(HSA Qualified Plan)
|
In-Network
|
Out-of-Network
|
Annual
Deductible (All services are subject to the deductible including those covered
under any additional riders, except as otherwise noted. The family deductible must be met in full
by any combination of family members before any benefits will be paid)
|
$2,700 single, $5,400 family |
$5,000 single, $10,000 family |
Coinsurance
|
10% (See also DME below) |
50% |
Annual Out-of-Pocket Maximum |
$4,000
single, $8,000 family |
$10,000
single, $20,000 family |
Annual Benefit Maximum – combined total of all in and out of network
services
|
$1,000,000 |
|
Pre-Existing Condition Waiting Period – not applicable to pregnancy or newborns |
Pre-existing
condition waiting period applies |
|
Services
|
Your Out-of-Pocket Responsibility |
|
Physician ServicesOffice visits for illness or injury, or second opinion Well-baby and well-child care including immunizations/inoculations Annual adult exam Annual gynecological exam |
Deductible
then 10% Covered
in full (not
subject to the deductible) Covered
in full (not
subject to the deductible) Covered in full (not subject to the deductible) |
Deductible
then 50% Deductible
then 50% Deductible
then 50% Deductible
then 50% |
Hospital ServicesInpatient hospital (semi-private room, anesthesia, X-ray, lab tests, etc.) Outpatient surgery |
Deductible then 10% Deductible then 10% |
Deductible
then 50% Deductible
then 50% |
Diagnostic TestingLaboratory services Radiology and imaging (X-rays, ultrasounds, CT scans, etc.) Mammogram (not subject to the deductible) Cytology screening (not subject to the deductible) Prostate cancer screening (not subject to the deductible) |
Deductible
then 10% (coinsurance waived when a
designated laboratory provider is used) Deductible
then 10% (coinsurance waived at
designated sites) Covered
in full Covered
in full Covered in full |
Deductible
then 50% Deductible
then 50% Deductible
then 50% Deductible
then 50% Deductible
then 50% |
Maternity
Physician
services Inpatient
hospital services Newborn
nursery |
Deductible
then 10% Deductible
then 10% Deductible
then covered in full |
Deductible
then 50% Deductible
then 50% Deductible
then 50% |
Emergency Care
Worldwide
emergency room care Ambulance |
Deductible
then 10% Deductible
then 10% |
All emergency care is considered in-network. |
Urgent Care – nonparticipating Urgent Care facility services
within the CDPHP UBI service area are not covered
|
Deductible
then 10% |
Deductible
then 50% |
|
|
Your Out-of-Pocket Responsibility
|
|
Services
|
In-Network |
Out-of-Network |
Physical Therapy
–
limit 30 visits per benefit period in- and out-of-network combined
|
Deductible
then 10% |
Deductible
then 50% |
Speech Therapy
|
Not
covered |
Not
covered |
Occupational
Therapy – limit 30 visits per benefit period in- and
out-of-network combined
|
Deductible
then 10% |
Deductible
then 50% |
Chiropractic
Benefits
|
Deductible
then 10% |
Deductible
then 50% |
Home Health Care
|
Deductible
then 10% |
Deductible
then 50% |
Skilled Nursing Facility
|
Not Covered
|
Deductible then 50%
|
Prosthetic
Devices and
|
Deductible
then 50% coinsurance Limited to $25,000
per lifetime
|
Covered
in-network only
|
Diabetic Care
Insulin and oral medications – Up to a 30-day supply Diabetic supplies (needles, syringes, etc.) – Up to a 30-day supply Glucometers Diabetic DME |
Deductible
then $15 Deductible
then $15 Deductible
then $15 Deductible
then $15 |
Deductible
then 50% Deductible
then 50% Deductible
then 50% Deductible
then 50% |
Mental Health Services
Outpatient mental health
services – up to 20 visits
per benefit period Inpatient mental health services – up to 30 days per benefit period Biologically based mental illness and coverage for children with serious emotional disturbance is available beyond those limits for outpatient and inpatient services |
Deductible
then 10% Deductible then 10%
|
Deductible
then 50% Deductible
then 50% |
Chemical Abuse and Dependency
Outpatient services – Up
to 60 visits per calendar year
Inpatient detoxification
– Up to 7 days per benefit period Inpatient rehabilitation
– Up to 30 visits per benefit
period
|
Deductible
then 10% Not
covered Not
covered |
Deductible
then 50% Not
covered Not
covered |
Dependent
Coverage
|
Up to age 19 |
|
|
This HDPPO Plan is underwritten by CDPHP Universal
Benefits, Inc. (CDPHP UBI). CDPHP UBI gives you access to a wide range of
physicians, specialists, and hospitals in addition to the option to access
physicians and providers outside the network. You also have access to a
variety of value-added services to help you and your family stay healthy. If
you have a question about CDPHP UBI, please contact the marketing department
at (518) 641-5000 or 1-800-993-7299 or visit our Web site at www.cdphp.com. You must comply with the CDPHP UBI managed
benefits program as set forth in the contract to receive the maximum benefits
for all services. Failure to do so will result in your being responsible for
an additional payment of 50 percent of the allowed amount up to a maximum of
$500 for each service otherwise payable, in addition to the applicable
copayments, deductible, and/or coinsurance. All benefits of this Plan are subject to coordination of benefits. This summary is designed to highlight the benefits of the plan being offered and does not detail all benefits, limitations, or exclusions. It is not a contract and may be subject to change. For more detailed information, a membership certificate is available for your review upon request. The insurance evidenced by this benefit summary meets the minimum standards for basic hospital and basic medical insurance as defined by the New York State Department of Insurance. It does not provide major medical insurance. |
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