Medical Plans Overview: Option Health Care Plans
Plan 1:
$1,000 Deductible Summary of Benefits
(Information as of 4/1/11)
PDF Format
Hospital Admission Certification . "Welcome" Outpatient Service Waiver . Annual Deductible . Plan Coinsurance . Lifetime Maximum . Hospital Services . Outpatient Services (Office Visits) . Drugs-Outpatient . Out-of-Pocket Limit .
Acupuncture . Ambulance Services . Chemical Dependency . Devices, Equipment & Supplies for Home Use .
Diabetic Suplies . Diagnostic Laboratory and Radiology Services . Emergency Services . Hearing Exams and Hearing Aids
Home Health Services . Hospice Services . Infertility Services . Manipulative Therapy . Maternity and Pregnancy Services
Mental Health Services . Naturopathy . Optical Services . Organ Transplants . Pre-Existing Conditions .
Preventive Services . Rehabilitation Services . Skilled Nursing Facility . Sterilization . TMJ Services . Tobacco Cessation
Limitations . Exclusions

Benefit
  Inside Network  Outside Network
Network (defined)
 
  • When care is provided or referred by the Managed Health Care Network (MHCN). Benefit allowances utilized inside the Network cannot be duplicated outside the Network.
  • No Out-of-Network Coverage
Hospital Admission Certification (back to top)
  • Not required.
  • No Out-of-Network Coverage
"Welcome" Outpatient Service Waiver (back to top)
 
  • No "Welcome" Outpatient Service Waiver.
  • No Out-of-Network Coverage
Annual Deductible (back to top)
 
  • $1,000 per Member or $3,000 per family unit per calendar year. Annual deductible does not apply to outpatient services.
  • No Out-of-Network Coverage
Plan Coinsurance (back to top)
 
  • 80% after annual deductible is satisfied
  • No Out-of-Network Coverage
Lifetime Maximum (back to top)
 
  • Unlimited
  • No Out-of-Network Coverage
Hospital Services (back to top)
Covered inpatient medical and surgical services, including acute chemical withdrawal (detoxification)
  • Covered at the plan coinsurance after the annual deductible is satisfied.
  • No Out-of-Network Coverage
Covered outpatient hospital surgery (including ambulatory surgical centers)
  • Coverage subject to the applicable outpaitent services copayment and at the plan coinsurance after the annual deductible is satisfied.
  • No Out-of-Network Coverage
Oupatient Services (Office Visits) (back to top)

Covered outpatient medical and surgical services
  • Covered subject to the lesser of the MHCN's charge or a $20 copayment and at the plan coinsurance after the annual deductible is satisfied.
  • No Out-of-Network Coverage

Allergy Testing
  • Covered subject to the applicable outpatient services copayment and at the plan coinsurance after the annual deductible is satisfied.
  • No Out-of-Network Coverage

Oncology
(radiation therapy, chemotherapy)
  • Covered subject to the applicable outpatient services copayment and at the plan coinsurance after the annual deductible is satisfied.
  • No Out-of-Network Coverage
Drugs - Outpatient
(Including mental health drugs, contraceptive drugs and devices and diabetic supplies)                              (back to top)

Prescription drugs, medicines, supplies and devices for a supply of thirty (30) days or less when listed in the GHO drug formulary
  • Covered subject to the lesser of the Managed Health Care Network's (MHCN’s) charge or a $20 copayment for generic drugs or the greater of a $40 copayment or 50% coinsurance for brand name drugs.
  • No Out-of-Network Coverage
Over-the-counter drugs and medicines
  • Not covered.
  • No Out-of-Network Coverage
Allergy Serum
  • Covered as a standard medical benefit subject to office visit cost shares.
  • No Out-of-Network Coverage
Injectables
  • Injections that can be self-administered are subject to the applicable deductible and coinsurance.
  • No Out-of-Network Coverage
Mail order drugs and medicines
  • Covered subject to two (2) times the applicable prescription drug cost share for each ninety (90) day supply or less.
  • No Out-of-Network Coverage
Growth hormones
  • Covered at the plan coinsurance after the annual deductible is satisfied, subject to a twelve (12) month waiting period.
  • No Out-of-Network Coverage
Out-of-Pocket Limit (Stop Loss) (back to top)

  • Limited to an aggregate maximum of $5,000 per Member or $15,000 per family per calendar year. Except as otherwise noted, total out-of-pocket expenses for the following Covered Services are included in the out-of pocket limit:
    • Plan coinsurance
    • Emergency services at a MHCN or non-MHCN Facility
    • Ambulance services
  • No Out-of-Network Coverage
Acupuncture (back to top)
 
  • Covered subject to the applicable outpatient services copayment and at the plan coinsurance for self-referrals to a MHCN Provider up to a maximum of eight (8) visits per Member per medical diagnosis per calendar year, after the annual deductible is satisfied. When approved by GHO, additional visits are covered.
  • No Out-of-Network Coverage
Ambulance Services (back to top)
Emergency ground/air transport

Non-emergent ground/air
interfacility transfer
  • Covered at 80%.

    Covered at 80% for MHCN-initiated transfers, except hospital-to-hospital ground transfers covered in full.
  • No Out-of-Network Coverage
Chemical Dependency (back to top)

Inpatient Services
  • Covered subject to the applicable inpatient services copayment and at the plan coinsurance after the annual deductible is satisfied.
  • No Out-of-Network Coverage

Outpatient services
  • Covered subject to the applicable outpatient services copayment. Annual deductible and coinsurance apply.
  • No Out-of-Network Coverage
Benefit period allowance
  • The benefit period and benefit period allowance provisions under chemical dependency services have been removed in accordance with federal law.
  • No Out-of-Network Coverage
 Devices, Equipment and Supplies (for home use) (back to top)
 Covered items include:
• Durable medical equipment
• Orthopedic appliances
• Post-mastectomy bras limited
to two (2) every six (6) months
  • Covered at 80%
  • No Out-of-Network Coverage
• Ostomy supplies
• Prosthetic devices
Diabetic
  • Covered at 80%
  • No Out-of-Network Coverage
Diabetic Supplies (back to top)
 
  • Insulin, needles, syringes and lancets - see Drugs-Outpatient. External insulin pumps, blood glucose monitors, testing reagents and supplies - see Devices, Equipment and Supplies. When Devices, Equipment and Supplies have a dollar maximum, diabetic supplies are not subject to this maximum benefit limit.
  • No Out-of-Network Coverage
Diagnostic Laboratory and Radiology Services (back to top)
 
  • Covered at the plan coinsurance after the annual deductible is satisfied.
  • No Out-of-Network Coverage
Emergency Services (back to top)
 
  • Covered subject to a $150 copayment per Member per emergency visit, then covered at the plan coinsurance after the annual deductible is satisfied. Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the emergency department. Emergency admissions are covered subject to the applicable inpatient services cost share.
  • Covered subject to a $150 copayment per Member per emergency visit, then covered at the plan coinsurance after the annual deductible is satisfied. Deductible is waived if the Member is admitted as an inpatient to the hospital directly from the emergency department. Emergency admissions are covered subject to the applicable inpatient services cost share. If the Member is admitted to a non-MHCN Facility they should contact the Emergency Notification Line as indicated on their GHO identification card in order to be covered.
Hearing Examinations and Hearing Aids (back to top)
 

  • $20 copay, deductible and coinsurance apply

    Hearing Hardware not covered
  • No Out-of-Network Coverage
Home Health Services (back to top)

  • Covered in full. No visit limit.
  • No Out-of-Network Coverage
Hospice Services (back to top)

  • Covered in full.
  • No Out-of-Network Coverage
Infertility Services (including sterility) (back to top)
 
  • Not covered.
  • No Out-of-Network Coverage
Manipulative Therapy (back to top)
  
  • Covered subject to the applicable outpatient services copayment and at the plan coinsurance for self-referrals to a MHCN Provider for manipulative therapy of the spine and extremities up to a maximum of ten (10) visits per Member per calendar year. Visits are covered subject to the applicable outpatient services copayment and at the plan coinsurance. Annual deductible does not apply to outpatient services.
  • No Out-of-Network Coverage
Maternity and Pregnancy Services (back to top)

Delivery and associated hospital care
  • Covered subject to the applicable inpatient services copayment and at the plan coinsurance after the annual deductible is satisfied.
  • No Out-of-Network Coverage
Routine prenatal and postpartum care
  • Covered subject to the applicable outpatient services copayment and at the plan coinsurance. Annual deductible does not apply to outpatient services.
  • No Out-of-Network Coverage
Mental Health Services (back to top)
 Inpatient services
  • No day/visit limits apply. Services are subject to applicable inpatient or outpatient services cost share.
  • No Out-of-Network Coverage
Outpatient Services
  • No day/visit limits apply. Services are subject to applicable inpatient or outpatient services cost share.
  • No Out-of-Network Coverage
Naturopathy (back to top)

  • Covered subject to the applicable outpatient services copayment and at the plan coinsurance for self-referrals to a MHCN Provider up to a maximum of three (3) visits per Member per medical diagnosis per calendar year. When approved by GHO, additional visits are covered subject to the applicable outpatient services copayment and at the plan coinsurance. Annual deductible does not apply to outpatient services.
  • No Out-of-Network Coverage
Optical Services (back to top)
 Routine Eye Examinations
  • Covered subject to the applicable outpatient services copayment once every twelve (12) months, except as Medically Necessary. Not subject to the annual deductible or plan coinsurance.
  • No Out-of-Network Coverage
Lenses, including contact lenses, and frames
  • Not covered.

    One contact lens per diseased eye when in lieu of an intraocular lens, is covered at the plan coinsurance after the annual deductible is satisfied following cataract surgery, provided the Member has been continuously covered by GHO since such surgery.
  • No Out-of-Network Coverage
Organ transplants (back to top)
 
  • Coverage subject to the applicable copayment deductible and the plan coinsurance
  • No Out-of-Network Coverage
Pre-Existing Conditions (back to top)
 
  • No waiting period
  • No Out-of-Network Coverage
Preventive Services (back to top)
Well adult and well child physicians, immunizations, pap smears, mammograms
  • Covered in full
  • No Out-of-Network Coverage
Rehabilitation Services (back to top)
Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under
  • Covered subject to the applicable inpatient services copayment and at the plan coinsurance for up to sixty (60) days per calendar year, after the annual deductible is satisfied.
  • No Out-of-Network Coverage
Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under
  • Covered subject to the applicable outpatient services copayment and at the plan coinsurance for up to sixty (60) visits per calendar year, after the annual deductible is satisfied.
  • No Out-of-Network Coverage
Skilled Nursing Facility (back to top)
 
  • Covered at the plan coinsurance up to sixty (60) days per Member per calendar year, after the annual deductible is satisfied.
  • No Out-of-Network Coverage
Sterizilation (back to top)
Vasectomy, tubal ligation
  • Covered subject to the applicable outpatient services copayment and at the plan coinsurance after the annual deductible is satisfied. Procedures to reverse a sterilization are not covered.
  • No Out-of-Network Coverage
Temporomandibular Joint (TMJ) Services (back to top)
Inpatient and outpatient TMJ services
  • Covered subject to the applicable copayment and at the plan coinsurance up to a $1,000 maximum per Member per calendar year, after the annual deductible is satisfied.
  • No Out-of-Network Coverage
Lifetime benefit maximum
  • Covered up to a $5,000 combined maximum per Member.
  • No Out-of-Network Coverage
Tobacco Cessation
Individual/Group sessions
  • Covered in full.
  • No Out-of-Network Coverage
Approved pharmacy products
  • Covered in full when prescribed and dispensed as part of the GHO designated tobacco cessation program.
  • No Out-of-Network Coverage
Limitations
   Coverage for cosmetic services is limited to breast reconstruction following mastectomy, and reconstructive breast reduction on non-diseased breast.
  • No Out-of-Network Coverage
Exclusions
   Services or programs not provided or authorized by MHCN staff (except as specified); travel medications; investigational or experimental procedures, drugs and devices; dental care; arch supports including custom shoe modifications or inserts and their fittings except for therapeutic shoes, modifications and shoe inserts for severe diabetic foot disease; convalescent or custodial care; cardiac rehabilitation programs; services covered by first-party insurance; services covered by government and military programs; employment, license, immigration or insurance examinations or reports.

Unless otherwise noted as covered, the following services are also excluded: diagnostic testing of sterility, infertility or sexual dysfunction; work-related conditions (including self-employment, L&I and worker’s compensation).
  • No Out-of-Network Coverage

©2010 - Benefit Consultants Northwest (BCNW)