Schedule of Benefits
UIF, 01/12 MD0000001832
The Harvard Pilgrim Health Care of New England USNH-STAFF/FACULTY POS Services listed are covered when Medically Necessary. Please see your Benefit Handbook for details. This Schedule is part of your Benefit Handbook. It states the Cost Sharing amounts that you must pay for Covered Benefits and some important limitations on your coverage. It also identifies any supplemental medical benefits covered by your Plan. There are two levels of coverage: In-Network and Out-of-Network. In-Network coverage applies when you use a Participating Provider for Covered Benefits. When using Participating Providers, Covered Charges are based on the contracted rate between Harvard Pilgrim Health Care of New England and the Provider. Out-of-Network coverage applies when you use a Non-Participating Provider for Covered Benefits. When using Non-Participating Providers, Covered Charges are based on the Providers charge for the service. In most cases, this will be higher than Harvard Pilgrim Health Care of New England’s contracted rate. Please refer to your Benefit Handbook for further information about how your In-Network and Out-ofNetwork coverage works. Except for allergy injections, nutritional counseling and prenatal and postpartum care, your plan has two levels of Copayments that apply to outpatient physician services you receive while a Member of the Plan. These are Level 1 Copayment, which is $10 and the Level 2 Copayment, which is $20. The Level 1 Copayment applies to outpatient physician services provided by your Primary Care Physician (PCP). All other outpatient physician services not provided by your PCP require you to pay the Level 2 Copayment.
General Cost Sharing Features
In-Network
Out-of-Network
Coinsurance
None
See below
Copayment
See below
None
Deductible
None
$300 per Member $600 per family
Out-of-Pocket Maximum
None
Penalty Payment
None
$500 per Member $1,000 per family 50% of the Covered Charges or $500, whichever is less
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Covered Benefits
Your Cost Sharing
Your Cost Sharing
In-Network
Out-of-Network
Outpatient Professional Services
Ambulance Transport, Non-Emergency
Nothing
Nothing
Cardiac Rehabilitation, Physical, Speech, and Occupational Therapies – combined up to 60 visits per calendar year
Nothing
Deductible, then 20% Coinsurance
Cardiac Rehabilitation, Physical, Speech, and Occupational Therapies provided in the home are subject to the benefit limitations described above.
Diagnostic Laboratory and X-rays
Nothing
Deductible, then 20% Coinsurance
Dialysis
Nothing
Deductible, then 20% Coinsurance
Early intervention services – up to a maximum of $3,200 per Member per calendar year and a lifetime maximum of $9,600
$10 Copayment
Formulas and Low Protein Foods
Nothing
Deductible, then 20% Coinsurance
Home Care - limited to 40 visits per calendar year for Non-Participating Providers
Nothing
Deductible, then 20% Coinsurance
Hospice
Nothing
Deductible, then 20% Coinsurance
Physician Services, except the services listed below
Level 1: $10 Copayment Level 2: $20 Copayment
Deductible, then 20% Coinsurance
Preventive care by a Physician*
Nothing
Deductible, then 20% Coinsurance
Prenatal and Postpartum Care*
Nothing
Deductible, then 20% Coinsurance
Preventive Tests and Procedures*
Nothing
Deductible, then 20% Coinsurance
Allergy Injections
Nothing
Deductible, then 20% Coinsurance
Nutritional Counseling
Nothing
Deductible, then 20% Coinsurance
Deductible, then 20% Coinsurance
*See page S7 for a list of Preventive Care Services and Tests
Surgical Day Care
$50 Copayment
Deductible, then 20% Coinsurance
Vision Hardware for Special Conditions
Nothing
Deductible, then 20% Coinsurance
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Covered Benefits
Your Cost Sharing
Your Cost Sharing
In-Network
Out-of-Network
Emergency Services
Ambulance Transport, Emergency
Nothing
Same as In-Network
Accidental Injury Dental Care - in a professional office must be received within six months of injury
Nothing
Deductible, then 20% Coinsurance
Emergency Room Care
$75 Copayment. This Copayment is waived if admitted directly to the hospital from the emergency room.
Same as In-Network
50% of your Emergency Room Care Copayment.
50% of your Emergency Room Care Copayment.
$200 Copayment per admission
Deductible, then 20% Coinsurance
Nothing
Deductible, then 20% Coinsurance
Urgent Care Services
Urgent care center treatment
Inpatient Services
Acute Hospital Care
Maternity Care
Rehabilitation Hospital Care and Skilled Nursing Facility Care - limited to a combined 100 days per calendar year
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Covered Benefits
Your Cost Sharing
Your Cost Sharing
In-Network
Out-of-Network
Mental Health Services
Inpatient Care
$200 Copayment per admission
20% Coinsurance
Partial Hospitalization
Nothing
20% Coinsurance
Outpatient Care Group Therapy
$10 Copayment
20% Coinsurance
Individual Therapy
$10 Copayment
20% Coinsurance
Medication Management
$10 Copayment
20% Coinsurance
Psychological Testing
$10 Copayment
Deductible, then 20% Coinsurance
Drug and Alcohol Rehabilitation Services $200 Copayment per admission
20% Coinsurance
Inpatient Care Inpatient Detoxification
Partial Hospitalization
Nothing
20% Coinsurance
Outpatient Care Group Therapy
$10 Copayment
20% Coinsurance
Individual Therapy
$10 Copayment
20% Coinsurance
Outpatient Detoxification
$10 Copayment
20% Coinsurance
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Covered Benefits
Your Cost Sharing
Your Cost Sharing
In-Network
Out-of-Network
Durable Medical Equipment and Prosthetic Devices
Covered to the extent Medically Necessary, including the following items listed below
Nothing
Deductible, then 20% Coinsurance
Blood Glucose Monitors, Insulin Pumps and Infusion Devices
Nothing
Deductible, then 20% Coinsurance
Breast Prostheses, including replacements and Mastectomy Bras
Nothing
Deductible, then 20% Coinsurance
Medical Equipment and Supplies for Diabetes Treatment
Nothing
Deductible, then 20% Coinsurance
Oxygen and Respiratory Equipment
Nothing
Deductible, then 20% Coinsurance
Prosthetic Arms and Legs
Nothing
Deductible, then 20% Coinsurance
Your Member cost sharing will depend upon the types of services provided, as listed in this Schedule of Benefits. For example, for services provided by a physician, see “Outpatient Professional Services”. For inpatient hospital care, see “Inpatient Services.”
Your Member cost sharing will depend upon the types of services provided, as listed in this Schedule of Benefits. For example, for services provided by a physician, see “Outpatient Professional Services”. For inpatient hospital care, see “Inpatient Services.”
Telemedicine Services
Outpatient and Inpatient Telemedicine Services
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Covered Benefits
Your Cost Sharing
Your Cost Sharing
In-Network
Out-of-Network
Autism Spectrum Disorders Treatment
Applied Behavior Analysis - limited to $36,000 per calendar year for Members through the age of 12 and $27,000 per calendar year for Members age 13 to 21
$10 Copayment
Deductible, then 20% Coinsurance
All other benefits are covered as stated in this Schedule of Benefits
Your Member Cost Sharing depends upon the type of service provided, as listed in this Schedule of Benefits. For example: For services provided by a physician or physical therapist, occupational therapist or speech therapist see “Outpatient Professional Services.”
Your Member Cost Sharing depends upon the type of service provided, as listed in this Schedule of Benefits. For example: For services provided by a physician or physical therapist, occupational therapist or speech therapist see “Outpatient Professional Services.”
Nothing
Deductible, then 20% Coinsurance
Hearing Aids
Hearing Aids - limited to $1,500 per hearing aid every 60 months, for each hearing impaired ear. No limit for Members up to the age of 19.
Supplemental Benefits
Annual Eye Examination
$10 Copayment
Deductible, then 20% Coinsurance
Chiropractic Care - limited to 20 visits per calendar year
$10 Copayment
Deductible, then 20% Coinsurance
Voluntary Sterilization
$20 Copayment
Deductible, then 20% Coinsurance
Voluntary Termination of Pregnancy
$20 Copayment
Deductible, then 20% Coinsurance
Infertility Treatment using Therapeutic Donor Insemination – limited to six cycles per lifetime
$20 Copayment
Deductible, then 20% Coinsurance
Infertility Drugs – limited to four months supply per calendar year
Subject to the applicable prescription drug Copayment listed on your ID card.
Subject to the applicable prescription drug Copayment listed on your ID card.
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Preventive Care Services and Tests Coverage is provided for the following preventive care services and tests as defined by federal law: Routine physical and gynecological examinations Routine prenatal and postpartum care, including counseling about alcohol and tobacco use, services to promote breastfeeding, routine urinalysis and screenings for the following: asymptomatic bacteriuria; hepatitis B infection; HIV and screenings for STDs (chlamydia, gonorrhea and syphilis); iron deficiency anemia; and Rh (D) incompatibility.
Routine nursery charges for newborn, including prophylactic medication to prevent gonorrhea and screenings for the following: hearing loss; congenital hypothyroidism; phenylketonuria (PKU); and sickle cell disease.
Abdominal aortic aneurysm screening (for males 65-75 one time only, if ever smoked)
Alcohol misuse screening and counseling (primary care visits only)
Aspirin for the prevention of heart disease (primary care counseling only)
Autism screening (for children at 18 and 24 months of age, primary care visits only)
Behavioral assessments (children of all ages; developmental surveillance, in primary care settings)
Blood pressure screening (adults, without known hypertension)
Breast cancer chemoprevention (counseling only for women at high risk for breast cancer and low risk for adverse effects of chemoprevention)
Breast cancer screening, including mammograms and counseling for genetic susceptibility screening
Cervical cancer screening, including pap smears
Cholesterol screening (for adults only)
Colorectal cancer screening, including colonoscopy, sigmoidoscopy and fecal occult blood test
Dental caries prevention - oral fluoride (for children to age 5 only) (Note: Coverage for fluoride is only provided if your Plan includes outpatient pharmacy coverage.)
Depression screening (adults, children ages 12-18, primary care visits only)
Diabetes screenings
Diet behavioral counseling (included as part of annual visit and intensive counseling by primary care clinicians or by nutritionists and dieticians)
Dyslipidemia screening (for children at high risk for higher lipid levels)
Folic acid supplements (women planning or capable of pregnancy only) (Note: coverage for folic acid is only provided if your Plan includes outpatient pharmacy coverage.)
Hemoglobin A1c
Hepatitis B testing
HIV screening
Immunizations, including flu shots (for children and adults as appropriate)
Iron deficiency prevention (primary care counseling for children age 6 to 12 months only)
Lead screening (for children at risk)
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Preventive Care Services and Tests (Continued)
Microalbuminuria test
Obesity screening (adults and children screening only, in primary care settings)
Osteoporosis screening (screening to begin at age 60 for women at increased risk)
Ovarian cancer susceptibility screening
Sexually transmitted diseases (STDs) – screenings and counseling
Tobacco use counseling (primary care visits only)
Total cholesterol tests
Tuberculosis skin testing
Vision screening (children to age 5 only)
Under federal law the list of preventive care services covered under this benefit may change periodically based on the recommendations of the following agencies: a. Grade “A” and “B” recommendations of the United States Preventive Services Task Force; b. With respect to immunizations, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and c. With respect to services for woman, infants, children and adolescents, the Health Resources and Services Administration. Information on the recommendations of these agencies may be found on the web site of the US Department of Health and Human Services at: http://www.healthcare.gov/center/regulations/prevention/recommendations.html HPHC-NE will add or delete services from this benefit for preventive care in accordance with changes in the recommendations of the agencies listed above. You can find a list of the current recommendations for preventive care on HPHC-NE’s web site at www.harvardpilgrim.org.
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