HMO Options January 1, 2015–December 31, 2015 Benefits Open Access Aetna Select HMO Network Coverage Nationwide Network CareFirst Open Access HMO Regional Network (MD, DC and Northern VA) COST SHARING LIFETIME LIMITS Calendar Year Deductible Individual Family None None None None $2,000 (includes copays) $6,000 (includes copays) $2,000 $6,000 Coinsurance 100% 100% Lifetime Maximum None None Primary Care Office Visit $10 copay $10 copay Gynecology Office Visit $10 copay for Well Woman visit or $15 copay for all other visits $10 for Well Woman visit or $15 copay for all other visits Specialist Office Visit $15 copay $15 copay Physical Therapy Office Visit 100% after copay (120 visits combined with Occupational Therapy). 100% after copay (30 visits per condition per calendar year) Speech Therapy Office Visit 100% after copay (60 visits) 100% after copay (30 visits per condition per calendar year) Occupational Therapy Visit 100% after copay (120 visits combined with Physical Therapy) 100% after copay (30 visits per condition per calendar year) Chiropractic Office Visit 100% after copay (limited to 30 visit maximum combined in and out of network) Preauthorization not required 100% after copay (limited to 20 visits per benefit period) Allergy Shots/Other Covered Injections 100% after copay 100% after copay Calendar Year Out-of-Pocket Maximum Individual Family PROFESSIONAL SERVICES Retiree Plan Participants under age 65 and over age 65: Expenses for non-covered services and charges in excess of reasonable and customary do not apply toward the out-of-pocket limit. The purpose of this Open Enrollment Guide is to give you basic information about your benefits options and how to enroll for coverage or make changes to existing coverage. This guide is only a summary of your choices and does not fully describe each benefit option. Please refer to your Certificates of Coverage provided by your health plan carriers for important additional information about the plans. Every effort has been made to make the information accurate; however, in the case of any discrepancy, the provisions of the legal documents will govern. 32 • Howard County Public School System—Benefits Enrollment Guide for Retirees HMO Options January 1, 2015–December 31, 2015 Benefits Open Access Aetna Select HMO Network Coverage Nationwide Network CareFirst Open Access HMO Regional Network (MD, DC and Northern VA) Allergy Serum 100% after copay Allergy Testing Covered as either a PCP or Specialist Covered as either a PCP or office visit Specialist office visit Diagnostic tests Included with PCP or Specialist copayment Diagnostic tests performed by 100% lab or other testing facility and billed separately from office visit 100% after copay 100% after copay 100% PREVENTIVE CARE Well Child Visit/Immunization $10 copay $10 copay Routine Adult Physical $10 copay $10 copay Routine Gynecological Exam $10 copay, one exam per calendar year $10 copay, one exam per calendar year Routine Pap Smear 100% when included with routine gynecological exam. One exam per calendar year. 100% when included with routine gynecological exam. One exam per calendar year. Routine Mammogram 100% baseline between age 35-39. 100% unlimited visits One per calendar year age 40 and over PSA Testing Covered based on place of service. One per calendar year for males age 40 and over Covered based on place of service. One per calendar year for males 40 and over INPATIENT CARE (Pre authorization required) Room and Board 100% Pre-authorization required 100% Pre-authorization required Physician/Surgical Services 100% 100% Anesthesia Services 100% 100% Intensive Care Unit/Critical Care Unit 100% 100% Maternity/Nursery/Birthing Center 100% 100% Skilled Nursing/Rehab Facility Care 100% limited to 120 days per calendar year 100% unlimited days Dialysis/Radiation/ Chemotherapy 100% 100% Hospice (Preauthorization Required) 100% 100% Physical/Speech/ Occupational Therapy 100% 100% Howard County Public School System—Benefits Enrollment Guide for Retirees • 33 HMO Options January 1, 2015–December 31, 2015 Benefits Open Access Aetna Select HMO Network Coverage Nationwide Network CareFirst Open Access HMO Regional Network (MD, DC and Northern VA) OUTPATIENT HOSPITAL SERVICES Surgical/Anesthesia Services 100% 100% Dialysis/Radiation/ Chemotherapy 100% 100% Outpatient Diagnostic Services 100% 100% MATERNITY/INFERTILITY SERVICES 1st prenatal visit 100% after copay 100% after copay Pre-and Postnatal care and delivery 100% 100% Routine nursery care 100% 100% Sterilization/Reverse Sterilization requires preauthorization 100% Reverse Sterilization is not covered 100% Reverse Sterilization is not covered Artificial Insemination (AI) 50% of Allowed Benefit (preauthorization; limited to 6 courses of treatment per lifetime) 50% of Allowed Benefit (limited to 6 courses of treatment per lifetime) In Vitro Fertilization (IVF)– maximum of 3 IVF attempts/ lifetime (Preauthorization Required) 50% of Allowed Benefit 50% of Allowed Benefit MEDICAL EMERGENCIES (USE OF ER) Emergency Room Urgent Care Center 100% after $50 ER copay 100% after $50 copay (waived if admitted) (waived if admitted) 100% after $15 copay 100% after $15 copay Retiree Plan Participants under age 65 and over age 65: Expenses for non-covered services and charges in excess of reasonable and customary do not apply toward the out-of-pocket limit. The purpose of this Open Enrollment Guide is to give you basic information about your benefits options and how to enroll for coverage or make changes to existing coverage. This guide is only a summary of your choices and does not fully describe each benefit option. Please refer to your Certificates of Coverage provided by your health plan carriers for important additional information about the plans. Every effort has been made to make the information accurate; however, in the case of any discrepancy, the provisions of the legal documents will govern. 34 • Howard County Public School System—Benefits Enrollment Guide for Retirees HMO Options January 1, 2015–December 31, 2015 Benefits Open Access Aetna Select HMO Network Coverage Nationwide Network CareFirst Open Access HMO Regional Network (MD, DC and Northern VA) MEDICAL EQUIPMENT/SUPPLIES Durable Medical Equipment 100% 100% Prosthetic Devices 100% 100% Orthopedic Devices 100% 100% Foot Orthotics 100% 100% (Pre-authorization required) (Subject to medical necessity) MENTAL HEALTH AND SUBSTANCE ABUSE (Preauthorization required for inpatient only) Mental Health: Inpatient 100% 100% Outpatient $15 copay $15 copay Inpatient 100% 100% Outpatient $15 copay $15 copay Ground: 100% non-emergency—not covered Ground: 100% non-emergency— not covered Air: 100% non-emergency—not covered Air: Covered 100% nonemergency—not covered Kidney, Cornea Bone Marrow Transplants Covered in full. The National Medical Excellence (NME) unit will arrange transplant services by a facility that is part of the Institutes of Excellence (IOE) transplant network. 100% Heart, Heart-Lung, Lung, Pancreas, Liver Transplants Covered in full. The National Medical Excellence (NME) unit will arrange transplant services by a facility that is part of the Institutes of Excellence (IOE) transplant network. 100% Substance Abuse: OTHER SERVICES Ambulance Performed at approved IOE facility. If non-IOE facility no coverage. Cardiac Rehabilitation 100% if performed in an outpatient hospital setting;100% after copay in office setting or freestanding cardiac rehabilitation center 100% after $15 copay Howard County Public School System—Benefits Enrollment Guide for Retirees • 35 HMO Options January 1, 2015–December 31, 2015 Benefits Open Access Aetna Select HMO Network Coverage Nationwide Network CareFirst Open Access HMO Regional Network (MD, DC and Northern VA) OTHER SERVICES (continued) Hearing Aids Hearing aids: 100% to a maximum of 100% to a maximum of $1,400 per $1,400 per ear during any 36 month ear during any 36 month period period for a child up to age 19. for a child up to the age of 18. Hearing exam: 100% after specialist copay. One exam every 12 months. Acupuncture Acupuncture therapy includes services provided by a licensed acupuncturist covered at 100% no copay subject to R&C 100% of Allowed Benefit no copay Vision (Routine eye exam) Routine eye exam covered at 100% after $15 copay. One exam every 12 months. Routine eye exam covered at 100% after a $10 copay. One exam per calendar year Retiree Plan Participants under age 65 and over age 65: Expenses for non-covered services and charges in excess of reasonable and customary do not apply toward the out-of-pocket limit. The purpose of this Open Enrollment Guide is to give you basic information about your benefits options and how to enroll for coverage or make changes to existing coverage. This guide is only a summary of your choices and does not fully describe each benefit option. Please refer to your Certificates of Coverage provided by your health plan carriers for important additional information about the plans. Every effort has been made to make the information accurate; however, in the case of any discrepancy, the provisions of the legal documents will govern. 36 • Howard County Public School System—Benefits Enrollment Guide for Retirees
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