Download SFMC Medical Option #1 - Stanislaus Surgical Hospital

Stanislaus Surgical Hospital Medical Plan Summary for Group #8410, Option 1
Effective January 1, 2016
GENERAL FEATURES
SERVICES PROVIDED BY,
OR PERFORMED AT,
STANISLAUS SURGICAL
HOSPITAL
SERVICES PROVIDED BY
MEMBER OF EXCLUSIVE
PROVIDER NETWORK
(EPO)
SERVICES PROVIDED
BY MEMBER OF
PARTICIPATING
PROVIDER NETWORK
(PPO)
Individual: $500.00
Family: $1,000.00
Calendar Year Deductible
SERVICES PROVIDED BY
OUT-OF-NETWORK
PROVIDER
(NON-PARTICIPATING)
Individual: $5,000.00
Family:
$10,000.00
If an employee has completed the Health Risk Analysis, the individual deductible
will be reduced to $300.00 and the family deductible will be reduced to $600.00.
Current plan participants have until January 31st to complete a new Health Risk
Analysis. New plan participants have 30 days from their effective date to complete
the HRA.
Unlimited
Unlimited
Annual Maximum
Lifetime Maximum
Calendar Year Out-of-Pocket
Maximum
The following will not be applied to
the Out-of-Pocket Maximum:
Reduced benefits for nonprecertification; Amounts applied to
the deductible; co-payments; Noncovered Expenses; Prescription
services; Amounts in excess of Plan
limits; Patient balances for bariatric
surgery
HOSPITAL / FACILITY EXPENSES
Inpatient Care - Includes Room &
board, Ancillary Charges, and Intensive
Care
Requires Pre-Certification
Maternity Inpatient Care - Employee,
Spouse/Domestic Partner, dependent
Individual: $3,500.00
Family: $10,500.00
STANISLAUS SURGICAL
EPO
PPO
HOSPITAL
Deductible applies to all services unless otherwise indicated.
**See provision for completing the Health Risk Analysis**
100% of Negotiated
Contract Rate
70% of Negotiated
Contract Rate
Without Pre-Certification:
$1,000.00 patient
copayment per admission,
and benefits will be
reduced by 50%
Without Pre-Certification:
$1,000.00 patient
copayment per admission,
and benefits will be
reduced by 50%
Not Available
Outpatient Care - Emergency Room,
including ER Physician
Copayment is waived if admitted to
the hospital or if services are within
48 hours of an accident
Urgent Care Facility
Individual: $15,000.00
Family: $45,000.00
OUT-OF-NETWORK
Deductible applies to all
services
Billed Charges reduced by
50%; Reimbursement at 50%
of reduced rate;
Without Pre-Certification:
$1,000.00 patient
Without PreCertification: $1,000.00 copayment per admission,
and benefits will be
patient copayment per
reduced by 50%
admission, and benefits
**See provisions for
will be reduced by 50%
emergency conditions
70% of Negotiated
Contract Rate
$1,000.00 patient copayment,
$1,000.00 patient
then 100% of Negotiated
copayment, then 100% of
Contract Rate
Negotiated Contract rate
Billed Charges reduced by
50%;
$1,000.00 patient
copayment, then 100% of
reduced rate
Not Available
$200.00 patient copayment,
then 85% of Negotiated
Contract Rate
$200.00 patient
copayment, then 85% of
Negotiated Contract rate
Billed Charges reduced by
50%;
$200.00 patient copayment,
then 85% of reduced rate
**See provisions for
emergency conditions
Not Available
$30.00 patient copayment,
then 100% of Negotiated
Contract Rate
Not subject to deductible
$30.00 patient copayment,
then 100% of Negotiated
Contract Rate
Not subject to deductible
50% of Stanislaus
Foundation allowable
Page 1 of 5
Stanislaus Surgical Hospital Medical Plan Summary for Group #8410, Option 1
Effective January 1, 2016
Surgery Centers - Including surgeries
performed in the outpatient hospital
setting
Requires Pre-Certification
MEDICAL SERVICES
100% of Negotiated
Contract Rate
70% of Negotiated
Contract Rate
Without Pre-Certification:
Without Pre-Certification:
$250.00 patient copayment $250.00 patient copayment
per occurrence
per occurrence
SERVICES PROVIDED BY,
OR PERFORMED AT,
STANISLAUS SURGICAL
HOSPITAL
EPO
70% of Negotiated
Contract Rate
Without PreCertification: $250.00
patient copayment per
occurrence
PPO
Deductible applies to all services unless otherwise indicated.
**See provision for completing the Health Risk Analysis**
Bariatric Surgery: Surgical
procedure only; must be performed
by an EPO provider and must be PreCertified; patient balances not
applied to annual out-of-pocket
maximum
Surgeon and covered inpatient MD
visits
Pre-Certification required for
surgery provided at a hospital or
any surgical facility
Assistant Surgeon
Anesthesia
Not Available
50% of Negotiated Contract
Rate
No coverage without precertification
100% of Negotiated Contract
85% of Negotiated
Rate
Contract Rate
Without Pre-Certification:
Without Pre-Certification:
$250.00 patient copayment $250.00 patient copayment
per occurrence
per occurrence
OUT-OF-NETWORK
Deductible applies to all
services
Not Covered
Not Covered
70% of Negotiated
Contract Rate
Without PreCertification: $250.00
patient copayment per
occurrence
50% of Stanislaus
Foundation Allowable
Without Pre-Certification:
$250.00 patient copayment
per occurrence
70% of Negotiated
85% of Negotiated Contract
100% of Negotiated Contract
Contract Rate for Assistant
Rate for Assistant Surgeons
rate for Assistant Surgeons
Surgeons
100% of Negotiated Contract
Rate
Billed Charges reduced by
50%; Reimbursement at 50%
of reduced rate;
Without Pre-Certification:
$250.00 patient copayment
per occurrence
50% of Stanislaus
Foundation Allowable for
Assistant Surgeons
85% of Negotiated
Contract Rate
70% of Negotiated
Contract Rate
50% of Stanislaus
Foundation Allowable
Routine Well Baby Care - Includes
Initial Hospital Confinement, Nursery
Care, Physician Visits, Circumcision
Not Available
85% of Negotiated
Contract Rate
70% of Negotiated
Contract Rate
50% of Stanislaus
Foundation allowable
Preventive Care - Well baby and Well
Child (through age 17) - includes
Office Visits, Routine Lab, X-rays &
Immunizations
Not Available
100% of Negotiated
Contract Rate
Not subject to deductible
100% of Negotiated
Contract Rate
Not subject to deductible
50% of Stanislaus
Foundation allowable
Preventive Care / Annual Routine
Physical Exams (age 18 and over)
One per calendar year; Guidelines
from nationally validated
recommendations of US Preventive
Services Task Force
Not Available
100% of Negotiated
Contract Rate
Not subject to deductible
70% of Negotiated
Contract Rate
50% of Stanislaus
Foundation allowable
Not Available
$20.00 patient copayment,
then 100% of Negotiated
Contract Rate
Not subject to deductible
$30.00 patient copayment,
then 100%
of Negotiated Contract
Rate
Not subject to deductible
Specialist Doctor Visit
(Home or Office)
Not Available
$20.00 patient copayment,
then 100%
of Negotiated Contract Rate
Not subject to deductible
$30.00 patient copayment,
then 100%
of Negotiated Contract
Rate
Not subject to deductible
Injectables
(Billed Separately)
Not Available
85% of Negotiated
Contract Rate
70% of Negotiated
Contract Rate
Doctor Visit
(Home or Office)
Page 2 of 5
50% of Stanislaus
Foundation Allowable
50% of Stanislaus
Foundation Allowable
50% of Stanislaus
Foundation Allowable
Stanislaus Surgical Hospital Medical Plan Summary for Group #8410, Option 1
Effective January 1, 2016
Allergy Injections and Testing
Diagnostic Tests and Services
(including pre-admission testing)
Cat Scans, MRIs, Bone Density
Requires Pre-Certification
MEDICAL SERVICES
Nuclear Medicine Facility
Requires Pre-Certification
Chemotherapy and Radiation
Therapy
Ambulance
Durable Medical Equipment and
Medical Supplies-- $3,000.00
calendar year maximum
Pre-Certification is required for
Durable Medical Equipment over
$1,000.00 or monthly rental
exceeding $250.00
Orthotics
Only if Medically Necessary and are
custom made for the feet
Physical, Occupational, and Speech
Therapy - Combined Maximum of 24
visits per calendar year
Requires Pre-Certification
Home Health Care, Hospice, and
Outpatient Private Duty Nursing Combined maximum of 100 visits
per calendar year
Requires Pre-Certification
Chiropractic Care - Including x-rays
Maximum $750.00 per calendar year
Not Available
85% of Negotiated
Contract Rate
70% of Negotiated
Contract Rate
50% of Stanislaus
Foundation Allowable
100% of Negotiated
Contract Rate;
(Quest Diagnostic and
Yosemite Pathology )
85% of Negotiated
Contract Rate
70% of Negotiated
Contract Rate
50% of Stanislaus
Foundation allowable
70% of Negotiated
Contract Rate
Without PreCertification: $250.00
patient copayment per
occurrence
50% of Stanislaus
Foundation allowable
Without Pre-Certification:
$250.00 patient copayment
per occurrence
100% of Negotiated
85% of Negotiated
Contract Rate;
Contract Rate
Without Pre-Certification:
Without Pre-Certification:
$250.00 patient copayment $250.00 patient copayment
per occurrence
per occurrence
SERVICES PROVIDED BY,
OR PERFORMED AT,
EPO
PPO
STANISLAUS SURGICAL
HOSPITAL
Deductible applies to all services unless otherwise indicated.
**See provision for completing the Health Risk Analysis**
100% of Negotiated Contract
Rate
85% of Negotiated
Contract Rate
Without pre-certification:
Without Pre-Certification:
$250.00 patient copayment $250.00 patient copayment
per occurrence
per occurrence
100% of Negotiated
Contract Rate
85% of Negotiated
Contract Rate
85% of Negotiated
85% of Negotiated
Contract Rate
Contract Rate
Without Pre-Certification:
Without Pre-Certification:
$250.00 patient copayment $250.00 patient copayment
per occurrence
per occurrence
85% of Negotiated
Contract Rate
85% of Negotiated
Contract Rate
$20.00 patient copayment,
$20.00 patient copayment,
then 100% of Negotiated
then 100% of Negotiated
Contract Rate
Contract Rate
Without Pre-Certification:
Without Pre-Certification:
$250.00 patient copayment $250.00 patient copayment
per occurrence
per occurrence
Not Available
70% of Negotiated Contract
Rate
Without Pre-Certification:
$500.00 patient copayment
per admission, and
benefits will be reduced by
50%
Not Available
$20.00 patient copayment,
then 100% of
Negotiated Contract Rate
Not subject to deductible
Page 3 of 5
70% of Negotiated
Contract Rate
Without PreCertification: $250.00
patient copayment per
occurrence
OUT-OF-NETWORK
Deductible applies to all
services
Billed Charges reduced by
50%; Reimbursement at 50%
of reduced rate
Without Pre-Certification:
$250.00 patient copayment
per occurrence
70% of Negotiated
Contract Rate
80% of Billed Charges
50% of Stanislaus
Foundation allowable
Paid as a PPO benefit
70% of Negotiated
Contract Rate
Without PreCertification: $250.00
patient copayment per
occurrence
50% of Stanislaus
Foundation allowable
Without Pre-Certification:
$250.00 patient copayment
per occurrence
70% of Negotiated
Contract Rate
50% of Stanislaus
Foundation allowable
70% of Negotiated
Contract Rate
Without PreCertification: $250.00
patient copayment per
occurrence
50% of Stanislaus
Foundation allowable
Without Pre-Certification:
$250.00 patient copayment
per occurrence
70% of Negotiated
50% of Stanislaus
Contract Rate
Foundation allowable
Without PreWithout Pre-Certification:
Certification: $500.00
$500.00 patient copayment
patient copayment per
per admission, and
admission, and benefits benefits will be reduced by
will be reduced by 50%
50%
$30.00 patient copayment,
then 100% of
Negotiated Contract Rate
Not subject to deductible
50% of Stanislaus
Foundation allowable
Stanislaus Surgical Hospital Medical Plan Summary for Group #8410, Option 1
Effective January 1, 2016
Acupuncture Care - Pain Management
Only
Maximum $750.00 per calendar year
Infertility - Only services to
determine a diagnosis will be
considered. Covered Expenses and
benefits are limited to $2,500.00 per
lifetime
Temporomandibular Joint
Dysfunction Syndrome (TMJ) / Jaw
Treatment
$3,000.00 Lifetime Maximum
Transplants
Mandatory Case Management and
Pre-Certification
OTHER COVERED SERVICES
Skilled Nursing Facility- Maximum of
60 days per calendar year
Requires Pre-Certification
Mental Illness - Inpatient
Requires Pre-Certification
Mental and Nervous Conditions Outpatient
Chemical Dependency and
Substance Abuse, Inpatient Care
Requires Pre-Certification
Chemical Dependency and
Substance Abuse Outpatient Care
Requires Pre-Certification
Not Available
$30.00 patient copayment,
then 100% of Negotiated
Contract Rate
Not subject to deductible
$30.00 patient copayment,
then 100% of
Negotiated Contract Rate
Not subject to deductible
50% of Stanislaus
Foundation allowable
85% of Negotiated
Contract Rate
50% of Negotiated
Contract Rate
50% of Negotiated
Contract Rate
Not Covered
Not Available
70% of Negotiated
Contract Rate
70% of Negotiated
Contract Rate
Not Covered
Not Available
70% of Negotiated
Contract Rate
Without Pre-Certification:
$500.00 patient copayment
per admission, and
benefits reduced 50%
70% of Negotiated
Contract Rate
Without PreCertification:
$500.00 patient
copayment per
admission, and benefits
reduced 50%
SERVICES PROVIDED BY,
OR PERFORMED AT,
EPO
PPO
STANISLAUS SURGICAL
HOSPITAL
Deductible applies to all services unless otherwise indicated.
**See provision for completing the Health Risk Analysis**
70% of Negotiated Contract
Rate
Not Available
Without pre-cert, $500.00
copayment and benefits
reduced by 50%
Not Covered
OUT-OF-NETWORK
Deductible applies to all
services
70% of Negotiated
Contract Rate
Billed Charges reduced by
50%; Reimbursement at 50%
of reduced rate Without
Without pre-cert, $500.00
pre-cert, $500.00
copayment and benefits
copayment and benefits
reduced by 50%
reduced by 50%
70% of Negotiated
Billed Charges reduced by
Contract Rate
50%; Reimbursement at 50%
Without Preof reduced rate;
Certification: $500.00
Without Pre-Certification:
patient copayment per $500.00 patient copayment
admission, and benefits per admission and benefits
reduced 50%
reduced 50%
Not Available
70% of Negotiated
Contract Rate
Without Pre-Certification:
$500.00 patient copayment
per admission, and
benefits reduced 50%
$20.00 patient copayment,
then 100% of Negotiated
Contract Rate
$20.00 patient copayment,
then 100% of
Negotiated Contract Rate
Not Available
70% of Negotiated
Contract Rate
Without Pre-Certification:
$500.00 patient copayment
per admission, and
benefits reduced 50%
70% of Negotiated
Billed Charges reduced by
Contract Rate
50%; Reimbursement at 50%
Without Preof reduced rate
Certification: $500.00
Without Pre-Certification:
patient copayment per $500.00 patient copayment
admission, and benefits
per admission, and
reduced 50%
benefits reduced 50%
$20.00 patient copayment,
$20.00 patient copayment,
then 100% of Negotiated
then 100% of Negotiated
Contract Rate
Contract Rate
Without Pre-Certification:
Without Pre-Certification:
$250.00 patient copayment $250.00 patient copayment
per occurrence
per occurrence
$30.00 patient copayment,
Billed Charges reduced by
then 100% of
50%; Reimbursement at 50%
Negotiated Contract Rate
of reduced rate
Without PreWithout Pre-Certification:
Certification: $250.00
$250.00 patient copayment
patient copayment per
per occurrence
occurrence
Page 4 of 5
$30.00 patient copayment,
then 100% of
Negotiated Contract Rate
50% of Stanislaus
Foundation allowable
Stanislaus Surgical Hospital Medical Plan Summary for Group #8410, Option 1
Effective January 1, 2016
Smoking Cessation Programs
Requires Pre-Certification
$250.00 Lifetime Benefit
85% of Negotiated
Contract Rate
70% of Negotiated
Contract Rate
Without Pre-Certification:
$250.00 patient copayment
per occurrence
70% of Negotiated
Contract Rate
Without PreCertification: $250.00
patient copayment per
occurrence
Not Covered
**If a participant receives inpatient care or outpatient emergency room care from an out-of-network provider due to an emergency
medical condition as defined in the Stanislaus Surgical Hospital Plan Document, and due to the emergent nature of the
condition, the patient is unable to convey the need to utilize network providers from their health plan, the initial 50%
reduction off billed charges will be eliminated. Services will still be subject to the out-of-network deductible, and the applicable outof-network reimbursement percentage.
UTILIZATION MANAGEMENT / PRE-CERTIFICATION: INETICARE (877) 608-2200
inetico.com, click on PRE-CERTIFICATION WITH INETIPASS
Requires Pre-Admission review of at least 3 working days for non-emergency hospital admissions and / or within 48
hours of an emergency. Failure to obtain approval results in a $1,000.00 patient copayment per admission, and
benefits will be reduced by 50%
Inpatient Admissions
Surgery (inpatient and outpatient) and
Surgery Centers
Requires prior certification at least 3 working days in advance. Failure to obtain approval results in an additional
$250.00 patient copayment per occurrence.
All Other Services Requiring
Pre-Certification
Requires prior certification at least 3 working days in advance. Failure to obtain approval results in either an additional
$250.00 or an additional $500.00 patient copayment per occurrence.
Prescription Drugs:
Prior Authorizations: (877) 526-9906
RESTAT Prescription Services: (800) 248-1062
Client #8410 Group #001
Participating RESTAT Pharmacies
Mandatory Generic Substitution.
Maximum 30-day supply.
Generic: $5.00 copayment
Brand Name: $250.00 Annual Deductible; $40.00 copayment
Non-formulary: $250.00 Annual Deductible; 50% copayment with a maximum copayment of $60.00
Mail Order Program
Approved Maintenance Medications
Only.
Maximum 90-day supply.
Generic: $10.00 copayment
Brand Name: $250.00 Annual Deductible; $80.00 copayment
Non-formulary: $250.00 Annual Deductible; 50% copayment with a maximum copayment of $120.00
Page 5 of 5