cooperative-SCW
Dean Health Plan
Unity Health Insurance
In Network
Out of Network
Exams covered in full.
Policies will cover one
standard hearing aid per
ear for members under
18 Covered at 100%.
Limited to one aid per
ear every 36 months.
18 and Over: One aid
per ear every 36 months.
Member pays 20% coinsurance.
Hearing aid evaluation
and fitting exam is
covered under office
visit.
Routine hearing exams
are not covered.
Policies will cover one
standard hearing aid
per ear for members
under 18 Covered at
100%. Limited to one
aid per ear every 36
months.
18 and Over: One aid
per ear every 36
months. Member pays
20% co-insurance.
Hearing aid evaluation
and fitting exam is
covered under office
visit.
Covered in full.
Chiropractic
Coverage
Covered in full at GHCSCW contracted providers.
Subject to deductible and
co-insurance.
Covered in full at
DHP provider
Subject to deductible
and coinsurance
Covered in full at
participating chiropractor.
X-ray and Lab
Test
Covered in full.
Prior authorization is
required for MRI, MRA,
PET, CT
Covered in full.
Prior authorization is
required for MRI, MRA,
PET, CT
Covered in full at
DHP provider
Subject to deductible
and coinsurance
Covered in full at Unity
providers.
Transplants
Covered at 100% Organ
transplants limited to bone
marrow, cornea, heart,
heart/lung, kidney, liver,
and pancreas in certain
conditions. Subject to the
approval of the Medical
Director.
Prior authorization is
required.
Subject to deductible and coinsurance. Organ
Organ transplants
limited to: bone
marrow, corneal,
heart, heart-lung,
liver, lung and
pancreas in certain
conditions. All
services require prior
authorization. Kidney
disease
treatment,including
transplants are
covered. Includes
retransplantation and
organ procurement
costs.
Subject to deductible
and coinsurance
Organ transplants
limited to: bone
marrow, corneal, heart,
heart-lung, liver, lung
and pancreas in certain
conditions. All services
require prior
authorization. Kidney
disease treatment,
including transplants
are covered. Includes
retransplantation and
organ procurement
costs.
Organ transplants limited to
cornea, heart, heart w/lung,
liver, lung, kidney, kidney
w/pancreas and bone marrow.
Kidney is subject to a
$30,000 annual maximum.
All transplants apply to a
$1,000,000 lifetime transplant
maximum. Prior
authorization required.
Hearing Exams
transplants limited to
bone marrow, cornea,
heart, heart/lung, kidney,
liver, and pancreas in
certain conditions.
Subject to the approval of
the Medical Director.
Prior authorization is
required.
In Network
Hearing aids:
including initial
evaluation and
fitting of hearing
aid will be covered
up to $500 for one
standard model
hearing aid per ear
every 36 months.
Out of Network
For out of network
providers, no coverage
for hearing aids
In Network
Exams covered in full.
Hearing Aids:
Children (0-25) Coverage of the cost of
hearing aids is limited to
the cost of one hearing aid
per ear once every three
years.
Adults (26 and older):
$400 benefit limit, one
hearing aid per ear once
every three years.
Out of Network
Exams are subject to deductible
and co-insurance. Benefits will
be limited to the usual,
customary and reasonable
charge.
Hearing Aids:
Children (0-25) - Coverage
of the cost of hearing aids is
limited to the cost of one
hearing aid per ear once
every three years. Subject
to 20% coinsurance. Coinsurance does not apply to
the out of pocket maximum.
Adults (26 and older): $400
benefit limit, one hearing aid
per ear once every three
years.
13
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
No coverage out of network.
Benefit
Group Health Cooperative-SCW
In Network
Out of Network
Unity Health Insurance
Dean Health Plan
In Network
Out of Network
Preauthorization
required.
Preauthorization
required.
In Network
Out of Network
Physician Visits
in Hospital
Covered in full.
Subject to Deductible and
co-insurance.
Covered in full.
Subject to deductible
and co-insurance.
Covered in full.
Involuntary
Infertility
Lifetime Benefits
Maximum for each
Member of $4,000, with a
maximum payment by
GHC-SCW of $2,000.
Lifetime Benefits
Maximum for each
Member of $4,000, with a
maximum payment by
GHC-SCW of $2,000.
50% co-payment of
first $4,000 within
limits of the plan
policy.
Includes diagnosis and
treatment
No coverage for out of
network providers.
50% of charges for
consultation, diagnostic
evaluation and treatment with
IUI up to a maximum benefit
of $2,000 per lifetime per
couple.
Prior Authorization is
required
Prior Authorization is
required.
Nurse Helpline
GHC_SCW Nurse Connect
24 hours/7 days per week.
1-855-661-7350 or 608661-7350
GHC_SCW Nurse
Connect 24 hours/7 days
per week. 1-855-661-7350
or 608-661-7350
Dean On Call,
available 24 hours per
day, 7 days per week
at 1-800-576-8773 (1800-NURSE)
Dean On Call, available
24 hours per day, 7
days per week at 1-800576-8773 (1-800NURSE)
Call your clinic for
provider on call-24 hours
per day/ 7 days a week.
Call your clinic for
provider on call-24 hours
per day/ 7 days a week.
On-line Access
GHC My Chart Schedule
appointments online*
 View selected test
results*
 Use online Pharmacy
to refill Medications.
 View and print
immunization records.
 Request an extension
for referral to
specialty care
 Communicate with
GHC clinic staff
using secure
electronic messaging*
 Get easy-tounderstand medical
GHC My Chart Get easy-tounderstand medical
information with
Healthwise Medical
Library
 View your Health
Summary,
medications,
allergies,
immunizations and
more
Visit www.ghcscw.com to
learn more about
GHCMyChart and Mobile
GHCMyChart
Dean Connect View Benefit
coverage,
 Review claims
status
 Print claims and
EOB’s
 Order ID cards
 View Pharmacy
claims, costs
 Check status of
authorizations or
referrals
 Change your
primary care
provider
Dean Connect View Benefit
coverage,
 Review claims
status
 Print claims and
EOB’s
 Order ID cards
 View Pharmacy
claims, costs
 Check status of
authorizations or
referrals
Change your
primary care
provider
MyChart 
View benefit
coverage

Print Summary
of Benefits and Coverage
(SBC)

Review claims
status

Print claim
profiles

Review claim
information for
dependent children under
age 12

Check eligibility

Print EOB’s
MyChart 
View benefit
coverage

Print Summary
of Benefits and
Coverage (SBC)

Review claims
status

Print claim
profiles

Review claim
information for
dependent children under
age 12

Check eligibility

Print EOB’s
Subject to deductible and coinsurance. Benefits will be
limited to the usual, customary
and reasonable charge.
No coverage out of network.
Unity will cover 50% of
covered charges for generic
Clomid and/or Pergonal up to
a maximum benefit of $1,000
per lifetime per couple.
My chart WebMD
available
14
information with
Healthwise Medical
Library
 View your Health
Summary,
medications, allergies,
immunizations and
more*
Please note:Available to
members who receive care
at GHC-SCW clinics,
including Capital, Deforest,
East, Hatchery Hill and
Sauk Trails.
Visit www.ghcscw.com to
learn more about
GHCMyChart and Mobile
GHCMyChart.
My chart webMD
available.


Order ID cards
Update personal
information

Ask questions
using Ask an Expert

Enroll in Unity’s
Fitness First and More
Program


Unity members who are
UW Health patients can
also view portions of their
medical record, schedule
appointments and send
messages to their health
care team through their
MyChart account.
Unity members who are
UW Health patients can
also view portions of their
medical record, schedule
appointments and send
messages to their health
care team through their
MyChart account.
Subject to deductible and
co-insurance. Benefits will
be limited to the usual,
customary and reasonable
charge.
Processing/Administration
and derivatives covered.
Blood is covered.
Autologous transfusion and
storage will be a covered
benefit.
Subject to 30% DME coinsurance. Co-insurance
does not apply to the
Annual Out-of-Pocket
Limit. Benefits will be
limited to the usual,
customary and reasonable
charge.
Blood and Blood
Plasma
Covered in full.
Processing/
Administration and
derivatives covered. Blood
is covered. Autologous
transfusion and storage will
be a covered benefit.
Subject to Deductible and
co-insurance.
Processing/
Administration and
derivatives covered.
Blood is covered.
Autologous transfusion
and storage will be a
covered benefit.
Covered in full
Processing/
Administration and
derivatives covered.
Blood is covered.
Autologous
transfusion and
storage will be
covered benefit.
subject to deductible
and co-insurance
Processing/
Administration and
derivatives covered.
Blood is covered.
Autologous transfusion
and storage will be a
covered benefit
Covered in full.
Processing/Administration
and derivatives covered.
Blood is covered.
Autologous transfusion and
storage will be a covered
benefit.
Prosthetic
Devices
Medical Supplies
Durable Medical
Equipment
(DME)
Covered at 80% of usual,
customary and reasonable
charges for specific
supplies. Maximum out-ofpocket of $2,500 per
member/ calendar year.
Prior authorization is
required.
Covered at 80% of usual,
customary and reasonable
charges for specific
supplies. Maximum outof-pocket of $2,500 per
member/ calendar year.
Prior authorization is
required.
Covered at 100% of
usual, customary and
reasonable charges for
specific supplies.
Durable Medical
Supplies/Equipment
greater than $500
require Prior
authorization
Subject to deductible,
then paid at 50%.
Covered at 100% of usual,
customary and reasonable
charges for specific
supplies.
Prior authorization is
required.
Purchase or rental of DME
with a per unit cost of $500
or more must be Prior
Authorized.
Order ID cards
Update personal
information

Ask questions
using Ask an Expert

Enroll in Unity’s
Fitness First and More
Program
Purchase or rental of DME
with a per unit cost of $500
or more must be Prior
Authorized.
15
Acupuncture or
Complimentary
Services
Complimentary Services of
Acupuncture, Massage
Therapy, Stress Reduction,
Yoga, Tai Chi, Movement
Therapy, Lifestyle Change
Classes, and more, as
outlined in the Member
Certificate and Healthy
You Publication.
Complimentary Medicine
professional services, when
provided by a GHC owned
and operated facility will
be covered at 50% of the
first $750 in eligible
charges.
See www.GHCSCW.com
for ongoing classes.
Not covered.
Not Covered
Not Covered
New for 2013-The
living Healthy
Rewards Program.
New for 2013-The
living Healthy Rewards
Program.
Living Healthy
Rewards is an online
well-being program
that encourages Dean
Health Plan members
to create healthy
habits. This replaces
the Wellness
Incentives Now(WIN)
program, and
members will enjoy
many advantages over
WIN:

Not a
reimbursement
program
unlike WIN,
members
don’t need
to spend
money to
get rewards.

No
restrictions
on how
members
spend the
money
received
from their
rewards.

Easy to use
online
tracking
system.

No family
maximums
reward.
Living Healthy
Rewards is an online
well-being program that
encourages Dean
Health Plan members to
create healthy habits.
This replaces the
Wellness Incentives
Now(WIN) program,
and members will enjoy
many advantages over
WIN:

Not a
reimbursement program
unlike WIN,
members
don’t need to
spend money
to get
rewards.

No
restrictions
on how
members
spend the
money
received from
their rewards.

Easy to use
online
tracking
system.

No family
maximums
reward.
Using the Living
Healthy program,
members are able to
track exercise, daily
steps, healthy eating
16
Using the Living
Healthy program,
members are able to
track exercise, daily
steps, healthy eating
and weight loss
progress. The Living
Healthy program is
Integrative Medicine
combines health care
disciplines with a variety of
therapeutic practices
to promote health and
healing.
Unity will
reimburse members age 18
and older up to your
Fitness First & More
program maximum ($100
individual/$200 family)
each calendar year for the
following services:

Acupuncture

FeldenkraisTM

Healing Touch

Massage
Therapy and
Bodywork
You must be a Unity
member on the date of your
service. Services must be
received from an eligible
provider. Please visit
unityhealth.com for more
information.
Not covered.
Prescription
Drugs
$6 Generic
$15 Brand Formulary.
1 co-pay for each 30 day
supply.
Co-payments for insulin
prescriptions are limited up
to a 30-day supply per
prescription at $30.
Prescriptions maybe
purchased at GHC
designated pharmacies or
Navitus Pharmacy.
Includes oral
contraceptives. Most
prescriptions limited to a
30-day supply. Oral
contraceptives available in
a 90-day supply. Brand
name prescription drug
buy-option: If a member
requests a brand name drug
when its generic is
available the member will
Non-Participating
Pharmacy’s are not
covered.
and weight loss
progress. The Living
Healthy program is
designed to reward
healthy behaviors,
regardless of whether
they go to a gym or
walk on a treadmill in
their own home and
without having to
spend money first.
Members age 18 and
older are eligible to
participate and earn
rewards up to $250
each. Rewards are
redeemable in the
form of a Visa Chase
Gift Card.
For more information
on the Living Healthy
Program, including
instructions and
commonly asked
questions, please visit
deancare.com/living
healthy
designed to reward
healthy behaviors,
regardless of whether
they go to a gym or
walk on a treadmill in
their own home and
without having to spend
money first.
Members age 18 and
older are eligible to
participate and earn
rewards up to $250
each. Rewards are
redeemable in the form
of a Visa Chase Gift
Card.
For more information
on the Living Healthy
Program, including
instructions and
commonly asked
questions, please visit
deancare.com/living
healthy
$6 Tier 1
$15 Tier 2
$30 Tier 3
Includes Insulin and
Disposable Diabetic
supplies
1 co-pay for each 30
day supply. You may
receive a 90-day
supply for a DHP
Approved
Maintenance
medication at a 2
month co-pay through
mail order only, Tier 3
medication would be 3
co-pays.
If member requests a
brand name drug when
a generic is available,
the member is
responsible for the
Out of network
Pharmacy
50% co-pay-Tier 1
50% co-pay-Tier 2
No coverage-Tier 3
Includes Insulin and
Disposable Diabetic
supplies
No Mail Order
Available
If member requests a
brand name drug when
a generic is available,
the member is
responsible for the
difference in cost
between the brand
name generic drug, as
well as the applicable
co-pay.
17
$6 1st Tier Drugs
$15 2nd Tier Drugs
$30 3rd Tier Drugs
$6 1st Tier Drugs
$15 2nd Tier Drugs
$30 3rd Tier Drugs
Members are limited to the
amount of Prescription
Drugs prescribed by the
physician, but not to
exceed a 30 day supply, or
one commercially prepared
unit, whichever is less. For
further information
regarding your drug
benefits, see your
Prescription Drug Benefit
Rider.
Members are limited to the
amount of Prescription
Drugs prescribed by the
physician, but not to
exceed a 30 day supply, or
one commercially prepared
unit, whichever is less. For
further information
regarding your drug
benefits, see your
Prescription Drug Benefit
Rider.
be responsible for the
difference in cost between
the brand name and generic
drugs, as well as the
applicable brand name copayment.
Extraction and
Replacement of
Teeth/Injury
Services
Initial repair of accidental
injury to sound and natural
teeth up to $1,500 per
accident. Prior
Authorization is required.
Care must be initiated
within ninety (90) days of
accident. Physical Therapy
evaluation is required for
treatment for TMJ before
an intra-oral splint is
considered as a treatment
option. Non-surgical
treatment of TMJ is limited
to a maximum payment of
$1,250 by GHC-SCW per
calendar year
difference in cost
between the brand
name generic drug, as
well as the applicable
co-pay.
Infertility drugs are
paid at 50% with no
benefit limit.
Subject to deductible and
co-insurance
Initial repair of accidental
injury to sound and
natural teeth up to $1,500
per accident. Prior
Authorization is required.
Care must be initiated
within ninety (90) days of
accident. Physical
Therapy evaluation is
required for treatment for
TMJ before an intra-oral
splint is considered as a
treatment option. Nonsurgical treatment of TMJ
is limited to a maximum
payment of $1,250 by
GHC per calendar year
Dental services that
are provided by an
appropriate provider
and are required to
treat sound natural
teeth that are injured
while you are covered
under this Policy.





The term
“injured”
does not
include
conditions
resulting
from eating,
chewing or
biting.
The tooth
must meet
the
definition of
sound,
natural
tooth.
The
evaluation
of the
injured tooth
must occur
within 72
hours of the
accident.
The repair of
the injured
tooth must
be initiated
within 120
days of the
injury,
The treatment
must be
18
Subject to deductible
and co-insurance
Dental services that are
provided by an
appropriate provider
and are required to treat
sound natural teeth that
are injured while you
are covered under this
Policy.

The term
“injured”
does not
include
conditions
resulting
from eating,
chewing or
biting.

The tooth must
meet the
definition of
sound, natural
tooth.

The evaluation
of the injured
tooth must
occur within
72 hours of
the accident.

The repair of
the injured
tooth must be
initiated
within 120
days of the
injury,

The treatment
must be
completed
within 24
Benefits are for repair of
Sound Natural Teeth, or
extraction and replacement
of non-restorable natural
teeth, damaged due to
trauma to the teeth or jaw.
Treatment must begin
within 90 days after the
accident and will be
covered for a maximum of
12 months after treatment
begins. Chewing accidents
and dental implants are not
covered by this provision.
This benefit is limited to
$1,000 per accidental
Injury.
Benefits are for repair of
Sound Natural Teeth, or
extraction and replacement
of non-restorable natural
teeth, damaged due to
trauma to the teeth or jaw.
Treatment must begin
within 90 days after the
accident and will be
covered for a maximum of
12 months after treatment
begins. Chewing accidents
and dental implants are not
covered by this provision.
This benefit is limited to
$1,000 per accidental
Injury.
Non-surgical treatment of
Temporomandibular
disorders (TMD) is limited
to $1,250 per member per
year.
Non-surgical treatment of
Temporomandibular
disorders (TMD) is limited
to $1,250 per member per
year.
Orthotics
Foot Orthotics that are
custom molded to the
member’s foot are covered
subject to the following
limitations.
1. The benefit is limited to
one pair of orthotics per
calendar year; and
2. The benefit is subject to
the co-insurance amount
and the Annual Maximum
specified in the Schedule of
Benefits.
Orthotics will be subject to
the DME/ Prosthetic
Appliance 20% Coinsurance up to the
Maximum Out-of -Pocket
of $2,500
Foot Orthotics that are
custom molded to the
member’s foot are
covered subject to the
following limitations.
1. The benefit is limited to
one pair of orthotics per
calendar year; and
2. The benefit is subject to
the co-insurance amount
and the Annual Maximum
specified in the Schedule
of Benefits. Orthotics will
be subject to the DME/
Prosthetic Appliance 20%
Co-insurance up to the
Maximum Out-of -Pocket
of $2,500
completed
within 24
months of
the injury.
Removal of impacted
wisdom teeth and the
repair or replacement
due to accidental
injury is at 100%
Temporomandibular
Disorders(TMD)
Coverage is limited to
the diagnostic
procedures and
Medically Necessary
surgical or nonsurgical treatment for
the correction of
TMD, non-surgical
treatment is limited to
$1,250 per member
per contract year.
Refer to Group
Member Certificate.
months of the
injury.
Removal of impacted
wisdom teeth and the
repair or replacement
due to accidental injury
is at 100%
Temporomandibular
Disorders(TMD)
Coverage is limited to
the diagnostic
procedures and
Medically Necessary
surgical or nonsurgical treatment for
the correction of TMD,
non-surgical treatment
is limited to $1,250 per
member per contract
year.
Refer to Group
Member Certificate.
Covered in full under
DME policy.
For out of network
providers, 50%
payment after
deductible.
Foot orthotics that are
custom molded to the
Member’s foot are covered
subject to the following
limitations:
1. Limited to one pair per
calendar year up to a
maximum benefit of $300
2. The benefit is subject to
the co-insurance amount
specified in the Summary
of Benefits and Coverage
(SBC).
Foot orthotics that are
custom molded to the
Member’s foot are covered
subject to the following
limitations:
1. Limited to one pair per
calendar year up to a
maximum benefit of $300
2. The benefit is subject to
the co-insurance amount
specified in the Summary
of Benefits and Coverage
(SBC).
Subject to 30% DME coinsurance. Co-insurance
does not apply to the
Annual Out-of-Pocket
Limit. Benefits will be
limited to the usual,
customary and reasonable
charge.
Purchase or rental of DME
with a per unit cost of $500
or more must be Prior
Authorized.
19
Cochlear Implant
Bone Anchored
Hearing Aid
(BAHA)
Limited to one cochlear
implant per Member
under age 18.
Must have bilateral
hearing loss and must
meet the cochlear
implant criteria and be
prior authorized by the
GHC-SCW Care
Management
Department.
Bilateral Cochlear
implants are not
covered.
Subject to Deductible
and co-insurance
Limited to one cochlear
implant per member
under age 18.
Must have bilateral
hearing loss and must
meet the cochlear
implant criteria and be
prior authorized by the
GHC-SCW Care
Management
Department.
Bilateral Cochlear
implants are not
covered.
Covered under DME
at 100% as long as it
is Approved prior to
obtaining before
service is done.
Limited to one BAHA
device per lifetime for
members under age 18.
Must have Bilateral hearing
loss and must meet the
BAHA criteria and be prior
authorized by the GHCSCW Care Management
Department
Limited to one BAHA
device per lifetime for
Members under age 18.
Subject to deductible and
20% coinsurance.
Must have Bilateral
hearing loss and must
meet the BAHA criteria
and be prior authorized by
the GHC-SCW Care
Management Department
Paid at 100% up to a
benefit maximum of
$500.00 Benefit
period is a total of 36
months and only
covers one hearing
aid. Bilateral aids only
covered for infants
and children under 18
years of age. Prior
approval is required
and must be obtained.
Bilateral BAHA devices
are not covered
BAHA Transmitter is
covered under Durable
Medical Equipment.
Please note: The Food and
Drug Administration
(FDA) recently approved
an increase application of
an existing technology for
bone anchored hearing
aids. Please contact Care
management for further
information regarding this
benefit.
Subject to deductible
and co-insurance
as long as it is
Approved prior to
obtaining before service
is done.
Cochlear implants, and the
cost of treatment related to
cochlear implants,
including procedures for
the implantation of
cochlear devices, that are
prescribed by a physician,
or by a licensed audiologist
for a Child under 26 years
of age are covered with
prior authorization at
100%.
Cochlear implants, and the
cost of treatment related to
cochlear implants,
including procedures for
the implantation of
cochlear devices, that are
prescribed by a physician,
or by a licensed audiologist
for a Child under 26 years
of age are covered with
prior authorization.
Subject to deductible and
co-insurance. Benefits will
be limited to the usual,
customary and reasonable
charge.
Bilateral BAHA devices
are not covered
BAHA Transmitter is
covered under Durable
Medical Equipment.
Please note: The Food
and Drug Administration
(FDA) recently approved
an increase application of
an existing technology for
bone anchored hearing
aids. Please contact Care
management for further
information regarding this
benefit.
20
Hearing Aids:
For out of network
providers, no coverage
for hearing aids.
Bone-anchored hearing
aids are excluded from
coverage, except for the
cost of treatment relating to
hearing aids and cochlear
implants for a child under
26 years of age that is
certified as deaf or hearing
impaired by a physician or
audiologist.
Bone-anchored hearing
aids are excluded from
coverage, except for the
cost of treatment relating to
hearing aids and cochlear
implants for a child under
26 years of age that is
certified as deaf or hearing
impaired by a physician or
audiologist.
Reduction
Mammoplasty
Covered at 100% Same as
any other surgical Services.
Must meet Reduction
Mammoplasty criteria and
be prior authorized by the
GHC-SCW Care
Management Department.
20% Co-insurance with a
Maximum Out-of-Pocket
of $2,500 per Member per
Calendar year.
Must meet Reduction
Mammoplasty criteria and
be prior authorized by the
GHC-SCW Care
Management Department.
Only covered if prior
authorization is
obtained and Criteria
met. May be done
inpatient or outpatient.
Covered at 100%.
Only covered if prior
authorization is
obtained and Criteria
met. May be done
inpatient or outpatient.
Subject to deductible
and co-insurance.
Only covered if prior
authorization is obtained
and criteria are met.
Covered at 100%.
Only covered if prior
authorization is obtained
and criteria are met.
Subject to deductible and
co-insurance. Benefits will
be limited to the usual,
customary and reasonable
charge.
When a Member
fails to obtain
Written Prior
Authorization for
designated
services from
care
Management
Department
Eligible charges will be
reduced by 50%
The 50% penalty will apply
first, before deductibles,
Co-insurance, or any other
plan payment or action, to
a Member maximum Outof-Pocket expense of $500
per event.
The 50% penalty does not
The 50% penalty will
apply first, before
deductibles, Co-insurance,
or any other plan payment
or action, to a Member
maximum Out-of-Pocket
expense of $500 per
event.
The 50% penalty does not
If you fail to obtain an
authorization for any
covered service
requiring one, a
penalty of 50% of the
allowed amount, up to
$500 maximum per
occurrence, is applied.
All copays,
Deductibles. And
coinsurance for
covered services still
apply. This penalty
will not count toward
your maximum out-ofpoct expence, It is the
responsibility o fthe
Member to ensure that
Prior Authorization
has been obtained for
all services, including
facility confinements
and/or surgery.
If you fail to obtain an
authorization for any
covered service
requiring one, a penalty
of 50% of the allowed
amount, up to $500
maximum per
occurrence, is applied.
All copays,
Deductibles. And
coinsurance for covered
services still apply.
This penalty will not
count toward your
maximum out-of-poct
expence, It is the
responsibility o fthe
Member to ensure that
Prior Authorization has
been obtained for all
services, including
facility confinements
and/or surgery.
No Benefit reduction
$500.00 Benefit reduction
applies when Prior
Authorization was required
but not obtained.
apply towards the Member’s
MOOP.
Services received from an InPlan Provider without a
required Prior Authorization,
will be paid as Out-of-Plan
Benefits after the 50% penalty
is applied.
apply towards the Member’s
MOOP.
21
DENTAL PLAN
Madison Metropolitan School District’s Dental Plan is with Delta Dental Plan of Wisconsin.
Delta Dental Plan of Wisconsin
P O Box 828
Stevens Point WI 54481-0828
Web Address: www.deltadentalwi.com
Phone number: 1-800-236-3712
Eligibility under the plan is limited to: Legally married spouse. Designated family partner meeting the definition outlined in District policy. Unmarried natural child, stepchild, or adopted
child; or eligible partner’s natural child, stepchild, or adopted child to the end of the calendar year in which age 27 is attained. Dependent child must be supported more than 50% by parent(s),
not married and not eligible for dental insurance through an employer. Dependent children at the age of 24 or if not supported by the parent will be subject to imputed income for the years they
continue on the plan. Grandchild eligible if dependent child is under the age of 18 years. Dependent child over limiting age is eligible if unable to provide own support due to physical or mental
handicap, subject to Delta Dentals approval.
22
SUMMARY OF DENTAL BENEFITS
*
Maximums:
Dental Benefits:
Orthodontia:
Preventative:
*
Deductible:
None
*
Co-Insurance
$1000 per person per year
$2,000 lifetime per person
Two appointments per year (January1 thru December 31)
Preventive:
Basic Benefits:
Major Services:
Orthodontia:
100%
50%
50%
65%
All services subject to Usual, Customary and Reasonable reimbursement
*
Description of Benefits
Preventive:
Bitewing X-Ray
Cleanings
Examinations
Fluoride Treatments (dependents under age 19)
Sealants (dependents under age 17) Panoramic X-ray (once per 24-month period)
Basic Benefits:
Crown Restoration
Denture Repair
Periodontics
Fillings
Prophylaxis
Oral Surgery
Root Canal Therapy
Space Maintainers (dependents under age 19)
Major Services:
Bridges
Implants
Orthodontia:
All procedures
Crowns
Onlays
Extractions
Inlays
Endodontics
Dentures
Note: Preauthorization is recommended for any dental service expected to exceed $300.00.
*
Exclusions #:
No benefit will be provided for dental services if:
1)
Covered by Workers’ Compensation or similar legislation, regardless of whether the participant elects to claim its benefits.
2)
Furnished by the United States Veterans Administration, any federal or state agency, or any local political subdivision, when the
participant or his/her property is not liable for their costs.
3)
Required because of an injury, sickness or disease caused by atomic or thermonuclear explosion, or radiation resulting there from, or
any type of military action whether friendly or hostile.
4)
Performed for cosmetic purposes.
5)
Performed either before the effective date or after the termination date of the participant’s coverage under this contract.
6)
For replacement of lost or stolen dentures or other prosthetic devices.
7)
Surgical services covered by a health insurance plan.
8)
Charges exceed carriers Reasonable and Customary amount.
9)
Crowns, bridges or dentures are replaced prior to five (5) years, then a prorated amount is paid.
#
This is a partial listing of exclusions.
11/01
23