Download The Health Plan Schedule of Benefits - Plan Year 2015

THE HEALTH PLAN
PEIA
SCHEDULE OF BENEFITS
EFFECTIVE JULY 1, 2014
PLANS A, B & C
The Health Plan of the Upper Ohio Valley, Inc.
52160 National Rd. East
St. Clairsville, OH 43950-9365
(740) 695-3585 or (800) 624 6961
TDD (740) 695-7919 or (800) 622-3925.
e-mail: [email protected]
www.healthplan.org
Questions to ask before selecting your health care plan.
Warning: If you or your family members are covered by more than one Health Care Plan, you may not be able to collect
benefits from both plans. Each Plan may require you to follow its rules or use specific doctors and hospitals. It may be
impossible to comply with both Plans at the same time. Before you enroll read all of the rules very carefully, including the
Coordination of Benefits Section, and compare them with the rules of any other Plan that covers you or your family.
What is a Health Maintenance Organization (HMO) or Health Insuring Corporation (HIC)?
A Health Maintenance Organization (HMO) in West Virginia, Health Insuring Corporation (HIC) in Ohio is an organized system of health care
delivery. The Health Plan is a state and federally qualified Health Maintenance Organization (HIC in Ohio). HMO’s/HIC’s contract with various
physicians and facilities to provide medical care to their members.
What does this mean? The Health Plan (“the Plan”) has an organized provider network to provide medical services to our members. In joining an
HMO/HIC, a member agrees to utilize the HMO’s/HIC’s provider network for care and usually receives a higher level of benefits than under a
standard insurance plan. The Health Plan is not considered to be an insurance company. Unlike traditional insurance, one’s medical care is
coordinated by a Primary Care Physician (PCP).
Are all Health Maintenance Organizations, or Health Insuring Corporations, the same?
No. We offer traditional and preventive health care through over 7,000 private physicians in this area. Some Health Maintenance
Organizations/Health Insuring Corporations are committed to a group practice, or clinic concept, requiring the use of physicians in a particular
location or facility. The Health Plan operates under a totally different concept. Therefore, when you join the Plan, you become a member of a
prepaid health care program based on the concept of virtually free choice of one’s personal physician from our Provider Directory.
Who pays for all of the medical services I use?
The dollars we collect as premium payments from employers pay for the services our members use. By encouraging our members to take
advantage of the preventive services available through our program, we believe that a substantial number of potentially expensive health problems
are taken care of before they become more serious and more costly. This concept is the basis for the success of
the Plan.
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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How do I choose my Primary Care Physician (PCP)?
The Health Plan wants you to have a Primary Care Physician or personal physician who knows you and your medical history. You will choose the
physician to coordinate all of your health care needs. Such a choice is not final. A member may change physicians once per calendar month.
You are entitled to services from many of the Plan’s physicians and hospitals.
What happens when I am out of the Service Area and need medical care?
If you are out of the Plan Service Area and receive medical services for a medical emergency, present your the Plan I.D. card for payment. If you
are admitted outside the Plan Service Area, the Plan should be notified within 48 hours or as soon as reasonably possible. On the back of the I.D.
card, the persons rendering services will find payment and billing instructions. If you encounter problems with such payment or if the emergency
room requires you to pay the bill, we ask that you pay for the services and send the bill to the Plan Customer Service Department. If a charge is
made to a member for any services with respect to benefits under your Agreement, written proof of such charge must be furnished to the Plan
within one year after the performance of the service.
Will you help me find a physician if I need one?
All of our members receive a listing of Plan physicians, hospitals and other health care providers.
The Provider Directory provides you with each physician’s address, phone number and specialty. If you need assistance, call the Plan office at
(740) 695-3585, (800) 624-6961, TDD (740) 695-7919, (800) 622-3925 or [email protected].
Can I have a second medical opinion?
A second medical opinion can be obtained. We have many Plan physicians in all of the medical specialties. As a member, you are entitled to the
services of many of these participants. While we endorse the idea of coordinated health care provided by a single physician, you can obtain a
second opinion from another Plan physician. This can be arranged through your Primary Care Physician.
Who can I talk to if I have more questions?
Call the Plan office at (740) 695-3585, (800) 624-6961, TDD (740) 695-7919, (800) 622-3925 or [email protected].
Insurance Fraud Warning: “Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.”
72 Hour Cancellation Right: Any person obligated for any part of a pre-payment may cancel such agreement within 72 hours after he/she has
signed an agreement or offered to enroll. Cancellation occurs when written notice of cancellation is given to the Plan. Notice of cancellation shall
be considered given when the prospective subscriber mails a letter to the Plan.
UTILIZATION REVIEW.
The Health Plan has a utilization review process in place that is designed to review the medical appropriateness and location of proposed or
received health care services. The review process consists of three areas: 1.) Prospective Review, a review conducted prior to an admission or
course of treatment, 2.) Concurrent Review, a review conducted during an admission or course of treatment and 3.) Retrospective Review, a
review conducted after health care services have been provided. Examples of services reviewed are physical therapy, home health services,
emergency services, out-of-plan care, surgeries, CT scans and MRIs.
Screening is first performed by registered nurses to evaluate whether the service and location of the service meet the Plan’s criteria for medical
appropriateness. For instances that do not meet review criteria, the nurses are required to involve physician reviewers. After careful review of
available clinical information, the physician reviewer may authorize or not authorize the services based on medical necessity.
If you have any questions regarding utilization review, or the need for preauthorization of any service, please call the Plan office at (740) 6953585, (800) 624-6961, TDD (740) 695-7919, (800) 622-3925 or [email protected].
CASE MANAGEMENT.
The Case Management program is a process of coordinating resources and creating flexible, quality, cost effective health care options to result in
a quality-efficient delivery of health care services. This individualized program is performed by registered nurses that focus on members with a
complex illness and/or injury.
PRIVACY OF PROTECTED HEALTH INFORMATION.
The Health Plan supplies each new subscriber with a copy of the Plan’s Privacy Practices in the initial enrollment packet, and each year thereafter
upon renewal. Members may also obtain a copy by calling the Plan or visiting our website.
Each subscriber will be notified, in writing, 60 days in advance of any revisions to the Plan’s Privacy Practices.
The Health Plan will only use and disclose the minimum amount of necessary protected health information without authorization when required for:
payment, operations, treatment or as required or permitted by law. To disclose protected information for purposes other than described, the Plan
will request a signed authorization from the member.
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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Plan members have the right to inspect or obtain copies of their medical records and offer corrections to these records in accordance with
applicable federal and state laws.
Access within the Plan to protected health information whether oral, written, electronic, or for the use of measurement data, is limited to personnel
on a “need-to-know” or “need-to-access” basis.
The Plan has policies and procedures in place to ensure employees adhere to privacy/security requirements.
The Health Plan will not disclose information to employers that directly or indirectly identifies an employee or their dependents.
Any questions regarding protected health information, please contact the Plan by calling at (740) 695-3585, (800) 624-6961, TDD (740) 695-7919,
(800) 622-3925 or [email protected].
Special Enrollment Periods under the Health Insurance Portability and Accountability Act (HIPAA).
HIPAA requires group health plans to offer two special 31-day enrollment periods for employees and dependents, who previously declined
coverage to enroll, without waiting for the plan’s next regular open enrollment.
1. Loss of Group Coverage. Plans must allow employees and dependents that lose other coverage to enroll if they have exhausted their
COBRA coverage; they cease to be eligible for the other coverage or employer contributions for the other coverage cease, legal separation,
divorce, death, termination of employment or reduction in hours.
The effective date of coverage will be the first of the following month upon the Plan’s receipt of the enrollment information.
2. Change in Family Status. Plans that offer dependent coverage must provide a special enrollment period when an employee gains
dependents by reason of marriage, birth, adoption or placement for adoption.
The effective date of coverage will be the date of event.
In some instances, the enrollee will be required to provide the Plan with a “Certificate of Coverage”.
SCHEDULE OF BENEFITS.
Benefits are subject to a contract year deductible that must be paid by the member before benefits are payable under this plan. Only expenses
that you and your eligible dependents incur for covered services count toward satisfying your annual deductible. To help employees with several
covered dependents, the deductible you pay for the entire family, regardless of family size, is specified as a family deductible maximum. To meet
the family deductible maximum, you can count the eligible expenses incurred by two (2) or more family members.
Primary care physician (“PCP”), Ob/gyn physician, specialty physician (including secondary care physician (“SCP”), mental health and substance
abuse office visits, certain diabetic services, and emergency room and urgent care visits require a copay which is separate from the deductible.
Deductible Maximum
Individual
Family
Plan A
$100
$200
Plan B
$250
$500
Plan C
$1,000
$2,000
The deductible amount contributed by any one (1) family member shall not exceed that of an individual annual deductible maximum
amount.
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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To determine the maximum amount of expenses you or your family can incur in one (1) year, refer to the annual out-of-pocket maximum listed
below. Once the maximum is met, Health Plan waives any additional copays for the remainder of the contract year. Expenses you incur for
copays, not to include supplemental services (e.g., prescription copays) count toward satisfying the out-of-pocket maximum. Expenses you incur
for satisfying your annual deductible do not accumulate toward your annual out-of-pocket maximum. The annual out-of-pocket maximum shall not
exceed 200% of the average annual premium cost for the member.
Annual Out-of-Pocket
Maximum
Individual
Family
Plan A
$3,600
$10,200
Plan B
$3,750
$10,500
Plan C
$4,500
$12,000
The copay amount contributed by any one (1) family member shall not exceed that of an individual annual out-of-pocket maximum
amount.
Copays paid by a member on any single covered basic health care service during a contract year shall not exceed 40% of the average cost to the
Plan to provide the service. Average cost to the Plan is that amount paid by the Plan for a particular service during the previous calendar year
derived by dividing the total amount paid by the number of services provided.
The annual out-of-pocket maximum refers to the amount of money you pay out of your pocket for eligible health care expenses. Copays, both
fixed dollar amounts and percentages, which you pay for covered services, count toward your out-of-pocket maximum. There is an annual
individual out- of-pocket maximum and an annual family out-of-pocket maximum. To meet the annual family out-of-pocket maximum, you can
count the annual eligible expenses incurred by two or more family members. Expenses you incur to satisfy your annual deductible will count
toward the annual out-of- pocket maximum.
ESSENTIAL HEALTH BENEFITS (as defined by federal law) means benefits in at least the following categories.
yAmbulatory patient services
yEmergency services
yHospitalization, maternity and newborn care
yMental health and substance use disorder
services (including behavioral health
treatment)
yPrescription drugs
yRehabilitative and habilitative services and devices
yLaboratory services
yPreventive and wellness services
yChronic disease management
yPediatric services including oral and vision care
Your plan may contain some or all of these types of benefits prior to 2014 when they become mandatory. If your plan contains any of these
benefits, there are certain requirements that may apply to these benefits.
LIFETIME DOLLAR LIMITS.
The essential health benefits provided by Health Plan are not subject to a lifetime dollar limit. Benefits that are not defined as essential health
benefits may have a lifetime dollar limit. If you have reached a lifetime dollar limit under Health Plan before the federal regulation prohibiting
lifetime dollar limits for essential health benefits became effective, and you are still eligible under Health Plan’s terms, and Health Plan is still in
effect, you will receive a notice that the lifetime dollar limit no longer applies and that you will have an opportunity to enroll or be reinstated under
Health Plan. If you are eligible for this enrollment opportunity, you will be treated as a special enrollee.
ANNUAL DOLLAR LIMITS.
Health Plan may have annual dollar limits on the claims Health Plan will pay each year for essential health benefits. Health Plan may include
other benefits not defined as essential health benefits, and those other benefits may have annual dollar limits. If Health Plan has annual dollar
limits on essential health benefits they are subject to the following.
For a plan year beginning on or after September 23, 2010, but before September 23, 2011, the limit can be no less than $750,000.
For a plan year beginning on or after September 23, 2011, but before September 23, 2012, the limit can be no less than $1.25 million.
For a plan year beginning on or after September 23, 2012, but before December 31, 2013, the limit can be no less than $2 million.
For a plan year beginning on or after January 1, 2014, there is no dollar limit for essential health benefits under Health Plan.
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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EXAMPLES OF
SERVICES REQUIRING PREAUTHORIZATION
Elective Admissions (including behavioral health)
Tertiary Care
Hysterectomy
Imaging (PET, PET-CT Fusion, SPECT of Brain)
Chiropractic Care
Podiatric Care
Audiology
Hyperbaric Oxygen
TMD & CMD Care
All Genetic Testing
Urinary/Fecal Incontinence Treatment
Wound Care Clinic
Autism Spectrum Disorder
Bariatric Surgery
Cosmetic Procedure
Varicose Vein Treatment
Botox Injections
Infertility
Speech Therapy
Home Health Services
Hospice
Home Infusion Therapy
Durable Medical Equipment:
Greater than $500
Non-Emergent Ambulance
If you, or your physician, have a question regarding preauthorization, please contact a HEALTH PLAN Customer Services Representative. St.
Clairsville/Morgantown areas: (740) 695-7902, (888) 847-7902, TDD (740) 695-7919, (800) 622-3925, email [email protected], Massillon area:
(330) 837-6880, (800) 426-9013, TDD (877) 236-2291 or email [email protected].
NOTE: TRUE EMERGENCY OR URGENT CARE SERVICES ARE COVERED WITHOUT REGARD TO PREAUTHORIZATION.
HELP US HELP YOU!
Help stop insurance fraud. Each incident uncovered and stopped saves you and every other policyholder money. That is as important to us as it
is to you. Health care fraud usually takes the form of false or misleading claims for payment submitted to insurance carriers and health care plans.
Local and toll-free “FRAUD” hotline phone numbers are now available. If at any time you may have concerns or questions about charges or
payments made for you or an eligible dependent, feel free to call the Plan’s Fraud Hotline at (740) 699-6111 or (877) 296-7283.
BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
INPATIENT HOSPITAL SERVICES
•Hospitalization: semi-private room, ICU/CCU, nursing
care, maternity and birthing room (48 hrs. normal, 96 hrs.
cesarean, see “Maternity care”), nursery, operating room,
therapy (oxygen and respiratory, physical, occupational
and speech), laboratory, therapeutic and diagnostic x-ray,
observation bed, other services and supplies
15% copay/admission
(after deductible)
20% copay/admission
(after deductible)
20% copay/admission (after
deductible)
•Physician visits and services
$0 (after deductible)
$0 (after deductible)
$0 (after deductible)
•Rehabilitation
$0 days 1-30, 20%
copay/days 31+ (after
deductible)
$0 days 1-30, 20%
copay/days 31+ (after
deductible)
$0 days 1-30, 20%
copay/days 31+ (after
deductible)
•Skilled Nursing Facility: limited to a maximum of 120
days per contract year and/or per qualifying diagnosis per
lifetime, (there may be instances where a non-contracting
facility may be covered, for additional information call (740)
695-7902 or (888) 847-7902
$35 copay/day (after
deductible)
$35 copay/day (after
deductible)
$35 copay/day (after
deductible)
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
PHYSICIAN OFFICE VISITS
•Audiology: audiological exam, one (1) per contract year
$20 copay/visit (deductible
waived)
$25 copay/visit
(deductible waived)
$25 copay/visit (deductible
waived)
•Chiropractic care: limited services, subject to Plan
review, limited to a maximum of 20 visits per contract year
$20 copay/visit (deductible
waived)
$25 copay/visit
(deductible waived)
$25 copay/visit (deductible
waived)
•Maternity care: pre and post-natal care/obstetrical
services*
$20 copay initial visit only
(deductible waived)
$25 copay initial visit only
(deductible waived)
$25 copay initial visit only
(deductible waived)
•Ob/gyn care
$20 copay/visit (deductible
waived)
$25 copay/visit
(deductible waived)
$25 copay/visit (deductible
waived)
•Podiatry care
$20 copay/visit (deductible
waived)
$25 copay/visit
(deductible waived)
$25 copay/visit (deductible
waived)
•Primary care physician (“PCP”)
$15 copay/visit (deductible
waived)
$15 copay/visit
(deductible waived)
$15 copay/visit (deductible
waived)
•Specialist care
$20 copay/visit (deductible
waived)
$25 copay/visit
(deductible waived)
$25 copay/visit (deductible
waived)
*Post delivery follow-up visits: 48 hrs. normal, 96 hrs.
cesarean, if mother and physician determine that the
hospital stay is to be shortened, 72 hrs. of follow-up care
will be provided at no charge and deductible waived
BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
DIABETIC COVERAGE (Treatment and/or management
for insulin or non-insulin dependent diabetes, diabetes
during pregnancy or those known to have risk factors)
•Annual retinal exam by Optometrist or
Ophthalmologist*
$0 (deductible waived)
$0 (deductible waived)
$0 (deductible waived)
•Insulin pumps and pump supplies: covered under
DME benefit, limited to the Plan’s basic allowance
30% copay (after
deductible)
30% copay (after
deductible)
30% copay (after deductible)
•Laboratory*
20% copay (after
deductible)
20% copay (after
deductible)
20% copay (after deductible)
$10/30% whichever is
greater copay
(deductible waived)
$10/30% whichever is
greater copay (deductible
waived)
$10/30% whichever is
greater copay (deductible
waived)
* If the exam reveals an abnormal condition, future
treatment may require Preauthorization and applicable
member costs will apply
* The Plan and the American Diabetes Association
recommend fasting blood glucose, lipid profile at least
annually, glycosylated hemoglobin (HbA1c) at least twice
per year, microalbuminuria at least annually
•Pharmacological agents: 31-day supply dispensed
monthly, subject to formulary*
* Members covered under a Health Plan prescription drug
rider will receive pharmacological agents through their
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
prescription drug rider. Non-formulary agents will be
covered only if a specific medical indication exists whereby
the listed formulary agents cannot be used and require
preauthorization.
•Self management education services: limited to 16
visits (maximum of eight (8) individual and eight (8) group)
per contract year, medically appropriate education on
proper self-management, treatment and diet
$0 (deductible waived)
$0 (deductible waived)
$0 (deductible waived)
•Supplies: glucometers, syringes, lancets, glucose test
strips, alcohol swabs, carpujet, urine ketone testing strips
and penlets*
$0 (deductible waived)
$0 (deductible waived)
$0 (deductible waived)
•Allergy injections and serum
$0 (after deductible)
$0 (after deductible)
$0 (after deductible)
•Ambulance service: emergency transportation, medically
necessary only *
$50 copay/incident (after
deductible)
$50 copay/incident (after
deductible)
$50 copay/incident (after
deductible)
*Supplied through pharmacies. The Plan may require the
use of specific brands of glucometers and test strips to
ensure consistency of training and education services.
OTHER SERVICES (PHYSICIAN’S OFFICE, HOSPITAL,
HOME SETTING, OTHER PLAN OR APPROVED
PROVIDER)
Note: applicable office visit copay may apply
*Scheduled transportation will be reviewed for medical
necessity and appropriateness
BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
•Ambulette service: will be reviewed for medical necessity
and appropriateness
$25/30% whichever is less
copay/incident (after
deductible)
$25/30% whichever is
less copay/incident (after
deductible)
$25/30% whichever is less
copay/incident (after
deductible)
•Autism Spectrum Disorder: separate 20 visit limit each
per contract year for physical, occupational and speech
therapies and ABA
30% copay/visit (after
deductible)
30% copay/visit (after
deductible)
30% copay/visit (after
deductible)
•Biofeedback therapy: for urinary or fecal incontinence
only
30% copay/visit (after
deductible)
30% copay/visit (after
deductible)
30% copay/visit (after
deductible)
•Cardiac rehabilitation: limited to a maximum of 12 weeks
or 36 visits per heart attack or heart surgery
$10 copay/visit (after
deductible)
$10 copay/visit (after
deductible)
$10 copay/visit (after
deductible)
•Dialysis
$0 (after deductible)
$0 (after deductible)
$0 (after deductible)
•Durable medical equipment (DME) and DME supplies:
rental or purchase is the option of Health Plan, limited to
Health Plan’s basic allowance
30% copay (after
deductible)
30% copay
(after deductible)
30% copay
(after deductible)
•Emergency care: copay waived if admitted
$100 copay/incident
(deductible waived)
$100 copay/incident
(deductible waived)
$100 copay/incident
(deductible waived)
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
•Family planning*
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
30% copay/visit/injection
(after deductible)
30% copay/visit/injection
(after deductible)
30% copay/visit/injection
(after deductible)
•Home health: services for intermittent skilled care only
(home health aide not covered)
$0 (after deductible)
$0 (after deductible)
$0 (after deductible)
•Home IV therapy/infusion therapy
$0 (after deductible)
$0 (after deductible)
$0 (after deductible)
•Hospice care
$0 (after deductible)
$0 (after deductible)
$0 (after deductible)
•Infertility services: limited to basic health care
30% copay/visit/injection
(after deductible)
30% copay/visit/injection
(after deductible)
30% copay/visit/injection
(after deductible)
•Oral surgical services: accidental or injury only, repair
limited to gums only
$0 (after deductible)
$0 (after deductible)
$0 (after deductible)
•Orthotics: limited to Plan’s basic allowance
30% copay (after
deductible)
30% copay (after
deductible)
30% copay (after deductible)
•Outpatient diagnostic and therapeutic services:
laboratory, radiology (to include ultrasound, MRI, MRA,
CAT and PET scans), diagnostic tests and therapeutic
treatments
20% copay (after
deductible)
20% copay (after
deductible)
20% copay (after deductible)
*As prescribed by Health care reform FDA-approved
contraceptive methods for women are covered at no
cost to members. Some contraceptives, like oral
contraceptives, are covered under the pharmacy benefit
when included in your plan.
BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
•Outpatient surgery: to include office setting
•Preventive services: initial Mammography starting at age
35, annual screening for cervical cancer, child health
supervision, screenings and tests for diseases, mental
health screenings including substance abuse, healthy
lifestyle counseling, vaccines and immunizations,
pregnancy counseling and screenings, well baby and well
child visits through age 21 and periodic physical exams.
Eligible preventive services have been determined by
recommendations and comprehensive guidelines of
governmental scientific committees and organizations.
Members will be notified at least 60 days in advance if any
item or service is removed from the list of eligible services.
Eligible services will be updated annually to include any
new recommendations or guidelines.
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
15% copay (after
deductible)
$0 copay/visit (deductible
waived)
20% (after deductible)
20% (after deductible)
$0 copay/visit (deductible
waived)
$0 copay/visit (deductible
waived)
In order to be exempt from
office visit Copayments,
services must qualify as
preventive services as
prescribed by section 223
of the Internal Revenue
Code.
In order to be exempt
from office visit
Copayments, services
must qualify as
preventive services as
prescribed by section 223
of the Internal Revenue
Code.
In order to be exempt from
office visit Copayments,
services must qualify as
preventive services as
prescribed by section 223 of
the Internal Revenue Code.
Please contact our Customer Services Department if you
have questions or need to determine whether a service is
eligible for coverage as a preventive service.
For a comprehensive list of recommended preventive
services, visit www.health
care.gov/center/regulations/prevention.html
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
•Prosthetic and prosthetic supplies: limited to Plan’s
basic allowance
30% copay (after
deductible)
30% copay (after
deductible)
30% copay (after deductible)
•Pulmonary rehabilitation: limited to a maximum of 12
weeks or 36 visits per contract year
$10 copay/visit (after
deductible)
$10 copay/visit (after
deductible)
$10 copay/visit (after
deductible)
•Radiation and chemotherapy
20% copay/visit (after
deductible)
20% copay/visit (after
deductible)
20% copay/visit (after
deductible)
•Specialty drugs: high cost medications used to treat very
specific diseases that require extensive management for
safety and effectiveness. These drugs require
preauthorization and may be dispensed through a
pharmacy
Covered under prescription
benefit
Covered under
prescription benefit
Covered under prescription
benefit
•Speech therapy: short term only, limited to the lesser of
maintenance level not to exceed 20 visits per occurrence.
$20 copay/visit (after
deductible)
$25 copay/visit
(after deductible)
$25 copay/visit
(after deductible)
•Therapy (physical and occupational)*
Visits 1-20, $20 copay per
visit per therapy type, visits
21+, 50% copay per visit
per therapy type
(after deductible)
Visits 1-20, $25 copay
per visit per therapy type,
visits 21+, 50% copay per
visit per therapy type
(after deductible)
Visits 1-20, $25 copay per
visit per therapy type,
visits 21+, 50% copay per
visit per therapy type
(after deductible)
$50 copay/incident
(deductible waived)
$50 copay/incident
(deductible waived)
$50 copay/incident
(deductible waived)
*Visits 21+ will be reviewed for medical necessity and
appropriateness.
•Urgent care: copay waived if admitted
BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
BEHAVIORAL HEALTH SERVICES (biologically based
or other mental health and substance abuse services)
To obtain mental health services, an Member may contact
a behavioral health provider or Health Plan for assistance
(877) 221-9295.
Note: Behavioral health services are covered under the
same terms and conditions as any other covered illnesses
unless otherwise noted.
•Inpatient mental health treatment: inpatient hospital
days, intensive outpatient hospital visits, partial
hospitalization visits or residential treatment programs
15% copay/admission
(after deductible)
20% copay/admission
(after deductible)
20% copay/admission (after
deductible)
•Outpatient mental health treatment: office visits,
hospital outpatient department or licensed outpatient
treatment facility
$15 copay/visit
(deductible waived)
$15 copay/visit
(deductible waived)
$15 copay/visit (deductible
waived)
•Inpatient substance abuse detoxification: limited to
detoxification only
15% copay/admission
(after deductible)
20% copay/admission
(after deductible)
20% copay/admission (after
deductible)
•Inpatient substance abuse rehabilitation: inpatient 15% copay/admission
(after deductible)
hospital days, intensive outpatient hospital visits,
partial hospitalization visits or residential treatment
programs
20% copay/admission
(after deductible)
20% copay/admission (after
deductible)
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
•Outpatient substance abuse treatment: office
visits, hospital outpatient department or licensed
outpatient treatment facility
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
$15 copay/visit
(deductible waived)
$15 copay/visit
(deductible waived)
$15 copay/visit (deductible
waived)
If services fall in more than one (1) copay category the
higher copay shall be applicable
D
D
D
When services are limited to a maximum number of days,
treatments, visits, etc., each visit, treatment, etc., must be
medically necessary and appropriate to be covered.
D
D
D
Percentage copays are based on the amount paid, allowed
or negotiated by the Plan
D
D
D
Members are responsible for any financial obligations for
non-covered services
D
D
D
Certain covered diabetic pharmacological agents, diabetic
supplied and DME/DME supplies listed under “Benefit
Description” are considered prescription benefits. Should
these benefits be denied as non-covered by the
prescription coverage, the Plan will process these
drugs/supplies as medical benefits as outlined in this
Schedule of Benefits. Please contact the Plan should you
have any questions.
D
D
D
OTHER INFORMATION
BENEFIT DESCRIPTION
These services are covered when they meet Plan guidelines, are
provided or arranged for by a Plan physician, deemed medically
necessary and appropriate, and approved by the Plan. There
may be specific limitations (see “Limitations and
Exclusions”).
MEMBER COST
MEMBER COST
MEMBER COST
PLAN A
PLAN B
PLAN C
Prescription Benefits
$10 copay Generic Retail
$5 copay Generic Retail
$10 copay Generic Retail
Prescriptions prescribed for mental health or substance
abuse will be covered under the same terms and conditions
as any other covered illnesses.
$20 copay Generic Mail
Order
$10 copay Generic Mail
Order
$20 copay Generic Mail
Order
50% copay Brand
Name if Generic is not
available Retail & Mail
Order
30% or $300 whichever is
less Generic Specialty
Drug copay
50% copay Brand
Name if Generic is not
available Retail & Mail Order
No coverage for Brand
Name prescriptions
30% or $300 whichever
is less Specialty Drug
copay
30% or $300 whichever is
less Specialty Drug copay
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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LIMITATIONS.
A. HOSPICE CARE.
Members who are diagnosed as having a terminal illness with a life expectancy of six (6) months or less may elect home-based hospice care. The
focus in hospice is care, not a cure. Treatment is provided for symptom and pain management. Care must be provided by a hospice provider
under the supervision of a physician and with participation of a Health Plan case manager.
B. PLASTIC SURGERY.
Plastic surgery procedures are covered ONLY for the reasons stated below:
Trauma/Accidental Injury Congenital Birth Defect
Payment will be made for hospital/medical services incurred in connection with these conditions for plastic surgery only under the following
circumstances.
• The requested procedure is required as a direct result of injury secondary to trauma or accident (e.g., motor vehicle accident).
• The requested procedure is required to correct a congenital birth defect (e.g., cleft lip or palate).
• Surgery required as result of an injury caused by the act of a person convicted of a crime involving family violence.
Coverage is subject to specific to Health Plan restrictions. Second opinion may be required.
Mastectomy/Breast Implants and Removal/Replacement of Implants
Benefits for reconstructive surgery after a mastectomy will be covered under inpatient services by Health Plan. The following benefits are
included.
• Coverage for reconstruction of the breast on which the mastectomy was performed.
• Surgery and reconstruction of the other breast to produce a symmetrical appearance.
• Coverage for prostheses (including mastectomy bras) and physical complications of all stages of the mastectomy, including lymphedemas.
No payment is made for surgical procedures for insertion of breast implants unless it is necessary for breast reconstruction with mastectomy
specifically related to breast cancer or cancer related indication or fibrocystic breast disease.
No payment is made for the removal/replacement of breast implants except for those inserted for reconstructive purposes specifically related to
mastectomy for breast cancer or cancer related indication or fibrocystic breast disease. Consideration will be given to those that have been
deemed medically necessary by Health Plan to remove/replace.
C. ORAL SURGICAL SERVICES.
Oral surgical coverage is limited and will only be covered as indicated.
Mandible/Maxillary/Jaw Structure
Conditions related to malposition of the bones of the jaw are not covered (e.g., orthognathic procedures).
Impacted wisdom teeth and full mouth extraction
Extraction of all teeth including impacted wisdom teeth, regardless of the cause and/or condition is not covered.
Odontogenic dentigerous cysts
Cysts that form in the mouth and/or jaw area will be covered only if they are medical (non-dental) in nature. Preauthorization by Health Plan is
required.
Diseases of the gums, that are non-dental in nature and deemed medically necessary and appropriate, are covered. Preauthorization by Health
Plan is required.
Accident/Injury
Oral surgical and hospital services resulting directly from acute trauma or an accident/injury (e.g., car accident) are limited to the following.
• Coverage is subject to specific Health Plan restrictions.
• Oral surgical services are limited to repair of hard or soft tissues of the face excluding the direct repair
of teeth.
• Must require the expertise of an oral surgeon, be medically necessary and approved by Health Plan.
Injuries to the gums, that are non-dental in nature and deemed medically necessary and appropriate, are covered. Preauthorization by Health
Plan is required.
Congenital Birth Defects
Payment will be made for medically necessary oral surgery and/or hospital/medical services to correct congenital birth defects (not developmental)
such as cleft lip or palate.
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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Anesthesia
Anesthesia is not covered when administered for dental procedures.
Coverage is subject to specific Health Plan restrictions.
D. SPECIALTY DRUGS (sometimes referred to as “Specialty Pharmacy”).
Specialty drugs are those high cost medications including drugs manufactured by biotechnology. Specialty drugs may be administered by
injection, oral, transdermal or inhaled. Specialty drugs are used to treat very specific diseases and require extensive management for safety and
effectiveness. Dosages need to be monitored for effect and adjustments may be needed for adequate response to affectively treat the disease.
Specialty drugs require complex dispensing techniques. Dispensing may be limited to pharmacies with specific skills and distribution programs to
assure proper delivery of these medications. Quantities limited to a 31-day supply (other quantity limits may apply).
Diseases that are targeted to receive therapy with specialty drugs include, but are not limited to, rheumatoid arthritis, severe chronic psoriasis,
multiple sclerosis, hepatitis C, hemophilia, certain cancers, growth deficiency, cystic fibrosis, Crohn’s disease and organ transplant.
Specialty drugs require prior authorization to assure the patient is an appropriate candidate for the drug. Approval periods for authorization may
vary according to agent prescribed. Additionally, oversight is an integral part of the prior authorization process. Health Plan will monitor the use of
the specialty drug for the following.
•Dose optimization
•Proper disposal of ancillary material used in the
•Appropriate monitoring (including required lab studies) delivery of the medication (e.g., syringes)
•Patient compliance to prescribed therapy
•Drug interaction monitoring
Self-administered and specialty drugs are a prescription benefit, not a medical benefit.
E. CLINICAL TRIALS.
Health Plan shall not deny the cost of any routine patient care administered to a member participating in any stage of an eligible cancer clinical
trial if that care would be otherwise covered if the member was not participating in a clinical trial.
Routine care is all health care services consistent with the coverage provided in this health benefit plan for the treatment of cancer, including the
type and frequency of any diagnostic modality, that is typically covered for a cancer patient who is not enrolled in a cancer clinical trial and that
was not necessitated solely because of the trial.
Evaluations for clinical trials are not covered.
An eligible cancer clinical trial is a cancer clinical trial that meets all of the following criteria.
• A purpose of the trial is to test whether the intervention potentially improves the trial participant’s health outcomes.
• The treatment provided as part of the trial is given with the intention of improving the trial participant’s health outcomes.
• The trial has a therapeutic intent and is not designed exclusively to test toxicity or disease pathophysiology.
The trial must do one (1) of the following.
• Tests how to administer a health care service, item or drug for the treatment of cancer.
• Tests responses to a health care service, item or drug for the treatment of cancer.
• Compares the effectiveness of a health care service, item or drug for the treatment of cancer with that of other health care services, items or
drugs for the treatment of cancer.
• Studies new uses of a health care service, item or drug for the treatment of cancer.
The trial must be approved by one of the following entities.
• The National Institutes of Health or one of its cooperative groups or centers under the United States Department of Health and Human Services.
• The United States Food and Drug Administration.
• The United States Department of Defense.
• The United States Department of Veterans’ Affairs.
F. AUTISM SPECTRUM DISORDER.
Coverage for the diagnosis, evaluation and treatment will be as follows.
y Individuals ages 18 months through 18 years.
y Individuals must be diagnosed at eight (8) or younger.
y Services must be ordered or prescribed by a licensed physician or licensed psychologist.
y Services include all traditionally recognized medical treatments and applied behavior analysis.
y Applied behavior analysis must be provided or supervised by a certified behavior analyst.
y Progress reports are required by Health Plan semi-annually.
y In order for treatment to continue, Health Plan must receive objective evidence or a clinically supportable statement of expectation that all of the
following apply.
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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a) The individual’s condition is improving in response to treatment.
b) A maximum improvement is yet to be attained.
c) There is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
G. CONTRACEPTIVES FOR WOMEN.
The following will be covered under the medical benefit at 100%.
a)
b)
c)
d)
IUD (intrauterine devices)
Diaphragms (covered under pharmacy benefit if purchased by prescription through a pharmacy)
Services to replace/remove/inject covered FDA-approved contraceptive methods.
Sterilization procedures such as tubal ligations.
EXCLUSIONS.
1. Hospital and medical services, or items, that are not medically necessary and/or appropriate as determined by Health Plan. Non-medical
treatment, including special education and training for dyslexia, global developmental delay, speech therapy for developmental delay of
speech, mental retardation, learning disabilities or behavioral disorders (not to include Autism Spectrum Disorder).
2. Cosmetic, plastic or reconstructive surgery or other services done primarily to improve, alter or enhance appearance, salabrasion,
chemosurgery or other such skin abrasion procedures to remove scars or tattoos or services related to body piercing (other than
complications) whether or not for psychological or emotional reasons, unless required by law.
3. Dental care (except for pediatric oral health risk assessments provided by a physician) including but not limited to: plates, crowns, bridges,
dental implants, endodontia, periodontia, prosthodontia, orthodontia and dentistry. Extraction of all teeth including wisdom teeth regardless of
the cause and/or condition. Osteotomies of the maxilla or mandible (considered dental procedure) regardless of the cause or condition,
whether congenital or acquired.
Limited benefits exist for treatment to diseased gums and cysts or abscesses. See “Limitations”.
4. Custodial or domiciliary care, respite care, private duty nursing, intermediate care, home health aid services, rest cures or other services
primarily to assist in the activities of daily living and personal comfort items.
5. Items or medical and hospital services deemed to be investigational or experimental by Health Plan in conjunction with its specialty
consultants, appropriate governmental agencies and other regulatory agencies as interpreted by Health Plan. If medically acceptable and
conventional techniques or treatment are available, new ones may not be covered. At such time as these new procedures, techniques or
treatments become non-experimental or investigational and are medically necessary and appropriate, then they may be covered.
6. If otherwise standard treatment items such as human tissues, anatomic structures and blood or blood derivatives are prohibited in the
treatment of an individual based only by non-medical considerations (e.g., relating to religious restrictions or personal preferences) the
alternative products used as substitutes are not a covered benefit.
7. Private rooms except when medically appropriate and authorized by Health Plan. Personal or comfort items and services (e.g., guest meals
and lodging, radio, television and phone).
8. Hospital or medical care for conditions that state or local law requires to be treated in a public facility.
9. Any injury or sickness to the extent any benefits, settlement, award or damages are received or payable (or could reasonably be expected to
be received or payable if claim was made) by reason of Workers' Compensation, employer's liability or similar law or act. This provision
applies even if you have waived your rights to Workers’ Compensation, employer’s liability or similar laws or acts.
10. Reversal of voluntary sterilization and associated services and/or expenses.
11. Sex transformation surgery and associated services and/or expenses except when medically necessary and appropriate. Procedures,
services and supplies related to sexual dysfunction, including but not limited to, penile implants.
12. Services not provided, arranged or authorized by your physician, except in an emergency or when allowed in this Certificate. Elective presurgery testing on an inpatient basis without the authorization of Health Plan’s Medical Director/s.
13. Medical equipment, appliances, devices or supplies of the following types.
. Equipment or supplies that are mainly for patient comfort or convenience. Items such as bathtub lifts or seats, massage devices,
elevators, stair lifts, escalators, hydraulic van or car lifts, orthopedic mattresses, walking canes with seats, trapeze bars, child
strollers, lift chairs, recliners, contour chairs, adjustable beds or back cushions.
. Exercise equipment such as exercycles, parallel bars, walking, climbing or skiing machines, health spas and hydrospray jet injectors.
. Educational equipment including augmentive communication devices.
. Environmental control equipment such as air conditioners, humidifiers or dehumidifiers, air cleaners or filters, portable heaters or dust
extractors.
. Hygienic products or supplies and equipment such as bed baths and toilet seats.
. Whirlpool pumps or equipment.
. Supplies such as tape, alcohol, Q-tips/swabs, gauze, bandages, thermometers, diapers (adult or infant), heating pads or ice bags.
. Professional medical equipment such as blood pressure kits or stethoscopes.
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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.
.
.
.
.
.
.
.
Nutritional products or supplements, food liquidizers or food processors and enterals.
Wigs or wig styling, vibrators or bathroom scales.
Home modifications or supplemental DME equipment, enhancers or modifiers beyond Health Plan’s basic allowance.
Duplicate equipment or repairs to duplicate equipment; the replacement of medical equipment, prosthetics or orthotics if required due to
loss, theft or destruction.
Limited replacement or repairs to medical equipment, prosthetics or orthotics only when required because of wear or because of a change in
the Member’s condition.
Any over the counter items such as stockings, collars or supports.
Medic Alert bracelets/devices, Count-a-Dose magnifiers and insulin carrying devices.
Replacement batteries for durable medical equipment.
14. Physical, psychiatric or psychological exams, testing or treatments not otherwise covered under Health Plan when such services are as
follows.
. Related to employment or school.
. To obtain or maintain insurance.
. Needed for marriage or adoption proceedings.
. Related to judicial or administrative proceedings or orders.
. Conducted for purposes of medical research.
. To obtain or maintain a license or official document of any type.
. To participate in sports.
15. Infertility services are limited to diagnostic and exploratory procedures to determine infertility including surgical procedures to correct medically
diagnosed disease or condition of the reproductive organs. Services must be deemed medically necessary by Health Plan.
Services such as in-vitro fertilization and gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), embryo transport,
surrogate parenting, donor semen, sperm washing, artificial insemination, drugs (oral, topical or injectable) and experimental services are not
covered.
16. Elective termination of pregnancy, except when determined medically appropriate.
17. Therapy and related services for a patient showing no progress. Speech therapy is not a covered benefit except when medically indicated
as a result of a congenital defect (e.g., cleft palate), stroke or
physical trauma.
18. Acupuncture, acupressure, hypnosis, electrolysis, Christian Science treatment and autopsy. Certain education or training classes including
Lamaze. Birth control implants (e.g., Norplant), Estrogen and Androgen pellet implants, paternity testing, massage and vision therapy.
19. Liposuction, panniculectomies, abdominoplasty (e.g., surgical removal of fatty tissue), gastric stapling and gastroplasty or any other surgical
treatment for obesity or morbid obesity.
20. Work hardening programs including functional capacity evaluations.
21. Marriage counseling.
22. Routine foot care including the following.
. Cutting, trimming or partial removal of toenails.
. Treatment of flat feet, fallen arches or weak feet.
. Strapping or taping of the feet.
. Arch supports.
. To remove in whole or in part of the following.
(a) Corns, callouses (thickening of the skin due to friction, pressure or other irritation).
(b) Hyperplasia (overgrowth of the skin).
(c) Hypertrophy (growth of tissue under the skin).
. Hygienic and preventive maintenance care. This includes cleaning and soaking the feet and the use of skin creams to maintain skin tone of
either ambulatory or bedfast patients. Any other service performed in the absence of localized illness, injury or symptoms involving the foot.
23. Weight loss services and associated expenses including but not limited to, surgical procedures, wiring of the jaw, weight control programs,
weight control drugs or products, nutritional products or supplements.
24. Safety devices. Devices used specifically for safety or to affect performance including sports-related activities.
25. Vaccines when related to occupation or occupational, professional and educational requirements and dependent immunizations beyond their
21st birthday. Injections and immunizations required for travel outside the USA and associated with natural disasters.
26. Organ transplants are covered but limited to the following.
Liver.
Bone Marrow.
Heart/Lung.
Corneal.
Heart.
Lung.
Kidney.
Pancreas.
Bowel.
Covered services include the transplant recipient’s reasonable travel and lodging expenses and donor
expenses for compatibility testing, harvesting an presentation to recipient and related expenses. Health Plan will not cover donor expenses IF
the donor has coverage that will.
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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Transplants must be deemed medically necessary and appropriate by Health Plan and meet Health Plan criteria.
Experimental and investigational transplants and related procedures (as determined by Health Plan) are not covered.
27. Optical services, routine vision exams/screenings (except for pediatric vision screenings provided by a physician), refractions, radial
keratotomy and other surgery to correct vision. Eyeglasses, contact lenses and fittings unless otherwise provided by a supplemental rider.
28. Non-medical ancillary services.
29. Physical exams or medical care required by court order or obtained in anticipation of judicial action.
30. Other limitations that are specifically stated in the Schedule of Benefits of this document.
31. Prescription, specialty and self-administered drugs, unless otherwise provided in a supplemental rider. Most over the counter medications
including but not limited to laxatives, antacids and vaginal yeast products.
32. Any services for which the member has no legal obligation to pay in the absence of this or similar coverage.
33. Services received from, rendered or prescribed by a provider with the same legal residence as a covered person or who is a member of the
covered person’s family. This includes spouse, brothers, sister, parent or child. Services received or rendered by a provider to themselves.
34. Services rendered outside the scope of a provider’s license.
35. Treatment in a state or federal hospital for military or service-related injuries or disabilities and/or services furnished, with or without charge, by
any government agency or program, including incarceration, Medicare, military agencies, National Guard or Reserves.
36. Rehabilitation therapy that is primarily educational or cognitive in nature.
37. Non-medical services related to the treatment of Temporomandibular Joint Dysfunction (TMD), Craniomandibular Joint Dysfunction (CMD) and
stylomandibular ligament including but not limited to braces, non-invasive conditions, experimental procedures, splints or other appliances.
As mandated by West Virginia law, West Virginia employers may purchase a TMD/CMD supplemental rider.
38.Services that in the judgment of your physician are not medically appropriate or not required by accepted standards of medical practice or
Health Plan rules governing services.
39. Hearing aids. Hearing exams unless there is a medical condition that requires such exam.
40. Megavitamin therapy, psychosurgery and nutritional based therapy.
41. Services performed after your physician has advised the Member that further services are not Medically appropriate or not covered services
42. Homeopathic treatments.
THE HEALTH PLAN MISSION STATEMENT
“In its mission to provide a comprehensive delivery of healthcare services, the Plan strives to protect the patient’s right to obtain
services in a cost efficient and quality system where patient dignity and satisfaction are enhanced by the services of the Plan and its
provider network.”
Any questions or problems, please call or write our Customer Services Department: St. Clairsville/Morgantown areas: 52160 National Rd. East, St.
Clairsville, OH 43950, (740) 695-7902 or (888) 847-7902, TDD (740) 695-7919 or (800) 622-3925, Massillon area: P.O. Box 4816, Massillon, OH 44648,
(330) 837-6880 or (800) 426-9013, TDD (877) 236-2291. You can also contact us via our website: www.healthplan.org. Nurse on Call and Utilization Review
Staff—24 hrs. a day/seven days a week: (330) 837-6880 or (800) 426-9013. Office hours are Monday - Friday, 8:30 a.m.-5:00 p.m.
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