Payable at 100%
Reasonable and customary physician fees and hospital charges are payable in full for outpatient surgery, outpatient diagnostic tests, outpatient initial and follow-up accident care within 90 days of an accident, or outpatient medical emergency care for the sudden onset of a condition which would result in permanent medical consequences in the absence of immediate medical attention.
Payable at 90%
After a $250 deductible per person ($500 per family) for expenses incurred in a calendar year, the Plan will pay 90% of reasonable and customary charges, subject to the limitations and exclusions specified for the following:
- Hospital room and board charges up to a hospital’s most common semi-private rate; full charges for intensive care, coronary care or special care units; and in-patient or out-patient miscellaneous services and supplies provided by a hospital when necessary to treat a condition of illness or injury. Admissions extending beyond 23 hours will be treated as in-patient services.
- Physician fees for office calls and other professional services. When multiple surgical procedures are performed, the reasonable and customary allowance will be adjusted.
- Routine exams, immunizations/vaccinations, and school physicals are covered for reasonable and customary charges for children through the age of 18.
- Charges of a licensed speech therapist to restore speech loss due to an injury, stroke, surgery or pediatric treatment for children to age 3 with a developmental disability such as Autism or Down syndrome, under the direction of an MD.
- TPN or other injectable drug therapy, but only from a vendor approved by the Plan on a case by case basis, if the cost of the medication exceeds $500 per month.
- Leg, arm, neck and back braces or services of a registered physical or occupational therapist, or their licensed assistants when working under the direction of a licensed RPT or OTR. Services of a licensed massage therapist (LMT) when under the direction of an M.D., D.O., or D.C. payable at 50% of reasonable and customary with a maximum benefit of $500 for services incurred in a calendar year.
- Professional ambulance service when medically necessary to transport a patient to the nearest hospital where required medical treatment can be provided. Ambulance service provided from a hospital to a nursing home or to the individual’s home when approved by the Claims Administrator.
- Durable medical equipment rental, or purchase thereof at the option of the Claim Administrator, when prescribed by a physician and where such rental equipment is not used customarily except for medical purposes.
- Artificial limbs and other prosthetic applications for accidents or illnesses incurred while covered under this Plan or the program it replaced.
- Oxygen, blood and related administration charges.
- Surgical and related supplies which are primarily only for medical purposes.
- Private duty nursing and hospice or home health care services when the service provider is not a relative and does not normally reside in the same home as the patient, but only when prescribed by a physician and approved by the Claim Administrator.
- Inpatient and outpatient mental and substance abuse treatment. (See Limitation and Exclusion #38 for PPO considerations on inpatient substance abuse treatment.)
- Hearing aids and batteries with a maximum of $1,000 per person with 50% coverage for batteries.
- When confined to and billed by a nursing home, OT, PT, lab and lab testing, but not room and board. If the patient is receiving primary Medicare skilled care benefits, prescription medications are also covered.
- Expenses related to medically supervised weight loss through either one of the following programs: OSF Weight Loss Center or Mid-Illini Surgical Associates. Coverage for medically supervised weight loss excludes the cost of food.
- Expenses related to bariatric surgery only after completion of medically supervised weight loss through Mid Illini Surgical Associates. Coverage for medically supervised weight loss excludes the cost of food.
Benefits will be reduced by 50% for hospital and related physician fees when care is received in Peoria County at a facility other than UnityPoint Methodist/Proctor if (1) the care is available at UnityPoint Methodist/Proctor, or (2) any additional time required to transport the patient to UnityPoint Methodist/Proctor would not jeopardize the patient’s health, or (3) an exception is not made by the Plan due to extenuating circumstances. This provision does not apply to care received outside of Peoria County.