These medical benefits will be payable as shown in the Summary of Benefits or as otherwise outlined in this Plan. Subject to the Plan’s provisions, limitations and Exclusions, the following are covered major medical benefits:
Charges related to the treatment of allergies.
Transportation by professional ambulance, including approved available air and train transportation (excluding chartered air flights), to a local Hospital or transfer to the nearest facility having the capability to treat the condition, if the transportation is connected with an Inpatient confinement.
Ambulatory Surgical Center
Services of an Ambulatory Surgical Center for Medically Necessary care provided.
Anesthesia, anesthesia supplies, and administration of anesthesia by facility staff.
Charges for bariatric surgery for the treatment of Morbid Obesity. Bariatric surgery will be a covered expense after completion of medically supervised weight loss program through Mid Illini Surgical Associates. Coverage for medically supervised weight loss excludes the cost of food.
Services of a birthing center for Medically Necessary care provided within the scope of its license.
Charges for blood and blood plasma (if not replaced by or for the patient), including blood processing and administration services. The Plan shall also cover processing, storage, and administrative services for autologous blood (a patient’s own blood) when a Participant is scheduled for Surgery that can be reasonably expected to require blood.
Cataract surgery and one set of lenses (contacts or frame-type) following the surgery.
Charges for chemotherapy, including materials and services of technicians.
Spinal adjustment and manipulation x-rays for manipulation and adjustment and other modalities performed by a Physician or other licensed practitioner, as limited in the Summary of Benefits, as applicable.
Charges for cochlear implants for Participants who are certified as deaf or hearing impaired by a Provider.
The charges for all Food and Drug Administration (FDA) approved contraceptives methods, except oral contraceptives, in accordance with Health Resources and Services Administration (HRSA) guidelines. NOTE: Oral contraceptives are covered under the Prescription Drug Benefits section.
Dental Services—Accident Only
Charges made for a continuous course of dental treatment started within 12 months from the date of the Injury to sound natural teeth. Sound natural teeth are defined as natural teeth that are free of active clinical decay, have at least 50% bony support and are functional in the arch.
Services and supplies used in Outpatient diabetes self-management programs are covered under this Plan when they are provided by a Physician.
Diagnostic Tests; Examinations
Charges for x-rays, microscopic tests, laboratory tests, esophagoscopy, gastroscopy, proctosigmoidoscopy, colonoscopy and other diagnostic tests and procedures.
Charges for dialysis.
Durable Medical Equipment
Charges for rental, up to the purchase price, of Durable Medical Equipment, including glucose home monitors for insulin dependent diabetics. At its option, and with its advance written approval, the Plan may cover the purchase of such items when it is less costly and more practical than rental. The Plan does not pay for any of the following:
- Any purchases without its advance written approval.
- Replacements or repairs that are not Medically Necessary.
- The rental or purchase of items which do not fully meet the definition of “Durable Medical Equipment.”
Treatment of glaucoma.
These services include:
- Occupational Therapy: Treatment or services rendered by a registered occupational therapist, under the direct supervision of a Physician, in a home setting or at a facility or Institution whose primary purpose is to provide medical care for an Illness or Injury, or at a free standing outpatient facility.
- Physical Therapy: Treatment or services rendered by a physical therapist, under direct supervision of a Physician, in a home setting or a facility or Institution whose primary purpose is to provide medical care for an Illness or Injury, or at a free standing duly licensed outpatient therapy facility.
- Speech-Language Pathology: Treatment for speech delays and disorders.
See the Summary of Benefits for treatment and/or frequency limitations, as applicable.
Charges for hearing aids, which includes examinations for the prescription, fitting, and/or repair of hearing aids.
Home Health Care
Charges for Home Health Care services and supplies are covered only for care and treatment of an Illness or Injury when Hospital or Skilled Nursing Facility confinement would otherwise be required. The Diagnosis, care, and treatment must be certified by the attending Physician and be contained in a home health care plan. Charges by a Home Health Care Agency for any of the following:
- Registered Nurses or Licensed Practical Nurses.
- Certified home health aides under the direct supervision of a Registered Nurse.
- Registered therapist performing physical, occupational or speech therapy.
- Physician calls in the office, home, clinic or outpatient department.
- Services, Drugs and medical supplies which are Medically Necessary for the treatment of the Participant that would have been provided in the Hospital, but not including Custodial Care.
- Rental of Durable Medical Equipment or the purchase of this equipment if economically justified, whichever is less.
Transportation services are not covered under this benefit.
Charges relating to Hospice Care, provided the Participant has a life expectancy of six months or less, subject to the maximums, if any, stated in the Summary of Benefits. Covered Hospice expenses are limited to:
- Room and Board for confinement in a Hospice.
- Ancillary charges furnished by the Hospice while the patient is confined therein, including rental of Durable Medical Equipment which is used solely for treating an Injury or Sickness.
- Medical supplies, Drugs and medicines prescribed by the attending Physician, but only to the extent such items are necessary for pain control and management of the terminal condition.
- Physician services and nursing care by a Registered Nurse, Licensed Practical Nurse or a Licensed Vocational Nurse (L.V.N.).
- Home health aide services.
- Home care furnished by a Hospital or Home Health Care Agency, under the direction of a Hospice, including Custodial Care if it is provided during a regular visit by a Registered Nurse, a Licensed Practical Nurse or a home health aide.
- Medical social services by licensed or trained social workers, Psychologists or counselors.
- Nutrition services provided by a licensed dietitian.
- Respite care.
- Bereavement counseling, which is a supportive service provided by the Hospice team to Participants in the deceased’s Family Unit after the death of the terminally ill person, to assist the Participants in adjusting to the death. Benefits will be payable up to 6 visits per Participant if the following requirements are met:
- On the date immediately before his or her death, the terminally ill person was in a Hospice Care Program and a Participant under the Plan.
- Charges for such services are Incurred by the Participants within six months of the terminally ill person’s death. The Hospice Care program must be renewed in writing by the attending Physician every 30 days. Hospice Care ceases if the terminal Illness enters remission.
Charges made by a Hospital for:
- Inpatient Treatment
- Daily semi private Room and Board charges.
- Intensive Care Unit (ICU) and Cardiac Care Unit (CCU) Room and Board charges.
- General nursing services.
- Medically Necessary services and supplies furnished by the Hospital, other than Room and Board.
- Outpatient Treatment
- Emergency room.
- Treatment for chronic conditions.
- Physical therapy treatments.
- X ray, laboratory and linear therapy.
Massage Therapist Services
Services of a licensed massage therapist (LMT), when under the direction of an M.D., D.O., or D.C. are payable at 50% of Reasonable and Customary with a maximum benefit of $500 for services incurred in a calendar year.
The Federal Women’s Health and Cancer Rights Act, signed into law on October 21, 1998, contains coverage requirements for breast cancer patients who elect reconstruction in connection with a Mastectomy. The Federal law requires group health plans that provide Mastectomy coverage to also cover breast reconstruction Surgery and prostheses following Mastectomy.
As required by law, the Participant is being provided this notice to inform him or her about these provisions. The law mandates that individuals receiving benefits for a Medically Necessary Mastectomy will also receive coverage for:
- Reconstruction of the breast on which the Mastectomy has been performed.
- Surgery and reconstruction of the other breast to produce a symmetrical appearance.
- Prostheses and physical complications from all stages of Mastectomy, including lymphedemas.
The reconstruction of the breast will be done in a manner determined in consultation with the attending Physician and the patient.
This coverage will be subject to the same annual Deductible and Coinsurance provisions that currently apply to Mastectomy coverage, and will be provided in consultation with the Participant and his or her attending Physician.
Medical foods are considered a covered charge if intravenous therapy (IV) or tube feedings are Medically Necessary. Medical foods taken orally are not covered under the Plan, except for PKU formula when Medically Necessary.
Dressings, casts, splints, trusses, braces and other Medically Necessary medical supplies, with the exception of dental braces or corrective shoes, but including syringes for diabetic and allergy Diagnosis, and lancets and chemstrips for diabetics.
Medically Supervised Weight Loss
Charges related to medically supervised weight loss provided by Mid Illini Surgical Associates. Coverage for medically supervised weight loss excludes the cost of food.
Mental Health and Substance Abuse Benefits
Benefits are available for Inpatient or outpatient care for mental health and Substance Abuse conditions, including individual and group psychotherapy, psychiatric tests, and expenses related to the Diagnosis when rendered by any of the following:
- Doctor of Medicine (MD).
- Licensed Clinical Psychologist (PhD).
- Licensed Clinical Psychiatric Social Worker (LCSW).
- Licensed Professional Counselor (LPC).
- Registered Nurse Clinical Specialist (RNCS).
Benefits are available for Residential Treatment Facility, Partial Hospitalization, and Intensive Outpatient Services.
Hospital and Physician nursery care for newborns who are Children of the Employee or spouse and properly enrolled in the Plan, as set forth below. Benefits will be provided under the Child’s coverage, and the Child’s own Deductible and Coinsurance provisions will apply:
- Hospital routine care for a newborn during the Child’s initial Hospital confinement at birth.
- The following Physician services for well-baby care during the newborn’s initial Hospital confinement at birth:
- The initial newborn examination and a second examination performed prior to discharge from the Hospital.
The Plan will cover Hospital and Physician nursery care for an ill newborn as any other medical condition, provided the newborn is properly enrolled in the Plan. These benefits are provided under the baby’s coverage.
Services of a Registered Nurse or Licensed Practical Nurse.
Charges for pathology services.
Services of a Physician for Medically Necessary care, including office visits, home visits, Hospital Inpatient care, Hospital Outpatient visits and exams, clinic care and surgical opinion consultations.
Expenses attributable to a Pregnancy. Pregnancy expenses of Dependent Children are not covered. Benefits for Pregnancy expenses are paid the same as any other Sickness. NOTE: Preventive care charges for Pregnancy are covered under the Preventive Care benefit in the Medical Benefits section.
Under the Newborns’ and Mothers’ Health Protection Act of 1996, group health plans and health insurance issuers generally may not restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn Child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending Provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a Provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). In no event will an “attending Provider” include a plan, Hospital, managed care organization, or other issuer.
In accordance with the Summary of Benefits and this section, benefits for the care and treatment of Pregnancy that are covered will be subject to all applicable Plan limitations and maximums (if any), and are payable in the same manner as medical or surgical care of an Illness.
Charges for Preventive Care services. This Plan intends to comply with the Affordable Care Act’s (ACA) requirement to offer In-Network coverage for certain preventive services without cost- sharing.
Benefits mandated through the ACA legislation include Preventive Care such as immunizations, screenings, and other services that are listed as recommended by the United States Preventive Services Task Force (USPSTF), the Health Resources Services Administration (HRSA), and the Federal Centers for Disease Control (CDC).
Below is a list of benefits mandated through the ACA legislation. This list can change as ACA legislation changes. Please see the websites below for further details.
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked.
- Alcohol misuse screening and counseling.
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk.
- Blood pressure screening.
- Cholesterol screening for adults of certain ages or at high risk.
- Colorectal cancer screening for adults 50 to 75.
- Depression screening.
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese.
- Diet counseling for adults at higher risk chronic disease.
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting.
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence and U.S.-born people not vaccinated as infants with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults at increased risk, and one time for everyone born 1945-1965.
- HIV screening for everyone ages 15 to 65, and other ages at increased risk. 14. Immunizations for adults – doses, recommended ages, and populations vary:
- Hepatitis A
- Hepatitis B
- Herpes Zoster
- Human Papillomavirus (HPV)
- Influenza (flu shot)
- Varicella (Chicken Pox)
- Lung cancer screening for adults 55-80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years.
- Obesity screening and counseling.
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk.
- Statin preventive medication for adults 40 to 75 at high risk.
- Syphilis screening for adults at higher risk.
- Tobacco use screening for all adults and cessation interventions for tobacco users.
- Tuberculosis screening for certain adults without symptoms at high risk.
- Anemia screening on routine basis.
- Breast cancer genetic test counseling (BRCA) for women at higher risk.
- Breast cancer mammography screenings every 1 to 2 years for women over 40.
- Breast cancer chemoprevention counseling for women at higher risk.
- Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women.
- Cervical Cancer screening
- Pap test (also called pap smear) every 3 years for women 21 to 65
- Human papillomavirus (HPV) DNA test with the combination of a pap smear every
- 5 years for women 30 to 65 who don’t want a pap smear every 3 years.
- Chlamydia infection screening for younger women and other women at higher risk.
- Contraception: Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care Provider for women with reproductive capacity (not including abortifacient drugs).
- Folic acid supplements for women who may become pregnant.
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before.
- Domestic and interpersonal violence screening and counseling for all women.
- Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes.
- Gonorrhea screening for all women at higher risk.
- Hepatitis B screening for pregnant women at their first prenatal appointment.
- HIV screening for sexually active women.
- Osteoporosis screening for women over age 60 depending on risk factors.
- Preeclampsia prevention and screening for pregnant women with high blood pressure.
- Rh incompatibility screening for all pregnant women and follow-up testing for all women (including those not pregnant) at higher risk.
- Sexually transmitted infections counseling for sexually active women.
- Syphilis screening for women at increased risk.
- Tobacco use and screening and interventions.
- Expanded tobacco intervention and counseling for pregnant tobacco users. 23. Urinary incontinence screening for women yearly.
- Urinary tract or other infection screening.
- Well-woman visits to get recommended services for women under 65.
- Alcohol, tobacco, and drug use assessments for adolescents.
- Autism screening for children 18 and 24 months.
- Behavioral assessments for children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
- Bilirubin concentration screening for newborns.
- Blood pressure screening for children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14, 15 to 17 years.
- Blood screening for newborns.
- Cervical dysplasia screening for sexually active females.
- Depression screening for adolescents beginning routinely at age 12.
- Developmental screening for children under age 3.
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders ages: 1 to 4 years, 5 to 10 years, 11 to 14, 15 to 17 years.
- Fluoride chemoprevention supplements for children without fluoride in their water source.
- Fluoride varnish for all infants and children as soon as teeth are present.
- Gonorrhea preventive medication for the eyes of all newborns.
- Hearing screening for all newborns; and for children once between 11 and 14 years, once between 15 and 17 years, and once between 18 and 21 years.
- Height, weight, and body mass index (BMI) measurements for children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14, 15 to 17 years.
- Hematocrit or hemoglobin screening for all children.
- Hemoglobinopathies or sickle cell screening for newborns.
- Hepatitis B screening for adolescents at high risk, including adolescents from countries with a 2% or more Hepatitis B prevalence, and U.S.-born adolescents not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence: 11-17 years.
- HIV screening for adolescents at higher risk.
- Hypothyroid screening for newborns.
- Immunization vaccines for children from birth to 18 – doses, recommended ages, and recommended populations vary:
- Diphtheria, tetanus, pertussis (whooping cough)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated poliovirus
- Influenza (flu shot)
- Varicella (chicken pox)
- Iron supplements for children ages 6 to 12 months at risk for anemia.
- Lead screening for children at risk of exposure.
- Maternal depression screening for mother of infants at 1, 2, 4, and 6 month visits.
- Medical history for all children throughout development ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14, 15 to 17 years.
- Obesity screening and counseling.
- Oral health risk assessment for young children ages: 0 to 11 months, 1 to 4 years, 5 to 10
- Phenylketonuria (PKU) screening for newborns.
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk.
- Tuberculin testing for children at higher risk of tuberculosis ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14, 15 to 17 years.
- Vision screening for all children.
See the following websites for more details:
The Preventive Care services identified through the above links are recommended services. It is up to the Provider and/or Physician of care to determine which services to provide; the Plan Administrator has the authority to determine which services will be covered. Preventive Care services will be covered at 100% for Non-Network Providers if there is no Network Provider who can provide a required preventive service. Benefits include gender-specific Preventive Care services, regardless of the sex the Participant was assigned at birth, his or her gender identity, or his or her recorded gender.
Preventive and Wellness Services for Adults and Children
In compliance with section (2713) of the Affordable Care Act, benefits are available for evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF).
Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved. With respect to infants, Children, and adolescents, evidence-informed Preventive Care and screenings as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).
Women’s Preventive Services
With respect to women, such additional Preventive Care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) not otherwise addressed by the recommendations of the United States Preventive Service Task Force (USPSTF), which will be commonly known as HRSA’s Women’s Preventive Services Required Health Plan Coverage Guidelines. The HRSA has added the following eight categories of women’s services to the list of mandatory preventive services:
- Well-woman visits.
- Gestational diabetes screening.
- Human papillomavirus (HPV) Deoxyribonucleic Acid (DNA) testing.
- Sexually transmitted infection counseling.
- Human Immunodeficiency Virus (HIV) screening and counseling.
- Food and Drug Administration (FDA)-approved contraception methods and contraceptive counseling.
- Breastfeeding support, supplies and counseling.
- Domestic violence screening and counseling.
A description of Women’s Preventive Services can be found at: https://www.hrsa.gov/womensguidelines/ or at the websites listed above.
Private Duty Nursing
Private duty nursing (outpatient only).
Prosthetics, Orthotics, Supplies and Surgical Dressings
Prosthetic devices (other than dental) to replace all or part of an absent body organ or part, including replacement due to natural growth or pathological change, but not including charges for repair or maintenance. Orthotic devices, but excluding orthopedic shoes and other supportive devices for the feet.
Charges for radiation therapy and treatment.
Routine Patient Costs for Participation in an Approved Clinical Trial
Charges for any Medically Necessary services, for which benefits are provided by the Plan, when a Participant is participating in a phase I, II, III or IV clinical trial, conducted in relation to the prevention, detection or treatment of a life- threatening Disease or condition, as defined under the ACA, provided:
- The clinical trial is approved by any of the following:
- The Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services.
- The National Institute of Health.
- The U.S. Food and Drug Administration.
- The U.S. Department of Defense.
- The U.S. Department of Veterans Affairs.
- An institutional review board of an institution that has an agreement with the Office for Human Research Protections of the U.S. Department of Health and Human Services.
- The research Institution conducting the Approved Clinical Trial and each health professional providing routine patient care through the Institution, agree to accept reimbursement at the applicable Allowable Expense, as payment in full for routine patient care provided in connection with the Approved Clinical Trial.
Second Surgical Opinions
Charges for second surgical opinions.
Skilled Nursing Facility
Charges made by a Skilled Nursing Facility or a convalescent care facility, up to the limits set forth in the Summary of Benefits, in connection with convalescence from an Illness or Injury (excluding drug addiction, chronic brain syndrome, alcoholism, senility, intellectual disability or other Mental or Nervous Disorders) for which the Participant is confined.
Sterilization for Men and Women
Charges for male sterilization procedures. Benefits for all Food and Drug Administration (FDA) approved charges related to sterilization procedures for women are covered under Preventive Care, to the extent required by the Affordable Care Act (ACA).
Surgical operations and procedures, unless otherwise specifically excluded under the Plan, and limited as follows:
- Multiple procedures adding significant time or complexity will be allowed at:
- One hundred percent (100%) of the Maximum Allowable Charge for the first or major procedure.
- Fifty percent (50%) of the Maximum Allowable Charge for the secondary and subsequent procedures.
- Bilateral procedures which add significant time or complexity, which are provided at the same operative session, will be allowed at one hundred percent (100%) of the Maximum Allowable Charge for the major procedure, and fifty percent (50%) of the Maximum Allowable Charge for the secondary or lesser procedure.
- Charges made for services rendered by an assistant surgeon will be allowed at twenty percent (20%) of the Maximum Allowable Charge for the type of Surgery performed.
- No benefit will be payable for incidental procedures, such as appendectomy during an abdominal Surgery, performed during a single operative session.
Surgical Treatment of Jaw
Surgical treatment of Diseases, Injuries, fractures and dislocations of the jaw by a Physician or Dentist.
Services for individual therapy are covered on an Inpatient or Outpatient basis. They are services or supplies used for the treatment of an Illness or Injury and include:
- Cardiac Therapy Charges for cardiac therapy.
- Cognitive Therapy Charges for cognitive therapy.
- Occupational Therapy Rehabilitation treatment or services rendered by a registered occupational
therapist, under the direct supervision of a Physician, in a home setting or at a facility or Institution whose primary purpose is to provide medical care for an Illness or Injury, or at a free standing outpatient facility.
- Physical Therapy Rehabilitation treatment or services rendered by a physical therapist, under direct supervision of a Physician, in a home setting or a facility or Institution whose primary purpose is to provide medical care for an Illness or Injury, or at a free standing duly licensed outpatient therapy facility.
- Respiration Therapy Respiration therapy services, when rendered in accordance with a Physician’s written treatment plan.
- Speech Therapy Speech therapy, for Rehabilitation purposes, by a Physician or qualified speech therapist, when needed due to a Sickness or Injury (other than a functional Nervous Disorder) or due to Surgery performed as the result of a Sickness or Injury, excluding speech therapy services that are educational in any part or due to articulation disorders, tongue thrust, stuttering, lisping, abnormal speech development, changing an accent, dyslexia, hearing loss which is not medically documented or similar disorders.
See the Summary of Benefits for treatment and/or frequency limitations, as applicable.
Organ or tissue transplants are covered for the following human to human organ or tissue transplant procedures:
- Bone marrow
- Heart and lung
In addition, the Plan will cover any other transplant that is not Experimental.
Covered Expenses will be considered the same as any other Sickness for Employees or Dependents as a recipient of an organ or tissue transplant. Covered Expenses include:
- Organ or tissue procurement from a cadaver consisting of removing, preserving and transporting the donated part.
- Services and supplies furnished by a Provider.
- Drug therapy treatment to prevent rejection of the transplanted organ or tissue.
Surgical, storage and transportation costs directly related to the procurement of an organ or tissue used in a transplant described herein will be covered. If an organ or tissue is sold rather than donated, no benefits will be available for the purchase price of such organ or tissue.