Ihc Hmo Coin Value Hmo 405 Platinum

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Details for the IHC Value HMO with Coinsurance.

Transcript of Ihc Hmo Coin Value Hmo 405 Platinum

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    Coverage Period:01/01/2014 - 12/31/2014

    Coverage for:Individual FAMILY

    34023

    | PlanType: HMO

    Stnd Value PLT HMOSummary of Benefits and Coverage: What this Plan Covers & What it Costs

    Questions: Call 1-800-275-2583 or visit us at www.amerihealth.com.If you arent clear about any of the underlined terms used in this form, see the Glossary.You can view the Glossary at www.amerihealth.com or call 1-800-275-2583 to request a copy.

    This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at www.amerihealth.com or by calling 1-800-275-2583.

    Important Questions Answers Why this Matters:

    What is the overalldeductible? $0 See the chart starting on page 2 for your other costs for services this plan covers.

    Are there other deductiblesfor specific services? No.

    You don't have to meet deductibles for specific services, but see the chart starting onpage 2 for other costs for services this plan covers.

    Is there an out-of-pocketlimit on my expenses?

    Yes. For participating providers$5,000 person / $10,000 family.

    The out-of-pocket limit is the most you could pay during a coverage period (usually oneyear) for your share of the cost of covered services. This limit helps you plan for healthcare expenses.

    What is not included in theout-of-pocket limit?

    This plan has no out-of-pocketlimit. Not applicable because there's no out-of-pocket limit on your expenses.

    Is there an overall annuallimit on what the plan pays? No.

    The chart starting on page 2 describes any limits on what the plan will pay for specificcovered services, such as office visits.

    Does this plan use anetwork of providers?

    Yes. Seewww.amerihealth.com/find_a_provider/index.html or call 1-800-275-2583 for a list ofparticipating providers.

    If you use an in-network doctor or other health care provider, this plan will pay some orall of the costs of covered services. Be aware, your in-network doctor or hospital may usean out-of-network provider for some services. Plans use the term in-network, preferred,or participating for providers in their network. See the chart starting on page 2 for howthis plan pays different kinds of providers.

    Do I need a referral to see aspecialist? Yes. Electronic referral required.

    This plan will pay some or all of the costs to see a specialist for covered services butonly if you have the plan's permission before you see the specialist.

    Are there services this plandoesn't cover? Yes.

    Some of the services this plan doesn't cover are listed in the Excluded Services & OtherCovered Services section. See your policy or plan document for additional informationabout excluded services.

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    Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.lCoinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if theplans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if youhavent met your deductible.

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    The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and theallowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

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    This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.l

    Common MedicalEvent Services You May Need

    Your Cost If You Use

    a ReferredProvider

    an Out Of NetworkProvider

    Limitations & Exceptions

    If you visit a healthcare providers officeor clinic

    Primary care visit to treat aninjury or illness $15 copay Not Covered -----------none-----------

    Specialist visit $25 copay Not Covered Referral Required

    Other practitioner office visit $25 copay Not Covered Therapeutic Manipulations: 30 visits per calendar yearlimitPreventive care / screening /immunization No charge Not Covered

    Routine Gynecological exam limited to 1 per benefitperiod.

    If you have a test

    Diagnostic test (x-ray, bloodwork) $25 copay Not Covered

    There is no cost for diagnostic services received in theEmergency Room or during a doctor's office visit.

    Imaging (CT/PET scans,MRIs) $50 copay Not Covered

    Precertification required. There is no cost fordiagnostic services received in the Emergency Roomor during a doctor's office visit.

    If you need drugs totreat your illness orcondition

    More informationabout prescriptiondrug coverage isavailable atwww.amerihealth.com/njapprovals

    Generic drugs $10 Copayment 50% CoinsurancePrior authorization required on some drugs; age,gender and quantity limits for some drugs; dayssupply limits on retail & mail order.

    Preferred brand drugs $40 Copayment 50% CoinsurancePrior authorization required on some drugs; age,gender and quantity limits for some drugs; dayssupply limits on retail & mail order.

    Non-preferred brand drugs $60 Copayment 50% CoinsurancePrior authorization required on some drugs; age,gender and quantity limits for some drugs; dayssupply limits on retail & mail order.

    Specialty drugs No charge Not CoveredPrior-authorization required. A complete list of drugsrequiring prior-authorization is available atwww.amerihealth.com/njapprovals.

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    Common MedicalEvent Services You May Need

    Your Cost If You Use

    a ReferredProvider

    an Out Of NetworkProvider

    Limitations & Exceptions

    If you haveoutpatient surgery

    Facility fee (e.g., ambulatorysurgery center) $225 copay Not Covered

    Some outpatient surgeries require pre-certification. Acomplete list of surgeries requiring pre-certification isavailable at www.amerihealth.com/njapprovals

    Physician/surgeon fees No charge Not CoveredSome outpatient surgeries require precertification. Acomplete list of surgeries requiring precertification isavailable at www.amerihealth.com/preapproval

    If you needimmediate medicalattention

    Emergency room services $75 copay $75 copay Your costs for Emergency Room services are waivedif you are admitted to the hospital.Emergency medicaltransportation No charge Not Covered -----------none-----------

    Urgent care $50 copay $50 copayYour costs for urgent care are based on care receivedat a designated Urgent Care center or facility, not yourphysicians office. Costs may vary depending onwhere you receive care.

    If you have ahospital stay

    Facility fee (e.g., hospitalroom)

    $225 copay per day,up to 5 days Not Covered Precertification required.

    Physician/surgeon fee No charge Not Covered Precertification required.

    If you have mentalhealth, behavioralhealth, or substanceabuse needs

    Mental/Behavioral healthoutpatient services $25 copay Not Covered -----------none-----------

    Mental/Behavioral healthinpatient services

    $225 copay per day,up to 5 days Not Covered Precertification required

    Substance abuse disorderoutpatient services $25 copay Not Covered -----------none-----------

    Substance abuse disorderinpatient services

    $225 copay per day,up to 5 days Not Covered Precertification required

    If you are pregnantPrenatal and postnatal care No charge Not Covered -----------none-----------Delivery and all inpatientservices

    $225 copay per day,up to 5 days Not Covered Pre-notification requested

    If you need helprecovering or haveother special healthneeds

    Home health care No charge Not Covered Precertification required

    Rehabilitation services $25 copay Not CoveredPhysical Therapy 30 visits; Occupational Therapy 30visits; Speech Therapy 30 visits, and CognitiveTherapy 30 visits, per calendar year

    Habilitation services $25 copay Not CoveredPhysical Therapy 30 visits; Occupational Therapy 30visits; Speech Therapy 30 visits, and CognitiveTherapy 30 visits, per calendar year

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    Common MedicalEvent Services You May Need

    Your Cost If You Use

    a ReferredProvider

    an Out Of NetworkProvider

    Limitations & Exceptions

    Skilled nursing care $225 copay, per dayup to 5 days Not Covered Precertification required

    Durable medical equipment 50% Not Covered Pre-certification required for purchases over $500 andall rentals.Hospice service No charge Not Covered -----------none-----------

    If your child needsdental or eye care

    Eye exam No charge Not Covered Pediatric Vision; once every 12 months.Glasses No charge Not Covered Pediatric Vision; once every 12 months.Dental check-up Not Covered Not Covered -----------none-----------

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    Excluded Services & Other Covered Services:

    Your Rights to Continue Coverage:

    Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at 1-877-585-5731 prompt #2. You may also contact your state insurance department. New Jersey Department of Banking and Insurance

    Consumer Protection Services - P.O. Box 329 - Trenton, NJ. 08625 - Phone: 1-800-446-7467 - Fax: 1-609-633-0807

    Your Grievance and Appeals Rights:

    If you are dissatisfied with a denial of coverage for claims