Virginia
Individual Program Summary of Benefits HMO Plans Important Information about your HealthKeepers plan
HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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Anthem HealthKeepers Summary of Benefits for Individual Program Offered by HealthKeepers, Inc., This Summary of Benefits explains the extent to which covered services are available to covered persons on your health care coverage. This summary is only a guide, not an official evidence of coverage. If there is any difference between this document and the information in your Evidence of Coverage, please understand that your Evidence of Coverage overrides this document.
Service Inpatient Hospital Services: • Inpatient hospital admission either within or outside the Service Area for any covered Inpatient hospitalization, including maternity care
Outpatient Visits and House Calls: • Primary Care Physician (PCP) office visit • Copayment per pregnancy including prenatal and postnatal care of the mother See the Claims and Payments chapter of your Evidence of Coverage for additional information regarding copayments for prenatal and postnatal care. • Approved Outpatient visit to providers other than Your PCP (such as specialist physicians or Urgent Care centers) or house calls • Per visit Copayment for a female Member to any HMO Physician for her annual gynecological examination • Pre-operative and post-operative office visit Diagnostic Tests: • In an office visit setting: • PCP • Specialty Care Providers • Complex diagnostic imaging services. Includes Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Positron Emission Tomography (PET) scan, Computed Tomographic Angiography (CTA), Computed Tomography (CT) scan, and Magnetic Resonance Spectroscopy (MRS). • In an outpatient facility department: • Diagnostic x-rays • Complex diagnostic imaging services. Includes Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Positron Emission Tomography (PET) scan, Computed Tomographic Angiography (CTA), Computed Tomography (CT) scan, and Magnetic Resonance Spectroscopy (MRS). Outpatient/Ambulatory Surgery: • Outpatient surgery received in a freestanding or hospital-based center • Outpatient surgery received in a physician’s office other than that of the PCP Short-Term Outpatient Rehabilitative Services: • Physical and Occupational Therapy: 30-combined visit maximum per member per calendar year • Speech Therapy: 30-visit maximum per member per calendar year Spinal Manipulation and Manual Medical Therapy Services: (30-visit calendar year limit per member) • Services must be received by a provider that participates in the American Specialty Health Networks (ASHN) Inpatient Mental Health and Substance Abuse Services: (Inpatient care limited to 30 days per Member per calendar year)
HealthKeepers,Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered marks Blue Cross and Blue Shield Association. Individual Program – NCQA (9/2011)
Copayment/Coinsurance $500 Copayment per Inpatient hospital admission
$15 Copayment $100 Copayment
$30 Copayment $0 Copayment $0 Copayment
$15 Copayment $30 Copayment $150 Copayment
$30 Copayment $150 Copayment
$50 Copayment $30 Copayment
$30 Copayment $30 Copayment
$30 Copayment
$500 Copayment per Inpatient hospital admission
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Service
Copayment/Coinsurance
Outpatient Mental Health and Substance Abuse Services: (Outpatient visits, other than those for medication management, limited to 20 visits per Member per calendar year) • Medication management visits, which are individual therapy sessions lasting up to 30 minutes in duration, and group therapy session • Any other Outpatient mental health or substance abuse visit
$15 Copayment
Emergency Services: (Within or outside the Service Area.) • Visit to a hospital Emergency room which does not result in Your direct admission into the hospital as an Inpatient • Visit to an Urgent Care center or a physician’s office in an Emergency situation
$50 Copayment
Out-of-Area Office Urgent Care Visits: Visit to a physician’s office or Urgent Care center for Emergency or Urgent Care services Injectable Medications: (excluding chemotherapy medication and allergy injections/serum) Home Care Services: Infusion Services: • Facility Services • Professional Provider Services • Ambulatory Infusion Centers Ambulance Services (Ground and Air):
$30 Copayment
$30 Copayment
$30 Copayment 20% Coinsurance $30 Copayment per calendar month $30 Copayment $30 Copayment $30 Copayment per calendar month $100 Copayment
Skilled Nursing Facility Stays: (100-day limit per confinement or admission.)
20% Coinsurance
Durable Medical Equipment, Appliances and Supplies:
$0 Copayment
Early Intervention Services: (Limited to $5,000 per Member per calendar year for any combination of services.) Dialysis Treatments:
Copayment determined by service rendered $30 Copayment per calendar month 20% Coinsurance
Prosthetics: Wellness services – Preventive care for adults and children ages 7 and above • Routine office visits • Labs, x-rays & immunizations • Screenings Fecal occult blood test Mammography screening Pap test Prostate Exams Prostate Specific Antigen Test Screenings for Colorectal Cancer (Appropriate Flexible Sigmoidoscopy, Colonoscopy, or Radiologic Imaging) Outpatient Prescription Drugs: Please note: if a generic drug is available and You request a brand name drug, You must pay the difference in the Allowable Charge between the generic and the brand name drug. This amount will be in addition to Your First-Tier Drug Copayment and such difference shall not be counted toward the calendar year limit. Outpatient Prescription Drug Services: (Up to a 30-day supply) • Per prescription dispensed for First-Tier Drug or refill • Per prescription dispensed for Second-Tier Drug or refill HealthKeepers,Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered marks Blue Cross and Blue Shield Association. Individual Program – NCQA (9/2011)
$0 Copayment
$10 Copayment $20 Copayment
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Service
Copayment/Coinsurance
• Per prescription dispensed for Third-Tier Drug or refill Mail Service Pharmacy: (Up to a 90-day supply.) • Per prescription dispensed for First-Tier Drug or refill • Per prescription dispensed for Second-Tier Drug or refill • Per prescription dispensed for Third-Tier Drug or refill
$35 Copayment
Calendar Year Limit for Copayments and Coinsurance:
$20 Copayment $40 Copayment $70 Copayment $1,500 per Member
What is Not Covered (Exclusions) To help manage the cost of health care premiums for all Anthem HealthKeepers members, we exclude from coverage certain services that are considered to be insufficiently effective, experimental, inappropriate or outside the practical scope of coverage. More information is provided in your Evidence of Coverage, but here is a detailed list of exclusions to help you evaluate the extent of your coverage. The following services will not, under any circumstances, be covered by HealthKeepers, Inc. Unless another type of service is specified, the word “services” means both services and supplies. Benefits for the following will not be provided: • Coverage does not include benefits for services received which are not authorized in advance by the HMO and pre-arranged by your PCP, unless otherwise specified in the Evidence of Coverage. • For non-grandfathered members age nineteen (19) and older and for all members on a grandfathered plan, your coverage does not include benefits for a pre-existing condition you receive during the first 12 months after your effective date of coverage. This exclusion shall not apply to a member who is an adopted child or a child placed in the subscriber’s home for adoption if the adoption or placement occurs while the subscriber is covered under this Evidence of Coverage. The phrase “placed in the subscriber’s home for adoption” shall mean the assumption and retention by a subscriber of a legal obligation for the total or partial support of such child in anticipation of adoption of such child. The child’s placement with the subscriber terminates upon the termination of such legal obligation. This exclusion shall also not apply to covered services for breast cancer when the member has been free from breast cancer for at least five years. Services for injuries or diseases related to your job. • Routine vision and hearing care, except as provided for children up to age 18. Services for radial keratotomy or other forms of refractive keratoplasty. • Services for, or related to, cosmetic surgery or procedures, including complications that result directly from such surgeries and/or procedures. Cosmetic surgeries and procedures are performed mainly to improve or alter a person’s appearance, including body piercing and tattooing. However, a cosmetic surgery or procedure does not include a surgery or procedure to correct deformity caused by disease, trauma, and/or congenital abnormalities which causes functional impairment, or from a previous therapeutic process. To determine if a surgical service is cosmetic or not, HealthKeepers, Inc. will not take into account the patient’s mental state. • Corrective appliances, artificial aids, devices and equipment not specifically listed as covered. • Implantable or removable hearing aids, with the exception of cochlear implants, or exams for these devices. • Guest meals, telephones, televisions and other convenience items as part of your inpatient stay. Private room, unless it is medically necessary and approved by us. • Care by interns, residents, house physicians, or other facility employees that are billed separately from the facility. • Telephone consultations, charges for missed appointments and other clerical charges. • Private duty nursing except as covered under your home health care benefit. • Benefits for home care services such as homemaker services (except as rendered as part of hospice care), maintenance therapy (except when part of approved early intervention services), food and home delivered meals, or custodial care and services. • Reversal of sterilization and complications incidental to such procedures. Procedures, services and supplies related to sex transformations. Penile implants and related services. Non-prescription contraceptive devices and infertility services including in vitro fertilization and embryo transplants. • Services or supplies provided or available under a U.S. government program or program for which the federal or state government pays all or part of the cost, or under the Medicare program or any similar program authorized by state or local laws unless a federal or state law makes the government program the secondary payor after benefits under the Evidence of Coverage have been paid. HealthKeepers,Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered marks Blue Cross and Blue Shield Association. Individual Program – NCQA (9/2011)
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• Routine foot care including the removal of corns or calluses and the trimming of nails. • Acupuncture and related services. The following spinal manipulation and manual medical therapy services: • any treatment or service not authorized by the American Specialty Health Networks (ASHN); • any treatment or service not provided by an ASHN provider; • services for examination and/or treatment of strictly non-neuromusculoskeletal disorders, or conjunctive therapy not associated with spinal or joint adjustment; • laboratory tests, x-rays, adjustments, physical therapy or other services not documented as medically necessary and appropriate, or classified as experimental or in the research state; • diagnostic scanning, including magnetic resonance imaging (MRI), computed axial tomography (CAT) scans, and/or other types of diagnostic scanning; thermography; • educational programs, non-medical self-care or self-help, or any self-help physical exercise training, or any related diagnostic testing; • air conditioners, air purifiers, therapeutic mattresses, supplies or any other similar devices or appliances; or • vitamins, minerals, nutritional supplements, or any other similar type products. • Services for biofeedback therapy, smoking or nicotine addiction. Remedial or special education services including diagnostic and other services. Marriage counseling, when such services extend beyond the period necessary for short-term evaluation or crisis intervention. • Experimental/investigative procedures as well as services related to or complications that result directly from such procedures except for clinical trials for cancer services as described by the National Cancer Institute. Nothing in this exclusion shall prevent a member from appealing our decision that a service is experimental/investigative. • Benefits for organ or tissue transplants, including complications caused by them, except when they are considered medically necessary, have received pre-authorization, and are not considered experimental/investigative. Autologous bone marrow transplants for breast cancer are covered only when the procedure is performed in accordance with protocols approved by the institutional review board of any United States medical teaching college. These include, but are not limited to, National Cancer Institute protocols that have been favorably reviewed and used by hematologists or oncologists who are experienced in high dose chemotherapy and autologous bone marrow transplants or stem cell transplants. This procedure is covered despite the exclusion in the plan of experimental/investigative services. • Services deemed not medically necessary, as determined by us, at our sole discretion. Nothing in this exclusion shall prevent a member from appealing our decision that a service is not medically necessary. • Any types of health services, supplies or treatments not specifically listed as covered, including complications as a result of such services, supplies or treatment. Any types of services, supplies or treatments not prescribed, performed or directed by a provider licensed to do so and any types of services, supplies or treatments received before the effective date or after the member’s coverage ends. • Benefits for dental or oral surgery, except in the following limited circumstances: 1. Dental services and dental appliances when required to treat medically diagnosed cleft lip, cleft palate or ectodermal dysplasia; 2. Medically Necessary dental services resulting from an accidental injury. You must submit a plan of treatment from your dentist or oral surgeon for prior approval by the HMO. For an injury that occurs on or after your effective date of coverage, you must seek treatment within 60 days after the injury. 3. Dental services to prepare the mouth for radiation therapy to treat head or neck cancer. All other procedures involving the teeth or areas surrounding the teeth are not covered. • Benefits for home care services such as homemaker services (except as rendered as part of hospice care), maintenance therapy, food and home delivered meals. • Genetic testing other than fetal screenings. Services for potential illnesses that may result from genetic predisposition are not covered in the absence of signs or symptoms. • Paternity testing. • Medical equipment, appliances, devices and supplies that have both a non-therapeutic and therapeutic use. • Medical equipment (durable) that is not appropriate for use in the home. • Benefits for amounts above the allowable charge for a service, self-administered services or self-care including self-administered injections, self-help training, and neurofeedback and related diagnostic tests. Benefits for educational or teacher services, except in limited services. • Benefits for services for which a charge is not usually made including services for which you would not have been charged if you did not have health care coverage. • Nutrition counseling and related services, except when provided as part of diabetes education. • Care of obesity or services related to weight loss or dietary control including weight reduction therapies/activities, except as specified in the Evidence of Coverage. • Benefits for the following skilled nursing facility stays: custodial care; treatment of psychiatric conditions and senile deterioration; and facility services during a temporary leave of absence from the facility. HealthKeepers,Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered marks Blue Cross and Blue Shield Association. Individual Program – NCQA (9/2011)
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• Benefits for physical therapy, occupational therapy, or speech therapy to maintain or preserve current functions if there is no chance of improvement or reversal except for children under age 3 who qualify for Early Intervention Services. Benefits for group speech therapy, group physical therapy, and recreation therapy. • The following mental health and substance abuse services: inpatient stays for environmental changes, cognitive rehabilitation therapy, educational therapy, vocational and recreational activities, coma stimulation therapy, services for sexual deviation and dysfunction, treatment of social maladjustment without signs of a psychiatric disorder, remedial or special education services and inpatient mental health treatments that meet the criteria listed in the Evidence of Coverage. • Benefits for rest cures, custodial, residential, or domiciliary care and services. • Your prescription drug benefit does not cover: over the counter drugs; any per unit, per month quantity over the specified limits; drugs used mainly for cosmetic purposes; drugs that are experimental, investigational, or not approved by the FDA; cost of medicine that exceeds the allowable charge for that prescription; drugs for weight loss; stop smoking aids; therapeutic devices or appliances (excluding diabetic supplies and equipment); injectable prescription drugs that are supplied by a provider other than a pharmacy; charges to inject or administer drugs; drugs not prescribed by a licensed provider; any refill dispensed after one year from the date of the original prescription order; infertility medications; medications used to treat sexual dysfunction; medicine covered by worker’s compensation, Occupational Disease Law, state or government agencies; and medicine furnished by any other drug or medical service Non-interactive telemedicine services. Non-interactive telemedicine services include an audio-only telephone, electronic mail message, or facsimile transmission. These exclusions are also listed in your Evidence of Coverage and related amendments.
HealthKeepers,Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered marks Blue Cross and Blue Shield Association. Individual Program – NCQA (9/2011)
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