06-30-04 Chapter 172 Employee Retiree Insurance and Benefits Board Meeting minutes

Browse Search

CoverageFirst 1000 Plan pays for services from Plan pays for services from Plan 35, Option 84 PARTICIPATING providers NONPARTICIPATING providers Hospital Services · Inpatient care (semiprivate room 100% after $1 00 copayment 70% after deductible and board, nursing care, leU) (2) per day for first five days per admission, and after deductible · Outpatient surgery - facility (2) 100% after $50 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $100 copayment 70% after deductible per visit after deductible (copayment is waived if admitted) Presaiption Drugs · Rx4 See attached rider, if applicable Other Medical · Skilled nursing facility (up to 80% after deductible 60% after deductible Services 60 days per calendar year) · Home health care (up to 100 visits per calendar year) (2) · Durable medical equipment (2) · Physical, speech and hearing therapy (2), (5) · Ambulance (1) · Private duty nursing (inpatient hospital only) · Hospice (2) · Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health · Inpatient (up to 30 days per 100% after $100 copayment 70% after deductible Services (4) calendar year) (2) per day for first five days per admission · Inpatient professional services 80% 60% · Outpatient (up to 30 visits per calendar year) -Individual sessions 100% after a $20 copayment 70% per visit - Group sessions 100% after a $10 copayment 70% per visit Serious · Inpatient (up to 45 days per Covered the same as any Covered the same as any Mental Illness calendar year) (2) other illness other illness · Outpatient (up to 60 visits per calendar year) Chemical Dependency · Inpatient (2) Covered the same as any Covered the same as any (lifetime maximum of · Outpatient other illness other illness three separate series of treatments for each insured person) * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details.