• - Acupuncture therapy if performed by a physician as a form of anesthesia in connection with surgery that is covered under this plan.
• - Ambulance services used locally to a hospital, nursing home or skilled nursing facility in the case of an emergency or medical necessity, or air ambulance when an emergency situation necessitates transfer.
• - Anesthesia in connection with a covered surgical procedure, when given by a physician.
• - Charges of a surgeon and assistant surgeon for covered surgical procedures. Note that when multiple procedures are performed at the same time, the second procedure will be paid at 50% up to the recognized charge. Charges for the assistant surgeon will be paid up to 20% of the covered charge for the surgical procedure.
• - Chemotherapy and radiation therapy services.
• - Chiropractic services for the detection and correction of nerve interference, resulting from or related to misalignment or partial dislocation of or in the vertebral column, by manual or mechanical means. Chiropractic services are limited to 30 visits per calendar year in the High Value plan and 20 visits per calendar year in the Select Value plan.
• - Complex imaging services provided on an outpatient basis are covered subject to medical necessity at the applicable coinsurance after the deductible has been met. Complex imaging includes but is not limited to:
• ○ Computed Axial Tomography (CAT) scans;
• ○ Magnetic Resonance Imaging (MRI); and
• ○ Positron Emission Tomography (PET) scans.
• - Diagnostic X-rays (except complex imaging) and lab services provided in the doctor’s office are covered under the doctor office visit charge for network providers.
• - Diagnostic X-rays (except complex imaging) and lab services ordered by the doctor and performed in an outpatient setting outside the doctor’s office are covered at 100%, no deductible in network or 60% after deductible out-of-network.
• - Drugs, medicines and supplies used for the treatment of erectile dysfunction due to psychogenic, organic, or mixed psychogenic and organic causes and also for the treatment of pulmonary hypertension. Dosage is limited to 6 tablets per month or 18 tablets for a 90-day supply. Rx services are covered under the prescription drug benefit.
• - Durable medical equipment. Certain devices may be subject to precertification. Examples of covered expenses include:
• ○ Man-made limbs or eyes to replace natural limbs or eyes;
• ○ Casts, orthopedic splints or crutches;
• ○ Trusses or braces required as a result of an injury or illness, or a disabling condition existing since birth;
• ○ Rental of equipment for giving oxygen or to aid in breathing if the equipment has a mouthpiece, hose and compressor;
• ○ Temporary rental (up to the purchase price) of wheelchairs or hospital beds or purchase of wheelchairs or hospital beds if the patient’s condition requires an indefinite, prolonged period of use;
• ○ Dialysis equipment rental, supplies, upkeep and training for you or your dependents to use this equipment;
• ○ Ostomy bags and supplies;
• ○ Glucometers, dextrometers, dextrostix and rental of infusion pumps and supplies;
• ○ Adaptive equipment or modifications to wheelchairs or hospital beds, which are prescribed by a physician as necessary for the treatment of the injury or illness; and
• ○ Medically necessary insulin and diabetic supplies.

Benefits will also be provided for adjustments, repair and replacements of covered prosthetic devices, special appliances and surgical implants when required because of wear or change in a patient’s condition (excluding dental appliances and post mastectomy holding bra).

• - Inhaler assisting devices requiring a prescription and dispensed through a pharmacy. Limited to one device per year. Rx services are covered under the prescription drug benefit.
• - Expenses relating to pregnancy for an employee or covered dependent spouse or domestic partner. No benefits are payable for expenses relating to the pregnancy of a dependent child/child of domestic partner; however, expenses relating to complications of pregnancy or delivery are covered.
• - Family planning services, including:
• ○ Injectable contraceptives and contraceptive devices provided in a doctor’s office, (up to $250/per calendar year);
• ○ Tubal ligation;
• ○ Vasectomy; and
• ○ Sterilization.
• - Hearing care, including one hearing exam per calendar year (subject to applicable physician visit copay) and hearing aids and associated fitting services, up to an $800/lifetime maximum benefit.
• - Home health care expenses if:
• ○ The charge is made by a licensed home health care agency; and
• ○ Care is given under a home health care plan; and
• ○ Care is given to a person in his or her home.

Care must be precertified. Private duty nursing is covered if provided by an R.N., or an L.P.N. if an R.N. is not available. Home health care benefits are not payable for:

• ○ Custodial care;
• ○ Transportation service;
• ○ Services of someone who lives with the patient or who is a member of your or your spouse or domestic partner’s family;
• ○ Services not included in the written home care plan of the physician of record; or
• ○ Services rendered at a time when the patient is not under the care of the physician who set up the home care plan.
• - Hospice care benefits during a terminal illness (where life expectancy is less than six months). Care must be precertified as described on page 41. Benefits are paid for up to six months from the date the hospice care plan is established, not to exceed the maximum lifetime inpatient and outpatient care combined benefit (180 days). Bereavement counseling for immediate family members during the six month period following the date of death is covered, up to a maximum of $500 (immediate family members include husband, wife, and children).

Hospice care benefits are not payable for:

• ○ Services provided by persons who do not regularly charge for their services;
• ○ Counseling which is not provided as part of the hospice care plan;
• ○ Services provided by homemakers, caretakers and similarly situated individuals;
• ○ Funeral expenses;
• ○ Treatment intended to cure the terminal illness; or
• ○ Financial or legal counseling, estate planning and the drafting of a will.
• - Hospital expenses, including daily room and board charges for a semi-private room, general nursing care and intensive care unit (ICU). If a facility with no semi-private rooms, the covered charge is limited to the lowest room rate. Coverage includes all other medically necessary miscellaneous services and supplies furnished by a hospital during covered inpatient hospital confinement.
• - Mammographic screening.
• - Mastectomy and charges related to a covered mastectomy in accordance with the Women’s Health and Cancer Rights Act, including:
• ○ Treatment of physical complications during any stage of the mastectomy, including lymphedemas;
• ○ Reconstruction of the breast on which the mastectomy has been performed;
• ○ Surgery and reconstruction on the non-diseased breast to attain the appearance of symmetry between the two breasts; and
• ○ Breast prostheses.
• - Medically necessary services and supplies furnished in a licensed ambulatory surgical center or birthing center.
• - Mental health and substance abuse services, as precertified by the insurance carrier, including:

Inpatient

• ○ Treatment that includes 24-hour nursing and daily, active treatment under the direction of a psychiatrist, or for children and adolescents, a board certified/eligible child and adolescent psychiatrist.
• ○ Charges of a facility and/or professional provider related to or because of psychiatric illness are covered as follows:
• - Inpatient facility charges;
• - Individual psychotherapy;
• - Group psychotherapy;
• - Psychological testing;
• - Family counseling (counseling with family members to assist in the covered person’s diagnosis and treatment);
• - Electroconvulsive therapy (electroshock treatment) or convulsive drug therapy, including anesthesia when administered concurrently with the treatment by the same professional provider.

Outpatient

• ○ Diagnosis or treatment of a mental disease, disorder, or condition, whether or not the cause of the disease, disorder, or condition is physical, chemical or mental in nature or origin. Care must be provided by a physician or licensed mental health/chemical dependency provider. Covered services include but are not limited to:
• - Assessment;
• - Diagnosis;
• - Medication management;
• - Psychological testing and assessment;
• - Electroconvulsive treatment (ECT);
• - Crisis intervention; and
• - Rehabilitation (drug and alcohol related);
• - Individual, group, family or conjoint psychotherapy, not including non-medical counseling services such as marriage and family therapy.
• ○ ECT, medication management, biofeedback treatments for mental health, and methadone maintenance treatments are covered under this benefit, but do not apply to the outpatient mental health/chemical dependency limits.

Alternative levels of care

Alternate levels of care are covered as follows and apply to annual maximum limits:

• ○ Acute partial hospitalization: Includes daily nursing and active treatment in a structured treatment program lasting 5-7 days per week and delivering at least 20 hours of active treatment per week, with patients going home each evening and/or weekend (each two days of partial hospitalization counts as one day of inpatient treatment);
• ○ Residential treatment center is medically supervised, psychiatric residential treatment-a level of care that includes individualized and intensive treatment on a 24-hour basis in a residential setting (each two days of residential treatment counts as one day of inpatient treatment); and
• ○ Intensive outpatient treatment (IOP): IOP is a structured program that includes combinations of individual and group process therapy, meeting at least three times per week, and delivering at least 4 hours of treatment per week.
• - Outpatient charges for medical care and supplies used on the premises of a hospital.
• - Pre-admission testing performed within 14 days of a scheduled inpatient hospital admission.
• - Prescription contraceptives, including oral contraceptives. Rx services are covered under the prescription drug benefit.
• - Preventive care services, including screening tests, immunizations and counseling services designed to detect and treat medical conditions to prevent avoidable premature injury, illness and death.
• - Professional service charges of a physician.
• - Post-delivery inpatient hospital care for a mother and her newborn child, regardless of whether or not the birth occurred in a hospital.
• - Services provided by licensed practical nurse (L.P.N.) practitioners.
• - Skilled nursing facility charges. Care must be precertified as described on page 41. Maximum covered daily charge based on semi-private room charge at facility.
• - Surgical treatment of teeth and gums, including Temporomandibular Joint Dysfunction (TMJD). Covered expenses include medically necessary treatment of accidental injury while covered by the plan to sound, natural teeth if provided within 48 hours of the accident. Oral surgical care is limited to medically necessary treatment of fractures, excision of tumors, cysts or abscesses, repair of cleft palate, wisdom teeth if involved in a pathological process (infections, tumor, cyst), diagnosis and medically necessary surgical treatment of TMJD. Benefits for TMJD treatment are provided on a case-by-case basis and do not include appliances or orthodontic treatment.

Charges for surgical benefits for cutting procedures for the treatment of disease, injuries, fractures and dislocations of the jaw when the service is performed by a physician or dentist are also considered covered services.

Normal extraction and care of teeth and structures directly supporting the teeth are not covered.

• - Therapy, limited to 60 visits per person per calendar year for each type listed below:
• ○ Physiotherapy services of a physiotherapist;
• ○ Services of a qualified speech therapist to restore speech loss or correct impairment due to congenital defect, illness or injury;
• ○ Medically necessary physical therapy for treatment of acute conditions; and
• ○ Occupational therapy which improves the patient’s ability to perform tasks required for independent functioning.
• - Transplants:

PPO Plan participants administered by Aetna will be referred to the National Medical Excellence (NME) Program for coordination of all solid organ and bone marrow transplants. Available transplants not performed at a facility through the NME program through Aetna will be paid at the out-of-network level of benefits regardless if the facility is a part of the Aetna Choice POS II network or not. Standard precertification provisions still apply.

PPO Plan participants being administered by Great West will be referred to the transplant network, LifeSource, for coordination of transplants. Available transplants not performed at a facility recommended by LifeSource will be paid at the out-of-network level of benefits. Standard precertification provisions still apply.

Normal network rules apply for transplants not available through NME or LifeSource, i.e. services performed at a network facility are payable on an in-network basis and those performed at a non-network facility are payable on an out-of-network basis.

Covered services include:

• ○ Hospital and physician services for the surgical removal of a human organ or tissue from a living donor to a transplant recipient only if:
• - The transplant recipient and donor are both enrolled for coverage under the plan. In this case, benefits will be provided for both patients under the recipient’s coverage; or
• - The transplant recipient is enrolled for coverage under the plan. In this case, benefits will be provided for the recipient. Benefits may also be provided for the donor for covered expenses under the recipient’s coverage (to the extent any benefits remain after payment of the recipient’s expenses), but only if those services are not eligible under any other coverage available to the donor.

These expenses are covered in connection with the specific organ and bone marrow transplants for a plan participant only if:

• - The recipient of the transplant is a medical plan participant;
• - The transplant is medically appropriate, non-experimental and represents the preferred method of treatment;
• - The participant satisfies the criteria of the participating hospital for the transplant; and
• - The medical plan participant precertifies the transplant with the claims administrator.

Transplants that may be covered include the following:

 

- Bone marrow	- Heart
- Cornea	- Heart/lung
- Kidney	- Lung
- Liver	- Pancreas

If the donor is enrolled for coverage under the plan but the transplant recipient is not; expenses for services rendered to the donor and to the transplant recipient will not be considered covered expenses under the plan.

Experimental and investigational transplants or transplants that are determined not medically appropriate by the claims administrator and the plan administrator will not be covered.

———————————————————————————————————-

Questions about your employee benefits or other Human Resources issues? Contact the Workplace Solutions Center at (888) 471-2271.