|
Summary of Benefits
PHSTD1106
| Major
Copayment Provisions |
HIP
Prime |
| PCP Office visits |
$20 copay per visit |
| Specialist Office visits |
$20 copay per visit |
| Hospital admission |
$500 copay per admission |
| Emergency Room copay |
$50 copay per visit |
| Prescription drugs |
Not covered |
| Inpatient
Hospital Services |
HIP
Prime |
| Hospital and
physician services |
Subject to Hospital
admission copay |
| Semiprivate room
and board |
Included in
Hospital admission copay |
| Operating and
recovery room, intensive and special care units, general nursing care,
prescribed drugs, anesthesia, X-rays and lab tests |
Included in
Hospital admission copay |
| Short-term speech,
physical, occupational and respiratory therapy (when part of an acute
admission) |
Included in
Hospital admission copay
Short term only |
| Speech, physical,
occupational and respiratory therapy (when part of a rehabilitation
admission) |
Not covered |
| Radiation therapy
and chemotherapy |
Included in
Hospital admission copay |
| Pre-admission
testing |
Included in
Hospital admission copay |
| Human organ
transplants |
Included in
Hospital admission copay |
| Outpatient
Medical Care |
HIP
Prime |
| PCP office visits |
Subject to PCP
office visit copay |
| Specialists office
visits |
Subject to
Specialist office visit copay |
| Preventive care,
including physical exams, eye and eye exams, health education and
counseling, pap smear, mammography and immunizations |
Included in PCP
office visit copay |
| Well-child care to
age 19 including immunizations |
No copay |
| Diagnostic services
including X-ray, lab tests, EKG's, MRI's and CAT scans |
Included in PCP
office visit copay |
| Prenatal, postnatal
care in physician's office |
No copay |
| Outpatient hospital
services and ambulatory surgery including physician and facility services |
$75 copay per visit |
| Second medical and
surgical opinion |
No copay |
| Disposable medical
supplies |
No copay |
| Wheelchairs |
Not covered |
| Routine foot care |
Not covered |
| Chiropractic services |
Subject to Specialist office
visit copay |
| Mental
Health and Alcohol and Substance Abuse Care |
HIP
Prime |
| Mental Health
Care |
|
| Inpatient |
Subject to Hospital
admission copay;
30 days per calendar year |
| Outpatient |
$35 copay per
visit;
20 visits per calendar year |
| Alcohol
and Substance Abuse Care |
|
| Inpatient
detoxification |
Subject to Hospital
admission copay;
7 days per calendar year |
| Inpatient
Rehabilitation Treatment |
Not covered |
| Outpatient
Rehabilitation Treatment |
Subject to
Specialist office visit copay;
60 visits per calendar year |
| Special
Kinds of Care |
HIP
Prime |
| Emergency and
Urgent Care |
|
| In hospital
emergency room |
Subject to
Emergency Room copay |
| In urgent care
facility |
Subject to PCP
office visit copay |
| In
physician's office |
Subject to PCP
office visit copay |
| Ambulance service
to hospital |
No copay |
| Home health care |
No copay; 40 visits
per calendar year |
| Hospice care |
No copay; 210 days |
| Skilled Nursing
Facility care |
No copay; 30 days
per calendar year |
| Dialysis
treatment |
$20 copay per visit |
| Diabetes
equipment, supplies and education |
$20 copay per month |
| Outpatient
physical, speech, occupational and respiratory therapy |
Subject to
Specialist office visit copay;
30 visits per calendar year |
| InterPlan® Care |
Urgent/Some
Specialty care covered |
| Family Planning
Services |
Covered |
| Dental Care |
|
| General Dental Care |
Covered at reduced
member fee schedule |
| Preventive Dental |
Oral exam (One
every 6 months - $5 copay per visit
Cleaning, including one application of flouride for children age 16 and
under (one every 6 months - $10 copay per visit) |
| Durable Medical
Equipment |
Not covered |
| Private Duty
Nursing |
Not covered |
| Hearing Aids |
Not covered,
Cochlear implants covered |
| Optical Care |
|
| Refractive Eye
Exams |
No copay per visit |
| Eyeglasses |
$45 for a complete
paid every 24 months |
| Footnotes |
| Except for
emergency care, the above benefits and services are covered only when
provided or referred by a HIP Primary Care physician and/or approved in
advance by the HIP Member Advocacy Program. HIP Participating Physicians
and Providers have contracted with HIP to provide care to our members;
they are not employees, agents, servants or representatives of HIP. This
summary is provided for information only; it does not contain complete
details of the Plan which are available only in the Contract or
Certificate of Coverage and Schedule of Benefits, and it does not
constitute an Agreement. |
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