Microsoft word - sage technical services-2011-bs.doc

Sage Technical Services
$2,000 Deductible Limited Benefit Health Plan
Benefit Summary Effective 1/2011
This is a limited benefit health plan that provides inpatient hospital benefits and limited outpatient benefits.
Benefits provided are not intended to cover all medical expenses. This summary provides a brief description of your
limited health plan benefits and is not a guarantee of benefit payment. Benefit payments will be made based upon policy provisions and eligibility criteria. Coverage is provided for covered services provided by both preferred and non-preferred providers. Preferred providers agree to accept the allowed amount for covered services. You will be responsible for the difference between the allowed amount and the billed charges, in addition to the responsibility shown below, when covered services are received from a non-preferred provider. Please refer to your benefit booklet for a complete explanation of benefits, limitations, exclusions, and general provisions. Annual Maximum
$2,000,000 per Insured each calendar year Deductible
Preferred and Non-Preferred Providers (combined): $2,000 per Insured
each calendar year. No family shall be obligated to meet more than $4,000
in the aggregate in any calendar year. Benefits are payable after the
deductible has been met.
Out-of-Pocket Expense
Preferred Providers: $2,500 per Insured each calendar year (plus
deductible).
Non-Preferred Providers: $3,500 per Insured each calendar year (plus
deductible).
Please Note: Insureds must access Preferred Providers in the state of Idaho and those states where Preferred Provider
networks are available in order to receive Preferred Provider benefits.
AMOUNT YOU PAY
Ambulance Services
Blood and Blood Plasma
Contraceptives
Not subject to the deductible
 Oral contraceptive prescription drugs  Injectable contraceptives (Depo Provera) AMOUNT YOU PAY
Diabetic Education
Diabetic Supplies (blood sugar diagnostics, lancets, swabs, and urine test strips)
Durable Medical Equipment (blood glucose monitors, insulin infusion devices, and
insulin pumps; and lifesaving equipment such as ventilators and oxygen)
 Preferred Provider
Home Health Care (60 visits calendar year maximum)
Hospice Care (inpatient/outpatient combined 14 days lifetime maximum)
Hospital Care
 Emergency room charge (copayment is in addition to deductible and coinsurance) or Non-Preferred Provider Note: See the Outpatient Laboratory and X-Ray Services section for benefits for
outpatient laboratory and x-ray charges.  Inpatient services Human Organ and Tissue Transplants
Mammography Services (illness and injury services)
Maternity Care (benefits are not provided for children)
 Physician services (prenatal and delivery)  Hospital services (room and board and general nursing care) Outpatient Laboratory and X-ray Services
AMOUNT YOU PAY
Phenylketonuria Formulas (PKU)
Physician Services
 Office, home, outpatient hospital visits, and 2nd and 3rd surgical opinions (4 visits Preferred and Non-Preferred Physician that provides primary health care needs and specializes in family practice, internal medicine, pediatrics, or Preferred and Non-Preferred Physician that provides care for a particular disease and/or condition and specializes in such areas as gastroenterology, cardiology, dermatology, neurology, or oncology. Note: See the Outpatient Laboratory and X-Ray Services section for outpatient
laboratory and x-ray benefits.  Inpatient hospital visits, surgeon fees, and routine newborn care Prescription Drugs (34 day supply or 100-unit doses, whichever is less. Mail-order
Not subject to the deductible
program: one copayment/coinsurance per each 30 day supply, not to exceed a 90 day supply)  Generic Out-of-pocket expense – Formulary and Non-formulary combined ($5,000
Note: A 90 day supply (copayment applies to each 30 day supply) of generic
maintenance drugs may be purchased from a retail pharmacy, subject to the copayment for generic drugs. Preventive Care
Not subject to the deductible
 Preferred Providers or a Non-Preferred Provider who is contracted with Regence BSI Routine visits for preventive care including well-baby care, screenings for Routine radiology and laboratory services including mammography and Routine procedures including routine colonoscopies  Non-Preferred Providers who do not otherwise have a contract with Regence BSI Routine visits for preventive care including well-baby care, screenings for Routine radiology and laboratory services including mammography and Routine procedures including routine colonoscopies Note: Preventive care services are not subject to the Preferred and Non-Preferred
Provider 4 office visit calendar year maximum. Preventive Medications (covered according to federal guidelines, with no
coinsurance, no deductible, and no copayment at participating pharmacies only) AMOUNT YOU PAY
Prosthetic Devices (external and internal breast prostheses)
Rehabilitation – Inpatient Services (15 days per calendar year maximum)
Skilled Nursing Facility (30 days calendar year maximum)
PREEXISTING CONDITION EXCLUSION
Exclusion Period for Preexisting Conditions: 12 months (credit may be given for prior qualifying previous coverage).
Exclusion Period does not apply to Insureds enrolled prior to reaching nineteen (19) years of age.
Important note: Preexisting condition means a physical or mental condition, regardless of the cause of the condition, for
which medical advice, diagnosis, care or treatment was recommended or received within the six (6) month period
immediately preceding the effective date of coverage.
Qualifying Previous Coverage means with respect to an individual, health benefits or coverage provided under any of
the following: Group health benefit plan; Health insurance coverage without regard to whether the coverage is offered in
the group market, individual market or otherwise; Medicare; Medicaid; medical and dental care for members and certain
former members of the uniformed services and their dependents (“uniformed services” means the armed forces, the
Commissioned Corps of the National Oceanic and Atmospheric Administration and the Public Health Service); a medical
care program of the Indian Health Services or of a tribal organization; a state high-risk pool coverage; Federal Employees
Health Benefits Program (FEHBP); a public health plan (a plan established or maintained by a state, a foreign country, the
U.S. government, or other political subdivision of a state, the U.S. government or foreign country that provides health
insurance coverage to individuals enrolled in the plan); or a health plan issued under the Peace Corps Act. A state
Children’s Health Insurance Program (CHIP), is creditable coverage, whether it is a stand-alone separate program, a
CHIP Medicaid expansion program, or a combination program, and whether it is provided through a group health plan,
health insurance, or any other mechanism.
EXCLUSIONS
Benefits will not be provided in any of the following circumstances or for any of the following conditions under the terms of the policy. However, these exclusions shall not apply with regard to an otherwise Covered Service 1) an Injury, if the Injury results from an act of domestic violence or a medical condition (including physical and mental) and regardless of whether such condition was diagnosed before the Injury, as required by federal law; or 2) a preventive service as specified under the Preventive Care benefit of the policy.  To the extent benefits are provided or covered by any governmental agency, except as otherwise provided by law.  Expenses for services incurred as a result of any work related injury or illness, including any claims that are resolved pursuant to a disputed claim settlement for which the Insured has or had a right to compensation.  Any injury or illness resulting from any act of war or from explosion of atomic or similar fissionable materials in war (declared or undeclared) or any illness or injury contracted or incurred during military service, including any complications or recurrences thereof, or national disaster.  Any situation in which no specific medical treatment plan or psychiatric plan is furnished, including but not limited to rest cure, detoxification setup, custodial care, etc.  Home infusion therapy.  Hospital benefits when hospitalization is primarily for diagnostic studies or physical therapy when such procedures could have been done adequately and safely on an outpatient basis.  Pregnancy tests unless provided by a physician and administered in the physician's office or in the hospital.  Maternity benefits (including involuntary complications of pregnancy) for dependent children.  Immunizations required for travel abroad, including but not limited to cholera, plague, typhoid, typhus, and yellow fever when services are provided by a Non-Preferred Provider who does not otherwise have a contract with Regence  Laetrile (amygdalin); acupuncture; chelation therapy (except for lead poisoning); homeopathic services; naturopathic services; thermography; massage therapy.  Routine eye refraction; eye glasses; visual therapy or training.  Radial keratotomy (refractive keratoplasty or other surgical procedures to correct refractive errors/astigmatism).  Routine hearing examinations; hearing aids.  Humidifiers; vaporizers; air conditioners; or any other air filtration or purification unit or system.  Physical fitness or physical therapy equipment including, but not limited to, whirlpools, spas, hot tubs; weight lifting equipment; charges in or by health spas; weight reduction programs.  Cosmetic and/or reconstructive services and supplies, including services and supplies related to a previous cosmetic procedure or complications of a previous cosmetic procedure, except as follows:  Related to breast reconstruction following a mastectomy to the extent required by law (refer to the Women's Health and Cancer Rights provision for additional information);  Due to a trauma, infection, or other disease of the involved part; or  Due to a congenital disease or anomaly for an insured child.  For the purposes of this exclusion, cosmetic means a procedure that primarily improves or changes appearance and does not primarily restore an impaired function of the body.  Investigative treatment as determined by Regence BSI.  Benefits which are payable under any automobile medical, personal injury protection ("PIP"), automobile no-fault, underinsured or uninsured, homeowner, commercial premises coverage, or similar contract or insurance, when such contract or insurance is issued to or makes benefits available to the Insured, whether or not application is duly made  Procedures related to sex transformations.  Services and supplies for or in connection with: (1) infertility treatment, except to the extent covered services are required to diagnose such a condition, (2) reversal of sterilization; (3) surrogate pregnancy; (4) assisted reproductive technology (ART) procedures; and (5) fertility drugs and medications (Pergonal, etc.).  Vasectomies (male sterilization) will be covered for physician services only.  Treatment of sexual dysfunction or sexual inadequacy, including erectile dysfunction and impotence; and medications  Outpatient rehabilitation services and supplies, including but not limited to physical, occupational, respiratory, or  Outpatient cardiac and pulmonary rehabilitation therapies.  Medical or surgical treatment for obesity and manifestations thereof, or for reversal or revisions of surgery for obesity.  Benefits in connection with transplants, except as set forth in human organ and tissue transplants of the policy.  Benefits in connection with harvesting and reinfusion of bone marrow for the treatment of any illness, except as set forth in the human organ and tissue transplants of the policy.  Any services, chemotherapy, radiation therapy (or any therapy that damages the bone marrow), supplies, drugs, and aftercare for or related to bone marrow transplant, stem cell support or peripheral stem cell support procedures for a condition not set forth in the human organ and tissue transplants of the policy.  Birth control devices and/or birth control prescription drugs, unless benefits are provided by an endorsement to the  Outpatient prescription drugs, unless benefits are provided by an endorsement to the policy.  Prescription drugs and medicines for smoking cessation.  Human Growth Hormone therapy.  Services and supplies provided by a chiropractor.  Services and supplies for the treatment of mental or neuropsychiatric conditions, chemical dependency, alcoholism and/or drug addiction. Prescription medications for the treatment of mental or neuropsychiatric conditions, chemical dependency, alcoholism and/or drug addiction, unless prescription drug benefits are provided by an endorsement to  Services connected with nonemergency, nonmaternity hospital admissions on Fridays or Saturdays, unless surgery is performed the day of admission or the day following admission.  Termination of pregnancy (elective abortion), except when performed to preserve the life of the enrolled female  Services and supplies related to dentistry, temporomandibular joint (TMJ) disorders, dental implants, orthodontic treatment, oral surgery (except for the treatment of a jaw fracture), orthognathic conditions, or orthognathic surgery, whether necessary due to an accident, disease, deformity, or dental treatment.  Orthodontic bracing for treatment of temporomandibular joint (TMJ) disorders.  Charges for services and supplies: (1) for which an Insured is not required to make payment, (2) that are made only because benefits are available under the Policy, or (3) for which an insured would have no legal obligation to pay in the absence of this or any similar coverage.  Expenses for services furnished by a provider who is related to the Insured by blood or marriage or who resides in the  Charges for telephone or internet consultations; missed appointments; claim form completion; interest charges; legal services; obtaining medical records; or provider travel and/or lodging expenses.  Durable medical equipment, including but not limited to accessories and supplies used in conjunction with durable medical equipment, heating pads, contour chairs, therapeutic beds, hospital beds, setup and delivery of durable medical equipment, except as provided in the policy.  Routine foot care (including removal of corns or calluses or trimming of nails); foot impression casting including x-rays incidental to casting; orthopedic shoes; arch supports and other supportive devices for the feet; and off-the-shelf shoe  Orthotic devices, including but not limited to braces, splints, orthopedic appliances, and other orthotic supplies.  Prosthetic devices, except for necessary prostheses following a mastectomy. See the prosthetic devices and Women’s Health and Cancer Right sections of the policy.  Convenience items such as telephones; television; guest trays or meals; personal hygiene items or services; or homemaker or housekeeping services, except by home health aides as ordered in a hospice treatment plan.  Drugs and supplies not requiring a prescription order, including but not limited to aspirin, antacid, benzyl peroxide preparations, cosmetics, medicated soaps, food supplements, syringes, and bandages; Antabuse, Methadone, Minoxidil, or Rogaine hair preparations; experimental drugs including those labeled, "Caution-Limited by Federal Law to Investigational Use"; and prescription medications related to health care services which are not covered under the policy. Notwithstanding this exclusion, Regence BSI may choose to cover certain over-the-counter medications when prescription drug benefits are provided under the policy. Such approved over-the-counter medications must be identified by Regence BSI in writing and will specify the procedures for obtaining benefits for such approved over-the- counter medications. Please note that the fact a particular over-the-counter drug or medication is covered does not require Regence BSI to cover or otherwise pay or reimburse the Insured for any other over-the-counter drug or  Diet and weight monitoring, and educational services.  Special foods or diets, vitamins, minerals, dietary and nutritional supplements, and nutritional therapy. See the Phenylketonuria Formulas section for PKU formulas benefits.  Biofeedback. Regence Revive-SGP-$2000-1-2011-BS  Wigs and artificial hair pieces.  Any services, supplies, or charges which result from the treatment of any direct or indirect complication of any illness or condition for which coverage is not or was not provided. LIMITATIONS
 Total benefits paid for office, home, and outpatient hospital visits, including second and third surgical consultative opinions shall be limited to a combined maximum of four (4) visits per Insured each calendar year for services provided by a preferred provider and non-preferred provider.  Total benefits paid for Inpatient rehabilitation services shall be limited to a maximum of fifteen (15) days per Insured  Total benefits paid for home health care visits shall be limited to a maximum of sixty (60) visits per Insured each  Total benefits paid for hospice care services shall be limited to a maximum of fourteen (14) days during an Insured’s  Total benefits paid for extended care in a skilled nursing facility shall be limited to a maximum of thirty (30) days per  Claims submitted to Regence BSI more than twelve (12) months after the last day on which covered services were rendered shall be ineligible for payment, unless it can be shown to the satisfaction of Regence BSI that there was unusual and justifiable cause for such late submission. myRegence.com is designed to advise you on health care and lifestyle options, navigate you through the health care
system, and reward you who make healthy choices. Go to www.myRegence.com and view claims; get fitness and
nutrition tips; learn about medical conditions, medications, and formulary information; search for doctors; and research cost and care options. THESE ADDITIONAL VALUABLE SERVICES ARE A COMPLEMENT TO THE GROUP
HEALTH PLAN, BUT ARE NOT INSURANCE.

Source: http://sageschools.net/Health%20Insurance%20Info/Sage%20Technical%20Services-2011-Benefit%20Summary%20Regence%20BSI.pdf