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rq-130901 north sound emergency medicine 2019 renewal hsa indiv benefits

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  Benefit Summary North Sound Emergency Medicine - Ind. HSA Group Number: 8196800 Effective Date  1/1/2019  Health Plan  Access PPO  Ref  RQ-130901This is a brief summary of benefits. THIS IS NOT A CONTRACT OR CERTIFICATE OF COVERAGE. All benefit descriptions, including alternative care,are for medically necessary services. The Member will be charged the lesser of the cost share for the covered service or the actual charge for that service.For full coverage provisions, including limitations, please refer to your certificate of coverage.In accordance with the Patient Protection and Affordable Care Act of 2010,The lifetime maximum on the dollar value of covered essential health benefits no longer applies. Members whose coverage ended by reason ofreaching a lifetime limit under this plan are eligible to enroll in this plan, andDependent children who are under the age of twenty-six (26) are eligible to enroll in this plan. Benefits Preferred Provider Network Out-of-NetworkPlan deductible Individual deductible: $1,500 per calendar yearFamily deductible: $3,000 per calendar yearUntil the total family annual deductible is met, benefits willnot be provided for any family memberIndividual deductible: $3,000 per calendar yearFamily deductible: $6,000 per calendar yearUntil the total family annual deductible is met, benefits willnot be provided for any family member Individual deductiblecarryover 4th quarter carryover does not apply4th quarter carryover does not apply Plan coinsurance Plan pays 80%, you pay 20% (plan pays 90%, you pay 10%enhanced benefit for outpatient visits) Enhanced benefitapplies when services are provided by an Enhancedprovider.Plan pays 60%, you pay 40% of the Allowed Amount. Out-of-pocket limit Individual out-of-pocket limit: $3,500Family out-of-pocket limit: $7,000Out-of-pocket expenses for the following covered servicesare included in the out-of-pocket limit:All cost shares for covered servicesIf enrolled on the family plan you must meet the family out-of-pocket maximumIndividual out-of-pocket limit: $7,000Family out-of-pocket limit: $14,000Out-of-pocket expenses for the following covered servicesare included in the out-of-pocket limit:All cost shares for covered servicesIf enrolled on the family plan you must meet the family out-of-pocket maximum Pre-existing condition (PEC) waiting period No PECSame as preferred provider network Lifetime maximum UnlimitedShared with preferred provider maximum Outpatient services (Office visits)No copay, deductible and coinsurance applyEnhanced benefit applies when services are provided by anEnhanced provider.No copay, deductible and coinsurance apply Hospital servicesInpatient services: Deductible and coinsurance apply Outpatient surgery: No copay, deductible and coinsuranceapply Inpatient services: Deductible and coinsurance apply Outpatient surgery: No copay, deductible and coinsuranceapply Prescription drugs (some injectable drugs maybe covered under Outpatientservices)Preferred generic/preferred brand/non-preferred20% or (10% enhanced) Plan Coinsurance up to a 30 daysupply; Deductible applies. Certain preventive medicationsare covered in full (at a PPN pharmacy, 1st fill only, thencovered at the PPN cost shares)Preferred generic/preferred brand/non-preferredNot covered Prescription mail order 2x the enhanced benefit prescription drug cost share up to a90 day supplyNot covered Acupuncture Covered up to 12 visits per calendar yearNo copay, deductible and coinsurance applyVisit limits shared with preferred provider networkNo copay, deductible and coinsurance apply Ambulance services Deductible and coinsurance applyPreferred provider deductible and coinsurance apply Chemical dependency Inpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance apply Inpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance apply  Devices, equipment andsupplies Durable medicalequipmentOrthopedicappliancesPost-mastectomybras limited to two (2)every six (6) monthsOstomy suppliesProsthetic devicesDeductible and coinsurance applyDeductible and coinsurance apply Diabetic supplies Insulin, needles, syringes and lancets-see Prescriptiondrugs. External insulin pumps, blood glucose monitors,testing reagents and supplies-see Devices, equipment andsupplies. When Devices, equipment and supplies orPrescription drugs are covered and have benefit limits,diabetic supplies are not subject to these limits.Insulin, needles, syringes and lancets-see Prescriptiondrugs. External insulin pumps, blood glucose monitors,testing reagents and supplies-see Devices, equipment andsupplies. When Devices, equipment and supplies orPrescription drugs are covered and have benefit limits,diabetic supplies are not subject to these limits. Diagnostic lab and X-rayservicesInpatient: Covered under Hospital services Outpatient: Deductible and coinsurance applyHigh end radiology imaging services such as CT, MRI andPET must be determined Medically Necessary and requireprior authorization except when associated with Emergencycare or inpatient services. Inpatient: Covered under Hospital services Outpatient: Deductible and coinsurance applyHigh end radiology imaging services such as CT, MRI andPET must be determined Medically Necessary and requireprior authorization except when associated with Emergencycare or inpatient services. Emergency services (copay waived if admitted)$0 copayDeductible and coinsurance apply$0 copayPreferred provider deductible and coinsurance apply Hearing exams (routine) No copay, deductible and coinsurance applyNo copay, deductible and coinsurance apply Hearing hardware Not coveredNot covered Home health services No visit limit, deductible and coinsurance applyNo visit limitDeductible and coinsurance apply Hospice services Deductible and coinsurance applyDeductible and coinsurance apply Infertility services Not coveredNot covered Manipulative therapy Covered up to 15 visits per calendar year without priorauthorization; additional visits when approved by the planNo copay, deductible and coinsurance applyVisit limits shared with preferred provider networkNo copay, deductible and coinsurance apply Massage services See Rehabilitation servicesSee Rehabilitation services Maternity services Inpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance apply Inpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance apply Mental Health Inpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance apply Inpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance apply Naturopathy No copay, deductible and coinsurance applyNo copay, deductible and coinsurance apply Newborn Services Initial hospital stay: See Hospital Services; Office visits: SeeOutpatient Services; Routine well care: See Preventive care.Any applicable cost share for newborn services is separatefrom that of the mother.Initial hospital stay: See Hospital Services; Office visits: SeeOutpatient Services; Routine well care: See Preventive care.Any applicable cost share for newborn services is separatefrom that of the mother. Obesity-related surgery(bariatric) Not coveredNot covered Organ transplants Unlimited, no waiting period Inpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance applyShared with preferred provider network Inpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance apply Preventive care Well-care physicals,immunizations, Pap smearexams, mammogramsCovered in fullWomen's contraception is covered as preventive, and Men'scontraception is covered in full after the annual deductiblehas been satisfied.Deductible and coinsurance applyWomen's preventive care services (including contraceptivedrugs and devices and sterilization) are subject to theapplicable Preventive Care cost share and benefitmaximums.Routine mammograms: Deductible and coinsurance apply Rehabilitation services Rehabilitation visits are a totalof combined therapy visits percalendar year Inpatient:  30 days per calendar year. Services with mentalhealth diagnoses are covered with no limit.Deductible and coinsurance apply Outpatient:  45 visits per calendar year. Services with mentalhealth diagnoses are covered with no limit.No copay, deductible and coinsurance apply Inpatient:  Day limits shared with preferred provider networkDeductible and coinsurance apply Outpatient:  Visit limits shared with preferred providernetworkNo copay, deductible and coinsurance apply  Skilled nursing facility Up to 60 days per calendar year, deductible and coinsuranceapplyDay limits shared with preferred provider network, deductibleand coinsurance apply Sterilization  (vasectomy,tubal ligation)Women's sterilization is covered as preventive, Men'ssterilization is covered in full after the annual deductible hasbeen satisfied Inpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance apply Outpatient Surgery:  See Hospital services; Outpatientsurgery sectionWomen's sterilization procedures are covered subject to theapplicable Preventive Care cost share and benefitmaximums. Temporomandibular Joint   (TMJ) servicesInpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance apply Inpatient:  Deductible and coinsurance apply Outpatient:  No copay, deductible and coinsurance apply Tobacco cessationcounseling Quit for Life Program - covered in fullApplicable cost shares apply Routine vision care (1 visit every 12 months)Covered in fullCovered in full Optical hardware   Lenses, including contact   lenses and framesNot coveredNot coveredAll plans offered and underwritten by Kaiser Foundation Health Plan of Washington Options, Inc.RQ-130901

Capitulo 6

Nov 9, 2018

Capitulo 7.pdf

Nov 9, 2018
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