• No results found

Schedule of Benefits Summary. Health Plan. Out-of-network Provider

N/A
N/A
Protected

Academic year: 2021

Share "Schedule of Benefits Summary. Health Plan. Out-of-network Provider"

Copied!
7
0
0

Loading.... (view fulltext now)

Full text

(1)

36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year

Schedule of Benefits Summary Health Plan

University Name: University of Nebraska - Student Plan Benefit Year: 2014/2015 Academic Year (see attached)

Payment for Services In-network

Provider

Out-of-network Provider Covered Services are reimbursed based on the Allowable Charge. Blue Cross and Blue Shield of Nebraska In-network Providers have agreed to accept the benefit payment as payment in full, not including Deductible, Coinsurance and/or Copayment amounts and any charges for non-covered services, which are the Covered Person’s responsibility. That means In-network providers, under the terms of their contract with Blue Cross and Blue Shield, can’t bill for amounts over the Contracted Amount. Out-of-network Providers can bill for amounts over the Out-of-network Allowance.

Covered Services provided by the University Student Health Clinics at UNK, UNL, UNO and UNMC will be covered with no cost-share to members, except as shown under the Prescription Drugs section.

Deductible (Embedded*)

 Individual $500 $1,000

 Family $1,000 $2,000

Coinsurance

 Covered Person Pays 20% 50%

 Plan Pays 80% 50%

Out-of-pocket Limit (Embedded*)

(includes Deductible, Coinsurance and Copays)

 Individual $2,500 $ 5,000

 Family $5,000 $10,000

Once the annual Out-of-pocket Limit is reached, most Covered Services are payable by the plan at 100% for the rest of the Benefit Year. In-network and Out-of-network Deductible and Out-of-pocket Limits cross accumulate. All other limits (days, visits, sessions, dollar amounts, etc.) do cross accumulate between In-network and Out-of-network, unless noted differently.

*Embedded – If you have single coverage, you only need to satisfy the individual Deductible and Out-of-pocket Limit amounts. If you have family coverage, no one family member contributes more than the individual amount. Family members may combine their covered expenses to satisfy the required family Deductible and Out-of-pocket amounts.

(2)

36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year

Covered Services – Illness or Injury In-network

Provider

Out-of-network Provider Physician Office

 Primary Care Physician Office Services $20 Copay Deductible and Coinsurance

 Specialist Physician Office Services $30 Copay Deductible and Coinsurance Primary Care Physician benefits include the office visit provided by a physician who has a majority of his or her practice in internal or general medicine, obstetrics/gynecology, general pediatrics or family practice. A Certified physician assistant and a Certified nurse practitioner are covered in the same manner as a Primary Care Physician.

Specialist Physician benefits include the office visits provided by a physician who is not a Primary Care Physician.

Physician Professional Services

(Outpatient and Inpatient Services) Deductible and Coinsurance Deductible and Coinsurance Urgent Care Facility Services (a single Copay applies to

each urgent care visit) $75 Copay Deductible and Coinsurance

Emergency Care Services (Services received in a Hospital emergency room setting)

 Facility $300 Copay then Deductible

and Coinsurance In-network level of benefits

 Professional Services Deductible and Coinsurance In-network level of benefits (Copayment is waived if admitted to the hospital within 24

hours for the same diagnosis)

Outpatient Hospital or Facility Services Deductible and Coinsurance Deductible and Coinsurance Inpatient Hospital or Facility Services Deductible and Coinsurance Deductible and Coinsurance

Preventive Services In-network

Provider

Out-of-network Provider Preventive Services

 Affordable Care Act (ACA) required

preventive services (may be subject to limits that include, but are not limited to, age, gender, and frequency)

Plan Pays 100% Deductible and Coinsurance

 Other covered preventive services not

required by ACA Plan Pays 100% Deductible and Coinsurance

Immunizations

 Pediatric (up to age 7) Plan Pays 100% Coinsurance

 Age 7 and older Plan Pays 100% Deductible and Coinsurance

 Related to an illness Same as any other illness Same as any other illness

Pre-classroom Enrollment In-network

Provider

Out-of-network Provider Immunizations and Testing (Services required by

University prior to admission) Plan Pays 100% Plan Pays 100%

(3)

36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year Mental Illness and/or Substance Dependence and Abuse

Covered Services

In-network Provider

Out-of-network Provider

Inpatient Services Deductible and Coinsurance Deductible and Coinsurance

Outpatient Services

 Office Services $20 Copay Deductible and Coinsurance

 All Other Outpatient Items & Services Deductible and Coinsurance Deductible and Coinsurance Emergency Care Services (Services received in a Hospital

emergency room setting)

 Facility $300 Copay then Deductible

and Coinsurance In-network level of benefits

 Professional Services Deductible and Coinsurance In-network level of benefits (Copayment is waived if admitted to the hospital within 24

hours for the same diagnosis)

Transgender Assignment/Reassignment In-network

Provider

Out-of-network Provider

Inpatient Services Deductible and Coinsurance Deductible and Coinsurance

Outpatient Services

 Office Services $20 Copay Deductible and Coinsurance

 All Other Outpatient Items & Services Deductible and Coinsurance Deductible and Coinsurance Emergency Care Services (Services received in a Hospital

emergency room setting)

 Facility $300 Copay then Deductible

and Coinsurance In-network level of benefits

 Professional Services Deductible and Coinsurance In-network level of benefits (Copayment is waived if admitted to the hospital within 24

hours for the same diagnosis)

Note: Surgery and related Covered Services limited to $75,000 while covered

(4)

36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year Other Covered Services – Illness or Injury In-network

Provider

Out-of-network Provider Accident Related Care (Supplemental Benefit)

(limited to $2,000 per person per Benefit Year, for charges in excess of this amount see the applicable service category)

Plan Pays 100% In-network level of benefits

Ambulance (to the nearest facility for appropriate care)

 Ground Ambulance Deductible and Coinsurance In-network level of benefits

 Air Ambulance Deductible and Coinsurance

Deductible and Coinsurance (In-network level of benefits if due to an emergency) Durable Medical Equipment Deductible and Coinsurance Deductible and Coinsurance Home Health Care

 Skilled Nursing Care (limited to 8 hours per

day Deductible and Coinsurance Deductible and Coinsurance

 Home Health Aide (limited to 60 days per

Benefit Year) Deductible and Coinsurance Deductible and Coinsurance

 Respiratory Care (limited to 60 days per

Benefit Year) Deductible and Coinsurance Deductible and Coinsurance

Hospice Services Deductible and Coinsurance Deductible and Coinsurance Independent Laboratory

 Diagnostic Plan Pays 100%

In-network level of benefits

 Preventive Same as Preventive Services

In-network level of benefits

Same as Preventive Services In-network level of benefits Intercollegiate Sports Injuries (limited to UNK and UNO

students and subject to $20,000 per person per Benefit Year)

Same as any other illness Same as any other illness Pediatric Dental (up to age 19)

 Preventive and Diagnostic Deductible and Coinsurance Deductible and Coinsurance

 Maintenance and Simple Restorative Deductible and Coinsurance Deductible and Coinsurance

 Complex Restorative Deductible and Coinsurance Deductible and Coinsurance

 Orthodontic Services (24 month wait applies)

Deductible then Covered Person pays 70%

Deductible then Covered Person pays 70%

NOTE: Age and frequency limits apply Dental Provider Network – Dental GRID

Pregnancy and Maternity Services (prenatal/postnatal

care and delivery) Deductible and Coinsurance Deductible and Coinsurance

Skilled Nursing Facility

Deductible and Coinsurance Deductible and Coinsurance (limited to 60 days per Benefit Year)

(5)

36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year Other Covered Services – Illness or Injury In-network

Provider

Out-of-network Provider

Temporomandibular and Craniomandibular Joint Disorder Deductible and Coinsurance Deductible and Coinsurance Therapy & Manipulations

 Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Benefit Year)

Deductible and Coinsurance Deductible and Coinsurance

 Chiropractic or osteopathic manipulative treatments or adjustments (combined limit to 20 sessions per Benefit Year)

Deductible and Coinsurance Deductible and Coinsurance Vision Exams

 Diagnostic (to diagnose an illness) See Physician Office Services See Physician Office Services

 Preventive (routine exam including refraction)

- Pediatric (up to age 19) See Pediatric Vision Services Section

See Pediatric Vision Services Section

- Adult (age 19 and over) limited to

$50 per Benefit Year

Plan Pays 100% up to $50 per Benefit Year then Not

Covered

Plan Pays 100% up to $50 per Benefit Year then Not

Covered

All Other Covered Services Deductible and Coinsurance Deductible and Coinsurance

Pediatric Vision Services In-network

Provider

Out-of-network Provider Pediatric Vision Services are limited to Covered Persons up to age 19

Vision Examination (including refraction and dilation,

limited to one exam per Benefit Year) Deductible and Coinsurance Deductible and Coinsurance Eyeglass Frames/Lenses or Contacts

(limited to one set of frames and eyeglass lenses per Benefit Year or one purchase of Contact lenses per Benefit Year)

Lenses Deductible then Covered

Person pays 50% In-network level of benefits

 Frames Deductible then Covered

Person pays 50% In-network level of benefits

 Contact Lenses (including evaluation and fitting, when in lieu of eyeglasses)

Deductible then Covered

Person pays 50% In-network level of benefits Medically Necessary Contact Lenses (in lieu of eyeglasses,

for specific conditions)

NOTE Certification required in excess of $600

Deductible then Covered

Person pays 50% In-network level of benefits Low Vision Services and Aids

 Comprehensive low vision evaluation (limited

to one every ( 5 ) Benefit Years) Deductible and Coinsurance Deductible and Coinsurance

 Follow-up low vision care (limited to four

visits in any (5) Benefit Year period) Deductible and Coinsurance Deductible and Coinsurance

 Low vision aids Deductible then Covered

Person pays 50% In-network level of benefits NOTE: Certification required for low vision Services and

aids

(6)

36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year

Prescription Drugs University of

Nebraska – Lincoln Health Center

Pharmacy

In-network Provider

Out-of network Provider

Retail and Mail order – per 30-day supply

 Generic drugs $5 Copay $10 Copay

In-network level of benefits +25%

Penalty

 Formulary Brand Name Drugs $30 Copay $40 Copay

In-network level of benefits +25%

Penalty

 Non-formulary Brand Name Drugs $80 Copay $80 Copay

In-network level of benefits +25%

Penalty NOTE: A 90-day supply is available at a retail Extended Supply Network pharmacy subject to 3 copays.

Specialty drugs

(specialty drugs must be purchased through a designated specialty pharmacy after two fills)

$100 Copay $100 Copay Not Covered

Contraceptives Formulary

- Generic Plan Pays 100% Plan Pays 100% 25% Penalty

- Brand Plan Pays 100% Plan Pays 100% 25% Penalty

Non-formulary

- Generic Same as any other Generic Drug

- Brand Same as any other Non-formulary Brand Name

- Ogestrel 0.5/50 $30 Copay $40 Copay

In-network level of benefits +25%

Penalty

- Nuvaring Plan Pays 100% Plan Pays 100% 25% Penalty

Please note: This Schedule of Benefits Summary is intended to provide you with a brief overview of your benefits. It is not a contract and should not be regarded as one. For more complete information about your plan, including benefits, exclusions and contract limitations, please refer to the master group contract. In the event there are discrepancies between this document and the contract, the terms and conditions of the contract will govern.

(7)

36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year University of Nebraska Medical Center

Benefit Year for the 2014/2015 Academic Year

Program Benefit Year

Allied Health, PA1, PT1, PT2, PT3, Medical Nutrition Perfusion 5 & 6, Cytotechnology, Medicine 1 & 2, Pharmacy 1, 2 & 3, Radiology, Oncology, Nursing, Post MS, graduate, RSTE Medical Family Therapy

August 25, 2014 through August 24, 2015

Accelerated Nursing May 12, 2014 through May 11,2015

Clinical Lab Science May 29, 2014 through May 28, 2015

New 4th Year Pharmacy (4th Year Student enrolling in plan for first time)

May 12, 2014 through May 11,2015

PA 2 & 3 September 2, 2014 through September 1, 2015

Post Graduate Dental Certificate July 1, 2014 through June 30, 2015

Post Graduate July 1, 2014 through June 30, 2015

New 3rd & 4th Year Medical Student July 7, 2014 through July 6, 2015 Visiting Scholars/Miscellaneous May 1, 2014 through April 30, 2015

University of Nebraska - Kearney Benefit Year for the 2014/2015 Academic Year

Program Benefit Year

Enrolled Students August 1, 2014 through July 31, 2015

Visiting Scholars/Miscellaneous May 1, 2014 through April 30, 2015 University of Nebraska - Lincoln

Benefit Year for the 2014/2015 Academic Year

Program Benefit Year

Enrolled Students August 14, 2014 through August 13, 2015

Visiting Scholars/Miscellaneous May 1, 2014 through April 30, 2015 University of Nebraska - Omaha

Benefit Year for the 2014/2015 Academic Year

Program Benefit Year

Enrolled Students August 14, 2014 through August 13, 2015

Visiting Scholars/Miscellaneous May 1, 2014 through April 30, 2015

References

Related documents

In-network: (No deductible) $5 per Aetna Whole Health designated primary care physician (PCP) *PCMH $25 per PCP office visit $35 per specialist visit Out-of-network: 40% of our

Nicos Sifakis (from Hellenic Open University) and Elif Kemaloğlu developed an online ELF-aware in-/pre-service teacher module and trained 32 in-service English language teachers

Physician Office: Deductible + $110 Copay per Visit/ Specialist Virtual Visits: No Charge/ Hospital Opt 1: Deductible + 50% Coinsurance.. Deductible + 50% Coinsurance/

Forward exchange trading gave rise to the notion of covered interest parity which related the differential between domestic and foreign interest rates to the

(1) The thermal mechanism within the WT generator is different from that of conventional machines with constant rotational speed, i.e., the power losses within a WT generator

• If you have an office visit with your Primary Care Physician or Specialist at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered

$30 copay with no deductible for office visits for Sparks Health Management Associates seeking medical care as covered by the plan at a Sparks Health Management owned

MEC conducted statistical analyses of SNP genotype (fetal genetic effects) and sequencing (Danish cohort, maternal triads, and Iowa cases and controls) data, and assisted in