HomeMy WebLinkAbout2016-26971 . ., •
Amendment to NationalONESM Plan
Grout Certificate
Keep this Amendment with your Group Certificate
Group Policyholder: City of Columbia Heights
Group Number: 90003
Effective Date: The later of January 1, 2016 and your effective date for coverage under the Group Policy.
Your Group Certificate is amended as follows:
1. In section "III. SERVICES NOT COVERED ", exclusion 13. is deleted and replaced by the following:
"13. Reversal of sterilization, assisted reproduction, including, but not limited to gamete intrafallopian tube transfer (GIFT),
zygote intrafallopian tube transfer (ZIFT), intracytoplasmic sperm injection (ICSI), and /or in -vitro fertilization (NF), and all
charges associated with such procedures; artificial insemination; diagnosis and treatment of infertility, including but not
limited to office visits, laboratory and diagnostic imaging services; surrogate pregnancy and related obstetric /maternity
benefits; and sperm, ova or embryo acquisition, retrieval or storage."
2. In section "III. SERVICES NOT COVERED ", exclusion 39. is deleted and replaced by the following:
"39. Commercial weight loss programs and exercise programs and all weight loss,!bariatric surgery."
3. In section "III. SERVICES NOT COVERED ", the following exclusions are added:
" #. Acupuncture.
#. All drugs used for the treatment of infertility."
AMD- 900.34
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JAA,44A�
Barbara E. Tretheway, Secretary
Empower NationalONEsm Plan
Benefits Chart
Group Policyholder: City of Columbia Heights
Group Number: 90003
Effective Date: The later of January 1, 2016 and your effective date of coverage under the Group Policy.
HealthPartners Insurance Company agrees to cover the services described below. The Benefits Chart
describes the level of payment that applies for each of the covered services. To be covered under this
section, the medical or dental services or items described below must be medically or dentally necessary.
Coverage for eligible services is subject to the exclusions, limitations, and other conditions of this Benefits
Chart and Group Certificate.
Covered services and supplies are based on established medical policies, which are subject to periodic
review and modification by the medical or dental directors. These medical policies (medical coverage
criteria) are available by calling Member Services, or logging on to your "myHealthPartners" account at
www.healthpartners.com.
The Network Benefits constitute a Qualified Plan. The Non - Network Benefits constitute a Non - qualified
plan. The Network Benefits are intended to constitute a high deductible health plan under Internal
Revenue Code section 223.
Benefits are underwritten by HealthPartners Insurance Company.
Coverage may vary depending on whether you select a network provider or a non - network provider.
The amount that we pay for covered services is listed below. You are responsible for the specified dollar
amount and /or percentage of charges that we do not pay.
When you use Non - Network providers, benefits are substantially reduced and you will likely incur
significantly higher out -of- pocket expenses. A Non - Network provider does not usually have an
agreement with HealthPartners to provide services at a discounted fee. In addition, Non - Network
Benefits are restricted to the usual and customary amount under the definition of "Charge." The usual
and customary amount can be significantly lower than a Non - Network provider's billed charges. If the
Non - Network provider's billed charges are over the usual and customary amount, you pay the difference,
in addition to any required deductible, copayment and /or coinsurance, and these charges do not apply to
the out -of- pocket limit. The only exceptions to this requirement are described below in the "Emergency
and Urgently Needed Care Services" section. This section describes what benefits are covered at the
Network Benefit level regardless of who provides the service.
These definitions apply to the Benefits Chart. They also apply to the Certificate.
Biosimilar Drug: A prescription drug, approved by the Food and Drug Administration (FDA), that the FDA
has determined is biosimilar to and interchangeable with a biological brand drug.
Biosimilar drugs are not considered generic drugs and are not covered under the generic
drug benefit.
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Brand Drug: A prescription drug, approved by the Food and Drug Administration (FDA), that is
manufactured, sold, or licensed for sale under a trademark by the pharmaceutical
company that originally researched and developed the drug. Brand drugs have the same
active - ingredient formula as the generic version of the drug. However, generic drugs are
manufactured and sold by other drug manufacturers and are generally not available until
after the patent on the brand drug has expired. A few brand drugs may be covered at the
generic drug benefit level if this is indicated on the formulary.
Charge: For covered services delivered by participating network providers, is the provider's
discounted charge for a given medical /surgical service, procedure or item.
For covered services delivered by non - network providers, is the provider's charge for a
given medical /surgical service procedure or item, according to the usual and customary
charge allowed amount.
The Usual and Customary Charge is the maximum amount allowed we consider in the
calculation of payment of charges incurred for certain covered services. It is consistent
with the charge of other providers of a given service or item in the same region. You
must pay for any charges above the usual and customary charge, and they do not apply to
the out -of- pocket limit.
A charge is incurred for covered ambulatory medical and surgical services, on the date
the service or item is provided. A charge is incurred for covered inpatient services, on
the date of admission to a hospital. To be covered, a charge must be incurred on or after
your effective date and on or before the termination date.
Combined Day Limit: Your total benefit is combined, for inpatient hospitalization, skilled nursing facility care
services and inpatient mental and chemical health services, and limited to 365 days per
period of confinement. Each day of such services provided under the Network Benefits
and Non- Network Benefits counts toward this combined day limit, for the same period of
confinement.
Copayment /Coinsurance: The specified dollar amount, or percentage, of charges incurred for covered services,
which we do not pay, but which you must pay, each time you receive certain medical
services, procedures or items. Our payment for those covered services or items begins
after the copayment or coinsurance is satisfied. Covered services or items requiring a
copayment or coinsurance are specified in this Certificate.
For services provided by a network provider:
An amount which is listed as a flat dollar copayment is applied to a network provider's
discounted charges for a given service. However, if the network provider's discounted
charge for a service or item is less than the flat dollar copayment, you will pay the
network provider's discounted charge. An amount which is listed as a percentage of
charges or coinsurance is based on the network provider's discounted charges, calculated
at the time the claim is processed, which may include an agreed upon fee schedule rate
for case rate or withhold arrangements.
For services provided by a non - network provider:
Any copayment or coinsurance is applied to the lesser of the provider's charges or
the usual and customary charge for a service.
A copayment or coinsurance is due at the time a service is provided, or when billed by
the provider. The copayment or coinsurance applicable for a scheduled visit with a
Network provider will be collected for each visit, late cancellation and failed
appointment.
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Deductible:
The specified dollar amount of charges incurred for covered services, which we do not
pay, but an enrollee or a family has to pay first in a calendar year. Our payment for
those services or items begins after the deductible is satisfied. For network providers,
the amount of the charges that apply to the deductible are based on the network
provider's discounted charges, calculated at the time the claim is processed, which may
include an agreed upon fee schedule rate for case rate or withhold arrangements. For
non - network providers, the amount of charges that apply to the deductible are the lesser
of the provider's charges or the usual and customary charge for a service. The Benefits
Chart indicates which covered services are not subject to the deductible.
Formulary:
This is a current list, which may be revised from time to time, of prescription drugs,
medications, equipment and supplies covered by us as indicated in the Benefits Chart
which are covered at the highest benefit level. Some drugs on the Formulary may require
prior authorization to be covered as formulary drugs. You may be granted an exception
to the formulary that is available to you upon request. These guidelines and procedures
include exceptions to the formulary for anti - psychotic prescription drugs prescribed to
treat emotional disturbances or mental illness if your health care provider (1) indicates to
the dispensing pharmacist, orally or in writing, that the prescription must be dispensed as
indicated and (2) certifies in writing to us that the prescribed drug will best treat your
condition. Also, you may continue to receive certain non - formulary prescription drugs
for diagnosed mental illness or emotional disturbance when our formulary changes or you
change health plans for up to one year following the change. The formulary, and
information on drugs that require prior authorization, are available by calling Member
Services, or logging on to your "myHealthPartners" account at www.healthpartners.com.
Generic Drug:
A prescription drug approved by the Food and Drug Administration (FDA) that the FDA
has determined is comparable to a brand drug product in dosage form, strength, route of
administration, quality, intended use and documented bioequivalence. Generally, generic
drugs cost less than brand drugs. Some brand drugs may be covered at the generic drug
benefit level if this is indicated on the formulary.
Lifetime Maximum Benefit:
The specified coverage limit paid for all charges combined and actually paid by us for
you under that coverage. Our payment ceases for you, when that limit is reached. You
have to pay for subsequent charges.
Out -of- Pocket Expenses:
You pay the specified copayments /coinsurance and deductibles applicable for particular
services, subject to the out -of- pocket limit described below. These amounts are in
addition to the monthly premium payments.
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Out -of- Pocket Limit: You pay the copayments /coinsurance and deductibles for covered services, to the
individual or family out -of- pocket limit. Thereafter we cover 100% of charges incurred
for all other covered services, for the rest of the calendar year. You pay amounts greater
than the out -of- pocket limit if any benefit maximums or the lifetime maximum are
exceeded.
Non - Network Benefits above the usual and customary charge (see definition of charge
above) do not apply to the out -of- pocket limit.
Non - Network Benefits for transplant surgery do not apply to the out -of- pocket limit.
You are responsible to keep track of the out -of- pocket expenses. Contact our Member
Services Department for assistance in determining the amount paid by the enrollee for
specific eligible services received. Claims for reimbursement under the out -of- pocket
limit provisions are subject to the same time limits and provisions described under the
"Claims Provisions" section of the Certificate.
Specialty Drug List: This is a current list, which may be revised from time to time, of prescription drugs,
medications, equipment and supplies, which are typically bio- pharmaceuticals. The
purpose of a specialty drug list is to facilitate enhanced monitoring of complex therapies
used to treat specific conditions. Specialty drugs are covered by us as indicated below.
The specialty drug list is available by calling Member Services, or logging on to your
"myHealthPartners" account at www.healthpartners.com.
Virtuwell: Virtuwell is an online service that you may use to receive a diagnosis and treatment for
certain routine conditions, such as a cold and flu, ear pain and sinus infections. You may
access the virtuwell website at www.virtuwell.com.
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Individual Calendar Year Deductible (applies to an employee enrolled for single coverage)
Network Benefits Non - Network Benefits
$1,500 $1,500
Family Calendar Year Deductible (applies to an employee and dependents enrolled for family coverage)
Network Benefits Non- Network Benefits
$3,000 $3,000
Deductibles under the Network Benefits and the Non - Network Benefits are combined.
Individual Calendar Year Out -of- Pocket Limit (applies to an employee enrolled for single coverage)
Network Benefits Non - Network Benefits
$1,500 $3,000
Family Calendar Year Out -of- Packet Limit (applies to an employee and dependents enrolled for family coverage)
Network Benefits Non - Network Benefits
$3,000 $6,000
The Out -of- Pocket Limits undcr the Network Benefits and the Non - Network Benefits are combined.
Any reduction in benefits for failure to comply with CareChece requirements will not apply toward the Out -of-
Pocket Limit.
Non- NetworkBenefts above the usual and customary charge will not apply toward the individual orfamily out -
of-pocket limit.
Lifetime Maximum Benefit for Transplant Surgery
Network Benefits Non - Network Benefits
Unlimited. $25,000
Lifetime Maximum Benefit
Network Benefits Non- Network Benefits
Unlimited. $2,000,000
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Notice: Some benefits listed in this Benefits Chart require precertification. See section I.K. "CareChecke"
of your Certificate for details.
A. AMBULANCE AND MEDICAL TRANSPORTATION
Covered Services:
We cover ambulance and medical transportation for medical emergencies and as shown below.
For Network Benefits. Transfers between network hospitals for treatment by network physicians are covered, if initiated by a
network physician. Transfers from a hospital or to home or to other facilities are covered, if medical supervision is required en
route.
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefits.
Not Covered:
+ See Services Not Covered in the Group Certificate Section III.
B. AUTISM BENEFIT
Covered Services:
We cover Applied Behavioral Therapy (ABA), Intensive Early Intervention Behavioral Therapy (IEIBT), and Lovaas for children
under age 18. For other autism services covered under this Certificate, see the habilitative benefit under Physical Therapy,
Occupational Therapy and Speech Therapy.
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
or dental directors. These medical policies (medical coverage criteria) are available on -line at www.healthpartners.com or by
calling Member Services.
Network Benefits Non- Network Benefits
100% of the charges incurred. No Coverage.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
C. BEHAVIORAL HEALTH SERVICES
Covered Services:
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
directors. These medical policies (medical coverage criteria) are available by calling Member Services, or logging on to your
"niyHealthPartners" account at www.healthpartners.com.
Mental Health Services
We cover services for mental health diagnoses as described in the Diagnostic and Statistical Manual of Mental Disorders — Fifth
Edition (DSMV) (most recent edition).
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We also provide coverage for mental health treatment ordered by a Minnesota court under a valid court order that is issued on the
basis of a behavioral care evaluation performed by a licensed psychiatrist or doctoral level licensed psychologist, which includes a
diagnosis and an individual treatment plan for care in the most appropriate, least restrictive environment. We must be given a
copy of the court order and the behavioral care evaluation, and the service must be a covered benefit under this plan, and the
service must be provided by a network provider, or other provider as required by law. We cover the evaluation upon which the
court order was based if it was provided by a network provider. We also provide coverage for the initial mental health evaluation
of a child, regardless of whether that evaluation leads to a court order for treatment, if the evaluation is ordered by a Minnesota
juvenile court.
a. Outpatient Services including intensive outpatient and day treatment services: We cover medically necessary outpatient
professional mental health services for evaluation, crisis intervention, and treatment of mental health disorders.
A comprehensive diagnostic assessment will be made of each patient as the basis for a determination by a mental
health professional, concerning the appropriate treatment and the extent of services required.
Outpatient services we cover for a diagnosed mental health condition include the following:
(1) Individual, group, family, and multi- family therapy;
(2) Medication management provided by a physician, certified nurse practitioner, or physician's assistant;
(3) Psychological testing services for the purposes of determining the differential diagnoses and treatment planning for
patients currently receiving behavioral health services;
(4) Day treatment and intensive outpatient services in a licensed program;
(5) Partial hospitalization services in a licensed hospital or community mental health center; and
(6) Psychotherapy and nursing services provided in the home if authorized by us.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Group Therapy
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
b. Inpatient Services, including psychiatric residential treatment for emotionally disabled children: We cover medically
necessary inpatient services in a hospital and professional services for treatment of mental health disorders. Medical
stabilization is covered under inpatient hospital services in the "Hospital and Skilled Nursing Facility Services" section.
We cover residential care for the treatment of eating disorders in a licensed facility, as an alternative to inpatient care, when it
is medically necessary and your physician obtains authorization from us.
We also cover medically necessary psychiatric residential treatment for emotionally disabled children as diagnosed by a
physician. This care must be authorized by us and provided by a hospital or residential treatment center licensed by the local
state or Health and Human Services Department. The child must be under 18 years of age and an eligible dependent
according to the terms of this Certificate. Services not covered under this benefit include shelter services, correctional
services, detention services, transitional services, group residential services, foster care services and wilderness programs.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
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Chemical Health Services
We cover medically necessary services for assessments by a licensed alcohol and drug counselor and treatment of Substance -
Related Disorders as defined in the latest edition of the DSM V.
a. Outpatient Services including intensive outpatient and day treatment services: We cover medically necessary
outpatient professional services for the diagnosis and treatment of chemical dependency. Chemical dependency treatment
services must be provided by a program licensed by the local Health and Human Services Department.
Outpatient services we cover for a diagnosed chemical dependency condition include the following:
(1) Individual, group, family, and multi- family therapy provided in an office setting;
(2) We cover opiate replacement therapy including methadone and buprenorphine treatment; and
(3) Day treatment and intensive outpatient services in a licensed program.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Network Benefits
Non - Network Benefits
We cover supervised lodging at a contracted We cover supervised lodging at a contracted
organization for insureds actively involved in an organization for insureds actively involved in an
affiliated licensed chemical dependency day treatment affiliated licensed chemical dependency day
or intensive outpatient program for treatment of treatment or intensive outpatient program for
alcohol or drug abuse. treatment of alcohol or drug abuse.
b. Inpatient Services: We cover medically necessary inpatient services in a hospital or primary residential treatment in a
licensed chemical health treatment center. Primary residential treatment is an intensive residential treatment program of
limited duration, typically 30 days or less.
We cover services provided in a hospital that is licensed by the local state and accredited by Medicare.
Detoxification Services. We cover detoxification services in a hospital or community detoxification facility if it is licensed
by the local Health and Human Services Department.
Covered services are based on established medical policies, which are subject to periodic review and modification by the
medical directors. These medical policies (medical coverage criteria) are available by calling Member Services, or logging
on to your " rnyHealthPartners" account at www.healthpartners.com.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Not Covered:
• Rest and respite services and custodial care, except as respite services are specifically described in this Benefits Chart under
the section "Home Hospice Services ". This includes all services, medical equipment and drugs provided for such care.
• Halfway houses, extended care facilities, or comparable facilities, residential treatment.
• Foster care, adult foster care and any type of family child care provided or arranged by the local state or county.
• Religious counseling; marital/relationship counseling and sex therapy.
• Professional services associated with substance abuse interventions. A "substance abuse intervention" is a gathering of
family and/or friends to encourage a person covered under this certificate to seek substance abuse treatment.
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1:
• Court ordered treatment, except as described in this Benefits Chart section C. subsection "Mental Health Services" and
section Q. "Office Visits for Illness or Injury" or as otherwise required by law.
• Vagus nerve stimulator treatment for the treatment of depression.
• Quantitative Electroencephalogram treatment for the treatment of behavioral health conditions.
• See Services Not Covered in the Group Certificate Section III.
D. CHIROPRACTIC SERVICES
Covered Services:
We cover chiropractic services for rehabilitative care. Chiropractic services are adjustments to any abnormal articulations of the
human body, especially those of the spinal column, for the purpose of giving freedom of action to impinged nerves that may cause
pain or deranged function.
Massage therapy which is performed in conjunction with other treatment/modalities by a chiropractor, is part of a prescribed
treatment plan and is not billed separately is covered.
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Limit of 20 visits per calendar year.
Not Covered:
• Massage therapy for the purpose of comfort or convenience of the insured.
• See Services Not Covered in the Group Certificate Section III.
E. CLINICAL TRIALS
Covered Services:
We cover certain routine services if you participate in a Phase I, Phase II, Phase III or Phase IV clinical trial that is conducted in
relation to the prevention, detection, or treatment of cancer or other life- threatening disease or condition as defined in the
Affordable Care Act. We cover routine patient costs for services that would be eligible under this Certificate if the service were
provided outside of a clinical trial.
Network Benefits
Coverage level is same as corresponding Network
Benefit, depending on type of service provided such as
Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
Not Covered:
Non - Network Benefits
Coverage level is same as corresponding Non - Network
Benefit, depending on type of service provided such as
Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
• The investigative item, device or service itself.
• Items or services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct
clinical management of the patient.
• A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.
• See Services Not Covered in the Group Certificate Section III.
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F. DENTAL SERVICES
Covered Services:
We cover services described below.
Accidental Dental Services: We cover dentally necessary services to treat and restore damage done to sound, natural, unrestored
teeth as a result of an accidental injury. Coverage is for damage caused by external trauma to face and mouth only, not for
cracked or broken teeth which result from biting or chewing. We cover restorations, root canals, crowns and replacement of teeth
lost that are directly related to the accident in which the insured was involved. We cover initial exams, x -rays, and palliative
treatment including extractions, and other oral surgical procedures directly related to the accident. Subsequent treatment must be
initiated within the Certificate's time -frame and must be directly related to the accident. We do not cover restoration and
replacement of teeth that are not "sound and natural" at the time of the accident.
Full mouth rehabilitation to correct occlusion (bite) and malocclusion (misaligned teeth not due to the accident) are not covered.
When an implant- supported dental prosthetic treatment is pursued, the accidental dental benefit will be applied to the prosthetic
procedure. Benefits are limited to the amount that would be paid toward the placement of a removable dental prosthetic appliance
that could be used in the absence of implant treatment. Care must be provided or pre - authorized by a HealthPartners dentist.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
For all accidental dental services, treatment andfor restoration must be initiated within six months of the date of
the injury. Coverage is limited to the initial course of treatment and1br initial restoration. Services must be
provided within twenty four months of the date of injury to be covered.
Medical Referral Dental Services
a. Medically Necessary Outpatient Dental Services: We cover medically necessary outpatient dental services. Coverage is
limited to dental services required for treatment of an underlying medical condition, e.g., removal of teeth to complete
radiation treatment for cancer of the jaw, cysts and lesions.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
b. Medically Necessary Hospitalization and Anesthesia for Dental Care: We cover medically necessary hospitalization
and anesthesia for dental care. This is limited to charges incurred by an insured who: (1) is a child under age 5; (2) is
severely disabled; (3) has a medical condition, and requires hospitalization or general anesthesia for dental care treatment;
or (4) is a child between age 5 and 12 and care in dental offices has been attempted unsuccessfully and usual methods of
behavior modification have not been successful, or when extensive amounts of restorative care, exceeding 4 appointments,
are required. The requirement of a hospital setting must be due to an insured's underlying medical condition. Coverage is
limited to facility and anesthesia charges. Anesthesia is covered in a hospital or a dental office. Oral surgeon/dentist
professional fees are not covered. The following are examples, though not all- inclusive, of medical conditions which may
require hospitalization for dental services: severe asthma, severe airway obstruction or hemophilia. Hospitalization
required due to the behavior of the insured or due to the extent of the dental procedure is not covered.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
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c. Medical Complications of Dental Care: We cover medical complications of dental care. Treatment must be medically
necessary care and related to medical complications of non- covered dental care, including complications of the head, neck,
or substructures.
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Oral Surgery: We cover oral surgery. Coverage is limited to treatment of medical conditions requiring oral surgery, such as
treatment of oral neoplasm, non - dental cysts, fracture of the jaws, trauma of the mouth and jaws, and any other oral surgery
procedures provided as medically necessary dental services.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Orthognathie Surgery Benefit: We cover orthognathic surgery= for the treatment of severe skeletal dysmorphia where a
functional occlusion cannot be achieved through non - surgical treatment alone and where a demonstrable functional impairment
exists. Functional impairments include but are not limited to significant impairment in chewing, breathing or swallowing.
Associated dental or orthodontic services (pre- or postoperatively including surgical rapid palatal expansion) are not covered as
part of this benefit.
Network Benefits Non- Network Benefits
1.00% of the charges incurred. 75% of the charges incurred.
Treatment of Cleft Lip and Cleft Palate of a Dependent Child: We cover treatment of cleft lip and cleft palate of a
dependent child, to the limiting age in the definition of an "Eligible Dependent', including orthodontic treatment and oral
surgery directly related to the cleft. Benefits for individuals age 26 up to the limiting age for coverage of the dependent are
limited to inpatient or outpatient expenses arising from medical and dental treatment that was scheduled or initiated prior to the
dependent turning age 19. Dental services which are not required for the treatment of cleft lip or cleft palate are not covered. If
a dependent child covered under this Certificate is also covered under a dental plan which includes orthodontic services, that
dental plan shall be considered primary for the necessary orthodontic services. Oral appliances are subject to the same
copayment, conditions and limitations as durable medical equipment.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Treatment of Temporomandibular Disorder (TMD) and Craniomandibular Disorder (CMD): We cover surgical and non-
surgical treatment of temporomandibular disorder (TMD) and cramomandibular disorder (CMD), which is medically necessary
care. Dental services which are not required to directly treat TMD or CMD are not covered.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Not Covered:
• Dental treatment, procedures or services not listed in this Benefits Chart.
• Accident related dental services if treatment is (1) provided to teeth which are not sound and natural, (2) to teeth which have
been restored, (3) initiated beyond six months from the date of the injury, (4) received beyond the initial treatment or
restoration or (5) received beyond twenty -four months from the date of injury.
• Oral surgery to remove wisdom teeth.
• See Services Not Covered in the Group Certificate Section III.
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G. DIAGNOSTIC IMAGING SERVICES
Covered Services:
We cover diagnostic imaging, when ordered by a provider and provided in a clinic or outpatient hospital facility
For Network Benefits, non - emergent, scheduled outpatient Magnetic Resonance Imaging (MRI) and computing Tomography
(CT) must be provided at a designated facility. Your physician or facility will obtain or verify prior authorization for these
services, as needed.
We cover services provided in a clinic or outpatient hospital facility (to see the benefit level for inpatient hospital or skilled
nursing facility services, see benefits under Inpatient Hospital and Skilled Nursing Facility Services).
(a) Outpatient Magnetic Resonance Imaging (MRI) and Computing Tomography (CT)
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
(b) All other outpatient diagnostic imaging services
Services for illness or injury
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Preventive services (MRI /CT procedures are not considered preventive)
Diagnostic imaging for preventive services is covered at the benefit level shown in the Preventive Services
section.
Not Covered:
• See Services Not Covered in the Group Certificate Section 1II.
H. DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES
Covered Services:
We cover equipment and services, as described below.
We cover durable medical equipment and services, prosthetics, orthotics, and supplies, subject to the limitations below, including
certain disposable supplies, enteral feedings and the following diabetic supplies and equipment: glucose monitors, insulin pumps,
syringes, blood and urine test strips and other diabetic supplies as deemed medically appropriate and necessary, for insureds with
gestational, Type I or Type II diabetes.
We cover special dietary treatment of Phenylketonuria (PKU) and oral amino acid based elemental formula if it meets our
medical coverage criteria.
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►101 �1�1 N ! I
External hearing aids (including osseointegrated or bone anchored) for insureds age 18 or younger who have hearing loss that is
not correctable by other covered procedures. Coverage is limited to one hearing aid for each ear every three years.
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Wigs for hair loss resulting from alopecia areata are limited to one per calendar year. No more than a 90 -day
supply of diabetic supplies are covered and dispensed at a time.
Special dietary treatment for Phenylketonuria (PKU) if it is recommended by a physician
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Oral amino acid based elemental formula if it meets our medical coverage criteria
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Limitations:
Coverage of durable medical equipment is limited by the following.
• Payment will not exceed the cost of an alternate piece of equipment or service that is effective and medically necessary.
• For prosthetic benefits, other than hair prostheses (i.e., wigs) for hair loss resulting from alopecia areata and oral appliances
for cleft lip and cleft palate, payment will not exceed the cost of an alternate piece of equipment or service that is effective,
medically necessary and enables insureds to conduct standard activities of daily living.
• We reserve the right to determine if an item will be approved for rental vs. purchase.
• Diabetic supplies and equipment are limited to certain models and brands.
• Durable medical equipment and supplies must be obtained from or repaired by approved vendors.
• Covered services and supplies are based on established medical policies which are subject to periodic review and
modification by the medical or dental directors. Our coverage policy for diabetic supplies includes information on our
required models and brands. These medical policies (medical coverage criteria) are available by calling Member Services, or
logging on to your "myHealthPartners" account at www.healthpartners.com.
Not Covered:
Items which are not eligible for coverage include, but are not limited to:
• Replacement or repair of any covered items, if the items are (i) damaged or destroyed by misuse, abuse or carelessness, (ii)
lost; or (iii) stolen.
• Duplicate or similar items.
• Labor and related charges for repair of any covered items which are more than the cost of replacement by an approved
vendor.
• Sales tax, mailing, delivery charges, service call charges.
• Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation.
BCH- 900.34
(NI- HDHPI500- 90003 -16) 13
• Communication aids or devices: equipment to create, replace or augment communication abilities including, but not limited
to, hearing aids (implantable and external, including osseointegrated or bone anchored) and fitting of hearing aids except as
required by law, speech processors, receivers, communication boards, or computer or electronic assisted communication,
except as specifically described in this Certificate. This exclusion does not apply to cochlear implants, which are covered as
described in the medical coverage criteria. Medical coverage criteria are available by calling Member Services, or logging on
to your "rnyHealthPartners" account at www.healthpartners.com.
• Household equipment which primarily has customary uses other than medical, such as, but not limited to, exercise cycles, air
purifiers, central or unit air conditioners, water purifiers, non - allergenic pillows, mattresses or waterbeds.
• Household fixtures including, but not limited to, escalators or elevators, ramps, swimming pools and saunas.
• Modifications to the structure of the home including, but not limited to, its wiring, plumbing or charges for installation of
equipment.
• Vehicle, car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier.
• Rental equipment while owned equipment is being repaired by non - contracted vendors, beyond one month rental of
medically necessary equipment.
• Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage.
• See Services Not Covered in the Group Certificate Section III.
I. EMERGENCY AND URGENTLY NEEDED CARE SERVICES
Covered Services:
We cover services for emergency care and urgently needed care if the services are otherwise eligible for coverage under this
Certificate.
Urgently needed care. These are services to treat an unforeseen illness or injury, which are required in order to prevent a serious
deterioration in your health, and which cannot be delayed until the next available clinic or office hours.
Urgently Needed care at clinics
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Emergency Care. These are services to treat: (1) the sudden, unexpected onset of illness or injury which, if left untreated or
unattended until the next available clinic or office hours, would result in hospitalization, or (2) a condition requiring professional
health services immediately necessary to preserve life or stabilize health. Emergency care also includes an immediate response
service available on a 24 -hour, seven- day -a -week basis for each child, or person, having a psychiatric crisis, a mental health
crisis, or a mental health emergency.
When reviewing claims for coverage of emergency services, our medical director will take into consideration a reasonable
layperson's belief that the circumstances required immediate medical care that could not wait until the next working day or next
available clinic appointment.
Emergency care in a hospital emergency room, including professional services of a physician
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefits.
Inpatient emergency care in a hospital
Network Benefits Non- Network Benefits
100% of the charges incurred. See Network Benefits.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
BCH- 900.34
(NI- HDHP1500- 90003 -16) 14
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
J. HEALTH EDUCATION
Covered Services:
We cover education for preventive services and education for the management of chronic health problems (such as diabetes).
Coverage includes medical nutrition therapy, that is provided by a certified, registered, or licensed health care professional
working in a program consistent with the national standards of diabetes self - management education as established by the
American Diabetes Association.
Provider office visit /session in connection with preventive services
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Deductible does not apply.
Provider office visit /session in connection with the management of a chronic health problem (such as diabetes)
Network Benefits Non - Network Benefits
100% of the charges incurred. 75 % of the charges incurred.
Deductible does not apply.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
K. HOME HEALTH SERVICES
Covered Services:
We cover skilled nursing services, physical therapy, occupational therapy, speech therapy, respiratory therapy and other therapeutic
services, non - routine prenatal and postnatal services, routine postnatal well child visits as described in the Coverage Criteria,
phototherapy services for newborns, home health aide services and other eligible home health services when provided in your home,
if you are homebound (i.e., unable to leave home without considerable effort due to a medical condition). Lack of transportation
does not constitute homebound status. For phototherapy services for newborns and high risk prenatal services, supplies and
equipment are included.
We cover total parenteral nutrition /intravenous ( "TPN /IV ") therapy, equipment, supplies and drugs in connection with IV
therapy. IV line care kits are covered under Durable Medical Equipment.
You do not need to be homebound to receive total parenteral nutrition/intravenous ( "TPN/IV ") therapy.
We cover palliative care benefits. Palliative care includes symptom management, education and establishing goals of care.
We waive the requirement that you be homebound for a limited number of home visits for palliative care (as shown in the
Benefits Chart), if you have a life- threatening, non - curable condition which has a prognosis of survival of two years or less.
Additional palliative care visits are eligible under the home health services benefit if you are homebound and meet all other
requirements defined in this section.
Home health services are eligible and covered only when they are:
1. medically necessary; and
2. provided as rehabilitative care, terminal care or maternity care; and
3. ordered by a physician, and included in the written home care plan.
BCH- 900.34
(N1- HDHP1500- 90003 -16) 15
l:
Limitations:
Home health services are not provided as a substitute for a primary caregiver in the home or as relief (respite) for a primary
caregiver in the home. We will not reimburse family members or residents in your home for the above services.
A service shall not be considered a skilled nursing service merely because it is performed by, or under the direct supervision of, a
licensed nurse. Where a service (such as tracheotomy suctioning or ventilator monitoring) or like services, can be safely and
effectively performed by a non - medical person (or self - administered), without the direct supervision of a licensed nurse, the
service shall not be regarded as a skilled nursing service, whether or not a skilled nurse actually provides the service. The
unavailability of a competent person to provide a non - skilled service shall not make it a skilled service when a skilled nurse
provides it. Only the skilled nursing component of so- called "blended" services (i.e. services which include skilled and non -
skilled components) are covered under this Certificate.
Physical therapy, occupational therapy, speech therapy, respiratory therapy, home health aide services and palliative care
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
TPN /IV therapy, skilled nursing services, non - routine prenatal/postnatal services, and phototherapy
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Each 24 -hour visit (or shifts of up to 24 -hour visits) equals one visit and counts toward the Maximum visits for
all other services shown below. Any visit that lasts less than 24 hours, regardless of the length of the visit, will
count as one visit toward the Maximum visits for all other services shown below. All visits must be medically
necessary and benefit eligible.
Routine postnatal well child visit
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Deductible does not apply.
Maximum visits for palliative care
If you are eligible to receive palliative care in the home and you are not homebound, there is a maximum of 8
visits per calendar year.
Maximum visits for all other services
Network Benefits I Non- Network Benefits
120 visits per calendar year. 60 visits per calendar year.
Each visitprovided under the Network Benefits and Non - Network Benefits counts toward the maximums shown
under both Maximum visits sections. The routine postnatal well child visit does not count toward the visit limit.
BCH- 900.34
(NI- HDHPI500- 90003 -16) 16
BENEFITS CHART
Not Covered:
• Financial or legal counseling services.
• Housekeeping or meal services in your home.
• Private duty nursing services. This exclusion does not apply if covered person is also covered under Medical Assistance
under Minnesota chapter 25613.0625, subdivision 7, with the exception of section 25613.0654 subdivision 4.
• Services provided by a family member or enrollee, or a resident in the enrollee's home.
• Vocational rehabilitation and recreational or educational therapy. Recreation therapy is therapy provided solely for the
purpose of recreation, including but not limited to: (a) requests for physical therapy or occupational therapy to improve
athletic ability, and (b) braces or guards to prevent sports injuries.
• See Services Not Covered in the Group Certificate Section III.
L. HOME HOSPICE SERVICES
Applicable Definitions:
Part -time. This is up to two hours of service per day, more than two hours is considered continuous care.
Continuous Care. This is from two to twelve hours of service per day provided by a registered nurse, licensed practical nurse, or
home health aide, during a period of crisis in order to maintain a terminally ill patient at home.
Appropriate Facility. This is a nursing home, hospice residence, or other inpatient facility.
Custodial Care Related to Hospice Services. This means providing assistance in the activities of daily living and the care
needed by a terminally ill patient which can be provided by primary caregiver (i.e., family member or friend) who is responsible
for the patient's home care.
Covered Services:
Home Hospice Program. We cover the services described below if you are terminally ill and accepted as a home hospice
program participant. You must meet the eligibility requirements of the program, and elect to receive services through the home
hospice program. The services will be provided in your home, with inpatient care available when medically necessary as
described below. If you elect to receive hospice services, you do so in lieu of curative treatment for your terminal illness for the
period you are enrolled in the home hospice program.
a. Eligibility: In order to be eligible to be enrolled in the home hospice program, you must: (1) be a terminally ill patient
(prognosis of six months or less); (2) have chosen a palliative treatment focus (i.e., emphasizing comfort and supportive
services rather than treatment attempting to cure the disease or condition); and (3) continue to meet the terminally ill
prognosis as reviewed by our medical director or his or her designee over the course of care. You may withdraw from the
home hospice program at any time.
b. Eligible Services: Hospice services include the following services provided by Medicare - certified providers, if provided in
accordance with an approved hospice treatment plan.
(1) Home Health Services:
(a) Part-time care provided in your home by an interdisciplinary hospice team (which may include a physician,
nurse, social worker, and spiritual counselor) and medically necessary home health services are covered.
(b) One or more periods of continuous care in your home or in a setting which provides day care for pain or
symptom management, when medically necessary, will be covered.
(2) Inpatient Services: We cover medically necessary inpatient services.
BCH- 900.34
(N1- HDHP1500- 90003 -16) 17
(3) Other Services:
(a) Respite care is covered for care in your home or in an appropriate facility, to give your primary caregivers
(i.e., family members or friends) rest and/or relief when necessary in order to maintain a terminally ill patient
at home.
(b) Medically necessary medications for pain and symptom management.
(c) Semi - electric hospital beds and other durable medical equipment are covered.
(d) Emergency and non- emergency care is covered.
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Respite care is limited to 5 days per episode, and respite care and continuous care combined are limited to 30
days.
Not Covered:
• Financial or legal counseling services; or
• Housekeeping or meal services in your home; or
• Custodial or maintenance care related to hospice services, whether provided in the home or in a nursing home; or
• Any service not specifically described as covered services under this home hospice services benefits; or
• Any services provided by members of your family or residents in your home.
• See Services Not Covered in the Group Certificate Section III.
M. HOSPITAL AND SKILLED NURSING FACILITY SERVICES
Covered Services:
We cover services as described below.
Medical or Surgical Hospital Services
Inpatient Hospital Services: We cover the following medical or surgical services, for the treatment of acute illness or
injury, which require the level of care only provided in an acute care facility. These services must be authorized by a
physician.
Inpatient hospital services include: room and board; the use of operating or maternity delivery rooms; intensive care
facilities; newborn nursery facilities; general nursing care, anesthesia, laboratory and diagnostic imaging services,
reconstructive surgery, radiation therapy, physical therapy, prescription drugs or other medications administered during
treatment, blood and blood products (unless replaced), and blood derivatives, and other diagnostic or treatment related
hospital services; physician and other professional medical and surgical services provided while in the hospital.
We cover up to 120 hours of services provided by a private duty nurse or personal care assistant who has provided home care
services to a ventilator - dependent patient, solely for the purpose of assuring adequate training of the hospital staff to
communicate with that patient.
Services for items for personal convenience, such as television rental, are not covered.
We cover, following a vaginal delivery, a minimum of 48 hours of inpatient care for the mother and newborn child. We
cover, following a caesarean section delivery, a minimum of 96 hours of inpatient care for the mother and newborn child. If
the duration of inpatient care is less than these minimums, we also cover a minimum of one home visit by a registered nurse
for post - delivery care, within 4 days of discharge of the mother and newborn child. Services provided by the registered nurse
include, but are not limited to, parent education, assistance and training in breast and bottle feeding, and conducting any
necessary and appropriate clinical tests. We shall not provide any compensation or other non - medical remuneration to
encourage a mother and newborn to leave inpatient care before the duration minimums specified.
BCH- 900.34
(N1- HDHP1500- 90003 -16) 18
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length
of stay in connection with childbirth for the mother of newborn child to less than 48 hours following a vaginal delivery, or
less than 96 hours following a caesarean section. However, Federal law generally does not prohibit the mother's or
newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48
hours (or 96 hours as applicable). In any case plans and issuers may not, under Federal law, require that a provider obtain
authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Each insured's admission or confinement; including that of a newborn child, is separate and distinct from the
admission or confinement of arty other insured.
Outpatient Hospital, Ambulatory Care or Surgical Facility Services: We cover the following medical and surgical
services, for diagnosis or treatment of illness or injury on an outpatient basis. These services must be authorized by a
physician.
Outpatient services include: use of operating rooms, maternity delivery rooms or other outpatient departments, rooms or
facilities; and the following outpatient services: general nursing care, anesthesia, laboratory and diagnostic imaging services,
reconstructive surgery, radiation therapy, physical therapy, drugs administered during treatment, blood and blood products
(unless replaced), and blood derivatives, and other diagnostic or treatment related outpatient services; physician and other
professional medical and surgical services provided while an outpatient.
For Network Benefits, non - emergent, scheduled outpatient Magnetic Resonance Imaging (MRI) and computing Tomography
(CT) must be provided at a designated facility. Your physician or facility will obtain or verify prior authorization for these
services, as needed.
To see the benefit level for diagnostic imaging services, laboratory services and physical therapy, see the benefits under
Diagnostic Imaging Services, Laboratory Services and Physical Therapy in this Benefits Chart.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Skilled Nursing Facility Care: We cover room and board, daily skilled nursing and related ancillary services for post acute
treatment and rehabilitative care of illness or injury, following a hospital confinement.
Network Benefits
100% of the charges incurred.
Limited to 120 day maximum per period of
confinement, subject to the combined day limit.
Non - Network Benefits
75% of the charges incurred.
Limited to 120 day maximum per period of
confinement, subject to the combined day limit.
Each day of services provided under the Network and Non - Network Benefits, combined, counts toward the
maximums shown above.
BCH- 900.34
(N1- HDHP1500- 90003 -16) 19
BENEFITS CHART
Not Covered:
• Services for items for personal convenience, such as television rental, are not covered.
• See Services Not Covered in the Group Certificate Section III.
N. LABORATORY SERVICES
Covered Services:
We cover laboratory tests when ordered by a provider and provided in a clinic or outpatient hospital facility.
We cover services provided in a clinic or outpatient hospital facility (to see the benefit level for inpatient hospital or skilled
nursing facility services, see benefits under Inpatient Hospital and Skilled Nursing Facility Services).
Services for illness or injury
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Preventive services
Network Benefits Non- Network Benefits
Laboratory services associated with preventive services are covered at the benefit level shown in the
Preventive Services section.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
O. LYME DISEASE SERVICES
Covered Services:
We cover services for the treatment of Lyme disease.
Network Benefits
Non - Network Benefits
Coverage level is same as corresponding Network Coverage level is same as corresponding Non -
Benefit, depending on type of service provided such Network Benefit, depending on type of service
as Office Visits for Illness or Injury, Inpatient or provided such as Office Visits for Illness or Injury,
Outpatient Hospital Services. Inpatient or Outpatient Hospital Services.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(NI- HDHP1500- 90003 -16) 20
Wmw .'
P. MASTECTOMY RECONSTRUCTION BENEFIT
Covered Services:
We cover reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the other
breast to produce symmetrical appearance, and prostheses and physical complications of all stages of mastectomy, including
lymphedemas.
Network Benefits
Non - Network Benefits
Coverage level is same as corresponding Network Coverage level is same as corresponding Non - Network
Benefit, depending on type of service provided such Benefit, depending on type of service provided, such as
as Office Visits for Illness or Injury, Inpatient or Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services. Outpatient Hospital Services.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
Q. OFFICE VISITS FOR ILLNESS OR INJURY
Covered Services:
We cover the following when medically necessary: professional medical and surgical services and related supplies, including
biofeedback, of physicians and other health care providers; blood and blood products (unless replaced) and blood derivatives.
We cover diagnosis and treatment of illness or injury to the eyes. Where contact or eyeglass lenses are prescribed as medically
necessary for the post - operative treatment of cataracts or for the treatment of aphakia, or keratoconus, we cover the initial
evaluation, lenses and fitting. Insureds must pay for lens replacement beyond the initial pair.
We also provide coverage for the initial physical evaluation of a child if it is ordered by a Minnesota juvenile court.
Office visits
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Convenience clinics
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Scheduled telephone visits
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
E- visits
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
BCH- 900.34
(7V]- HDHP1500- 90003 -16) 21
C •
Injections administered in a physician's office, other than immunizations
Allergy injections
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
All other injections
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Not Covered:
• Court ordered treatment, except as described in this Benefits Chart section C., subsection "Mental Health Services" and
section Q. "Office Visits for Illness or Injury" or as otherwise required by law.
• See Services Not Covered in the Group Certificate Section III.
R. PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY
Covered Services:
We cover the following physical therapy, occupational therapy and speech therapy services:
1. Medically necessary rehabilitative care to correct the effects of illness or injury.
2. Habilitative care rendered for congenital, developmental or medical conditions which have significantly limited the
successful initiation of normal speech and normal motor development.
Massage therapy which is performed in conjunction with other treatmentimodalities by a physical or occupational therapist, is
part of a prescribed treatment plan and is not billed separately is covered.
We cover services provided in a clinic. We also cover physical therapy provided in an outpatient hospital facility. To see the
benefit level for inpatient hospital or skilled nursing facility services, see benefits under Inpatient Hospital and Skilled Nursing
Facility Services.
Rehabilitative Care
Network Benefits
100% of the charges incurred.
Habilitative Care
Non - Network Benefits
75% of the charges incurred.
Physical and Occupational Therapy combined are
limited to 20 visits per calendar year.
Speech Therapy is limited to 20 visits per calendar
year.
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Physical, Occupational and Speech Therapy
combined are limited to 20 visits per calendar year.
BCH- 900.34
(NI- HDHP1500- 90003 -16) 22
Not Covered:
• Massage therapy for the purpose of comfort or convenience of the insured.
• See Services Not Covered in the Group Certificate Section III.
S. PORT WINE STAIN REMOVAL SERVICES
Covered Services:
We cover port wine stain removal services.
Network Benefits
Coverage level is same as corresponding Network
Benefit, depending on type of service provided such
as Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
Not Covered:
Non - Network Benefits
Coverage level is same as corresponding Non -
Network Benefit, depending on type of service
provided such as Office Visits for Illness or Injury,
Inpatient or Outpatient Hospital Services.
• See Services Not Covered in the Group Certificate Section III.
T. PRESCRIPTION DRUG SERVICES
Covered Services:
We cover prescription drugs and medications, which can be self - administered or are administered in a physician's office. We
cover off -label use of formulary drugs to treat cancer if the drug is recognized for the treatment of cancer in one of the standard
reference compendia or in one article in the medical literature as defined by Minnesota Statute 62Q.525.
For Network benefits, drugs and medications must be obtained at a Network Pharmacy.
Outpatient drugs (other than tobacco cessation, contraceptive, specialty and growth deficiency drugs)
Network Benefits
100% of the charges incurred.
Drugs for the treatment of sexual dysfunction are
limited to six doses per month.
Non - Network Benefits
60% of the charges incurred.
Drugs for the treatment ofsexual dysfunction are
limited to six doses per month.
Tobacco cessation drugs are covered for all FDA - approved tobacco cessation drugs (including over - the - counter drugs) for
a minimum of 90 days.
Network Benefits
Formulary Drugs:
100% of the charges incurred.
Deductible does not apply.
Non - Network Benefits
60% of the charges incurred.
BCH- 900.34
(N1- HDHP1500- 90003 -16) 23
Mail Order Drugs
Network Benefits
Non - Network Benefits
You may also get outpatient prescription drugs which See Network Mail Order Drugs Benefit.
can be self - administered through HealthPartners mail
order service. Outpatient drugs ordered through this
service are covered at the benefit percent shown in
Outpatient Drugs above.
New prescriptions to treat certain chronic conditions
and trial drugs will be limited to quantity limits
described at the end of this section.
Drugs for the treatment of sexual dysfunction are
limited to 18 doses per 90 —day supply.
Specialty Drugs are not available through the mail
order service.
Specialty Drugs which are self - administered
Network Benefits Non - Network Benefits
See Network Outpatient drugs benefit. See Non - Network Outpatient Drugs benefit.
For Network Benefits, Specialty Drugs are limited to drugs on the specialty drug list and must be obtained from a
designated vendor.
Drugs for the treatment of growth deficiency
Network Benefits Non - Network Benefits
80% of the charges incurred. 75% of the charges incurred.
For Network Benefits, Growth Deficiency Drugs are limited to drugs on the specialty drug list and must be
obtained from a designated vendor.
Contraceptive drugs
Network Benefits
100% of the charges incurred for formulary drugs
Deductible does not apply.
If a physician requests that a non - formulary
contraceptive drug be dispensed as written, the drug
will be covered at 100 %, not subject to the
deductible.
Non - Network Benefits
60% of the charges incurred.
BCH- 900.34
(.VI- HDHPI500- 90003 -16) 24
Unless otherwise specified in the Prescription Drug Services section, you may receive up to a 30 -day supply per
prescription. Certain drugs may require prior authorization as indicated on the formulary. HealthPartners may
require prior authorization for the drug and also the site where the drug will be provided. Certain drugs are
subject to our utilization review process and quantity limits as indicated on our formulary. New prescriptions are
limited to a 30 -day supply. Certain non - formulary drugs require prior authorization. In addition, certain drugs
may be subject to may quantity limits applied as part of our trial program. A 90 -day supply will be covered and
dispensed only atpharrnacies that participate in our extended day supplyprograrn. No more than a 30 -day supply
of Specialty Drugs will be covered and dispensed at a time.
If an insured requests a brand drug when there is a generic equivalent, the brand drug will be covered up to the
charge that would apply to the generic drug, minus any required copayment. If a physician requests that a brand
drug be dispensed as written, and we determine the brand drug is medically necessary, the drug will be paid at the
brand drug benefit.
Not Covered:
Replacement of prescription drugs, medications, equipment and supplies due to loss, damage or theft.
Nonprescription (over the counter) drugs or medications, unless listed on the formulary and prescribed by a physician or
legally authorized health care provider under applicable state law, including, but not limited to, vitamins, supplements,
homeopathic remedies, and non -FDA approved drugs. We cover off -label use of drugs to treat cancer as specified in the
"Prescription Ding Services" section of this Benefits Chart. This exclusion does not include over - the - counter contraceptives
for women as allowed under the Affordable Care Act when the insured obtains a prescription for the item. In addition, if the
insured obtains a prescription, this exclusion does not include aspirin to prevent cardiovascular disease for men and women
of certain ages; folic acid supplements for women who may become pregnant; fluoride chemoprevention supplements for
children without fluoride in their water source; and iron supplements for children ages 6 -12 who are at risk for anemia.
All drugs for the treatment of infertility.
Medical cannabis.
• See Services Not Covered in the Group Certificate Section III.
U. PREVENTIVE SERVICES
Covered Services:
We cover preventive services which meet any of the requirements under the Affordable Care Act (ACA) shown in the bulleted
items below. These preventive services are covered at 1001%" under the network benefits with no deductible, copayments or
coinsurance. (If a preventive service is not required by the ACA and it is covered at a lower benefit level, it will be specified
below). Preventive benefits mandated under the ACA are subject to periodic review and modification. Changes would be
effective in accordance with the federal rules. Preventive services mandated by the ACA include:
• Evidence -based items or services that have in effect a rating of A or B in the current recommendations of the United
States Preventive Services Task Force with respect to the individual;
• Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the
Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the
individual;
• With respect to infants, children, and adolescents, evidence - informed preventive care and screenings provided for in
comprehensive guidelines supported by the Health Resources and Services Administration; and
• With respect to women, preventive care and screenings provided for in comprehensive guidelines supported by the
Health Resources and Services Administration.
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
or dental directors. These medical policies (medical coverage criteria) are available by calling Member Services, or logging on to
your "myHealthPartners" account at www.healthpartners.com.
In addition to any ACA mandated preventive services referenced above, we cover the following eligible preventive services.
BCH- 900.34
(NI- HDHP1500- 90003 -16) 25
RM 01 TI KY:I�
Benefits are limited to $300 per calendar year for the following items: 1., 5., 6., 7., 9. and 10. combined
under the Non - Network Benefits.
1. Routine health exams and periodic health assessments. A physician or health care provider will counsel you as to
how often health assessments are needed based on age, sex and health status. This includes screening for tobacco use,
at least two tobacco cessation attempts per year (for those who use tobacco products), all FDA approved tobacco
cessation medications including over - the - counter drugs (as shown in the prescription drugs section) and at least four
counseling sessions of at least ten minutes each for tobacco cessation.
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Deductible does not apply.
2. Child health supervision services, including pediatric preventive services, routine immunizations, developmental
assessments and laboratory services appropriate to the age of the child from birth to 72 months, and appropriate
immunizations to age 18.
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefit.
Deductible does not apply.
3. Routine prenatal care and exams to include visit- specific screening tests, education and counseling.
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefit.
Deductible does not apply.
4. Routine postnatal care and exams to include health exams, assessments, education and counseling relating to the period
immediately after childbirth.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Deductible does not apply.
5. Routine screening procedures for cancer, including colorectal screening, pap smears, ovarian cancer screening and prostate
screening. Women's preventive health services below describe additional routine screening procedures for cancer.
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Deductible does not apply.
BCH- 900.34
(NI - HDHP1500- 90003 -16) 26
Ia Mel 01aIIMEN I M!141
6. Routine eye and hearing exams
Network Benefits Non- Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Deductible does not apply.
7. Professional voluntary family planning services
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Deductible does not apply.
8. Adult immunizations
Network Benefits Non - Network Benefits
100° o of the charges incurred. 75% of the charges incurred.
Deductible does not apply.
9. Women's preventive health services including mammograms; screenings for cervical cancer; breast pumps; human
papillomavirus (HPV) testing; counseling for sexually transmitted infections; and counseling and screening for human
immunodeficiency virus (HIV); and all FDA approved contraceptive methods as prescribed by a doctor; sterilization
procedures, education and counseling (see prescription drug services section for coverage of contraceptive drugs).
For women whose family history is associated with an increased risk for BRCA1 or BRCA2 gene mutations, we cover
genetic counseling and BRCA screening without cost sharing, if appropriate and as determined by a physician.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Deductible does not apply.
10. Obesity screening and management. We cover obesity screening and counseling for all ages during a routine
preventive care exam. If you are an adult age 18 or older and have a body mass index of 30 or more, we also cover
intensive obesity management to help you lose weight. Your primary care doctor can coordinate these services.
Network Benefits Non - Network Benefits
100% of the charges incurred. 75% of the charges incurred.
Deductible does not apply.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
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V. SPECIFIED NON - NETWORK SERVICES
Covered Services:
We cover the following services when you elect to receive them from a non - network provider, at the same level of coverage we
provide when you elect to receive the services from a network provider:
1. Voluntary family planning of the conception and bearing of children.
2. Testing and treatment of sexually transmitted diseases (other than HIV).
3. Testing for AIDS or other HIV - related conditions.
Network Benefits Non - Network Benefits
Coverage level is same as corresponding Network See Network coverage for the services covered.
Benefit, depending on type of service provided, such as
Office Visits for Illness or Injury.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
W. TRANSPLANT SERVICES
Applicable Definitions:
Autologous. This is when the source of cells is from the individual's own marrow or stem cells.
Allogeneic. This is when the source of cells is from a related or unrelated donor's marrow or stem cells.
Autologous Bone Marrow Transplant. This is when the bone marrow is harvested from the individual and stored. The patient
undergoes treatment which includes tumor ablation with high -dose chemotherapy and/or radiation. The bone marrow is reinfused
(transplanted).
Allogeneic Bone Marrow Transplant. This is when the bone marrow is harvested from the related or unrelated donor and
stored. The patient undergoes treatment which includes tumor ablation with high -dose chemotherapy and /or radiation. The bone
marrow is reinfused (transplanted).
Autologous /Allogeneic Stem Cell Support. This is a treatment process that includes stem cell harvest from either bone marrow
or peripheral blood, tumor ablation with high -dose chemotherapy and /or radiation, stem cell reinfusion, and related care.
Autologous /allogeneic bone marrow transplantation and high dose chemotherapy with peripheral stem cell rescue /support are
considered to be autologous /allogeneic stem cell support.
Designated Transplant Center. This is any health care provider, group or association of health care providers designated by us
to provide services, supplies or drugs for specified transplants for our insureds.
Transplant Services. This is transplantation (including retransplants) of the human organs or tissue listed below, including all
related post - surgical treatment, follow -up care and drugs and multiple transplants for a related cause. Transplant services do not
include other organ or tissue transplants or surgical implantation of mechanical devices functioning as a human organ, except
surgical implantation of an FDA approved Ventricular Assist Device (VAD) or total artificial heart, functioning as a temporary
bridge to heart transplantation.
Covered Services:
We cover eligible transplant services (as defined above) while you are covered under this Certificate. Transplants that will be
considered for coverage are limited to the following:
1. Kidney transplants for end -stage disease.
2. Cornea transplants for end -stage disease.
3. Heart transplants for end -stage disease.
4. Lung transplants or heart/lung transplants for: (1) primary pulmonary hypertension; (2) Eisenmenger's syndrome; (3) end -
stage pulmonary fibrosis; (4) alpha 1 antitrypsin disease; (5) cystic fibrosis; and (6) emphysema.
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5. Liver transplants for: (1) biliary atresia in children; (2) primary biliary cirrhosis; (3) post -acute viral infection (including
hepatitis A, hepatitis B antigen e negative and hepatitis C) causing acute atrophy or post - necrotic cirrhosis; (4) primary
sclerosing cholangitis; (5) alcoholic cirrhosis; and (6) hepatocellular carcinoma.
6. Allogeneic bone marrow transplants or peripheral stem cell support associated with high dose chemotherapy for: (1) acute
myelogenous leukemia; (2) acute lymphocytic leukemia; (3) chronic myelogenous leukemia; (4) severe combined
immunodeficiency disease; (5) Wiskott- Aldrich syndrome; (6) aplastic anemia; (7) sickle cell anemia; (8) non - relapsed or
relapsed non - Hodgkin's lymphoma; (9) multiple myeloma; and (10) testicular cancer.
7. Autologous bone marrow transplants or peripheral stem cell support associated with high -dose chemotherapy for: (1) acute
leukemias; (2) non - Hodgkin's lymphoma; (3) Hodgkin's disease; (4) Burkitt's lymphoma; (5) neuroblastoma; (6) multiple
myeloma; (7) chronic myelogenous leukemia; and (8) non - relapsed non - Hodgkin's lymphoma.
8. Pancreas transplants for simultaneous pancreas- kidney transplants for diabetes, pancreas after kidney, living related
segmental simultaneous pancreas kidney transplantation and pancreas transplant alone.
To receive Network Benefits, charges for transplant services must be incurred at a Designated Transplant Center. The transplant -
related treatment provided, including the expenses incurred for directly related donor services, shall be subject to and in
accordance with the provisions, limitations, maximums and other terms of this Certificate.
Medical and hospital expenses of the donor are covered only when the recipient is an insured and the transplant and directly
related donor expenses have been prior authorized for coverage. Treatment of medical complications that may occur to the donor
are not covered. Donors are not considered insureds, and are therefore not eligible for the rights afforded to insureds under this
Certificate.
The list of eligible transplant services and coverage determinations are based on established medical policies, which are subject to
periodic review and modification by the medical director.
Network Benefits Non- Network Benefits
See Network Inpatient Hospital Services Benefit. See Non - Network Inpatient Hospital Services Benefit.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Not Covered:
• We consider the following transplants to be investigative and do not cover them: surgical implantation of mechanical devices
functioning as a permanent substitute for human organ, non -human organ implants and /or transplants and other transplants
not specifically listed in the Certificate.
• See Services Not Covered in the Group Certificate Section III.
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X. ADDITIONAL SERVICES COVERED UNDER THE PLAN
Covered Services:
We cover the following additional program:
Medication Therapy Disease Management Program. If you meet our criteria for coverage, you may qualify for our
Medication Therapy Disease Management program.
The program covers consultations with a designated pharmacist.
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
directors. These medical policies (medical coverage criteria) are available by logging on to your "my HealthPartners" account at
www.healthpartners.com or by calling Member Services.
Network Benefits Non- Network Benefits
100% of the charges incurred. No Coverage.
Deductible does not apply.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
Y. WEIGHT LOSS SURGERY OR BARIATRIC SURGERY
Covered Services:
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
directors. These medical policies (medical coverage criteria) are available on -line by logging on to your "myHealthPartners"
account at www.bealthpartners.com or by calling Member Services.
Network Benefits Non - Network Benefits
No Coverage. No Coverage.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
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Empower NationalONEsm Plan
Benefits Chart
Group Policyholder: City of Columbia Heights
Group Number: 90003
Effective Date: The later of January 1, 2016 and your effective date of coverage under the Group Policy.
HealthPartners Insurance Company agrees to cover the services described below. The Benefits Chart
describes the level of payment that applies for each of the covered services. To be covered under this
section, the medical or dental services or items described below must be medically or dentally necessary.
Coverage for eligible services is subject to the exclusions, limitations, and other conditions of this Benefits
Chart and Group Certificate.
Covered services and supplies are based on established medical policies, which are subject to periodic
review and modification by the medical or dental directors. These medical policies (medical coverage
criteria) are available by calling Member Services, or logging on to your "myHealthPartners" account at
www.healthpartners.com.
The Network Benefits constitute a Qualified Plan. The Non - Network Benefits constitute a Non - qualified
plan. The Network Benefits are intended to constitute a high deductible health plan under Internal
Revenue Code section 223.
Benefits are underwritten by HealthPartners Insurance Company.
Coverage may vary depending on whether you select a network provider or a non - network provider.
The amount that we pay for covered services is listed below. You are responsible for the specified dollar
amount and /or percentage of charges that we do not pay.
When you use Non - Network providers, benefits are substantially reduced and you will likely incur
significantly higher out -of- pocket expenses. A Non - Network provider does not usually have an
agreement with HealthPartners to provide services at a discounted fee. In addition, Non - Network
Benefits are restricted to the usual and customary amount under the definition of "Charge." The usual
and customary amount can be significantly lower than a Non - Network provider's billed charges. If the
Non - Network provider's billed charges are over the usual and customary amount, you pay the difference,
in addition to any required deductible, copayment and /or coinsurance, and these charges do not apply to
the out -of- pocket limit. The only exceptions to this requirement are described below in the "Emergency
and Urgently Needed Care Services" section. This section describes what benefits are covered at the
Network Benefit level regardless of who provides the service.
These definitions apply to the Benefits Chart. They also apply to the Certificate.
Biosimilar Drug: A prescription drug, approved by the Food and Drug Administration (FDA), that the FDA
has determined is Biosimilar to and interchangeable with a biological brand drug.
Biosimilar drugs are not considered generic drugs and are not covered under the generic
drug benefit.
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Brand Drug: A prescription drug, approved by the Food and Drug Administration (FDA), that is
manufactured, sold, or licensed for sale under a trademark by the pharmaceutical
company that originally researched and developed the drug. Brand drugs have the same
active - ingredient formula as the generic version of the drug. However, generic drugs are
manufactured and sold by other drug manufacturers and are generally not available until
after the patent on the brand drug has expired. A few brand drugs may be covered at the
generic drug benefit level if this is indicated on the formulary.
Charge: For covered services delivered by participating network providers, is the provider's
discounted charge for a given medical /surgical service, procedure or item.
For covered services delivered by non - network providers, is the provider's charge for a
given medical /surgical service procedure or item, according to the usual and customary
charge allowed amount.
The Usual and Customary Charge is the maximum amount allowed we consider in the
calculation of payment of charges incurred for certain covered services. It is consistent
with the charge of other providers of a given service or item in the same region. You
must pay for any charges above the usual and customary charge, and they do not apply to
the out -of- pocket limit.
A charge is incurred for covered ambulatory medical and surgical services, on the date
the service or item is provided. A charge is incurred for covered inpatient services, on
the date of admission to a hospital. To be covered, a charge must be incurred on or after
your effective date and on or before the termination date.
Combined Day Limit: Your total benefit is combined, for inpatient hospitalization, skilled nursing facility care
services and inpatient mental and chemical health services, and limited to 365 days per
period of confinement. Each day of such services provided under the Network Benefits
and Non - Network Benefits counts toward this combined day limit, for the same period of
confinement.
Copayment /Coinsurance: The specified dollar amount, or percentage, of charges incurred for covered services,
which we do not pay, but which you must pay, each time you receive certain medical
services, procedures or items. Our payment for those covered services or items begins
after the copayment or coinsurance is satisfied. Covered services or items requiring a
copayment or coinsurance are specified in this Certificate.
For services provided by a network provider:
An amount which is listed as a flat dollar copayment is applied to a network provider's
discounted charges for a given service. However, if the network provider's discounted
charge for a service or item is less than the flat dollar copayment, you will pay the
network provider's discounted charge. An amount which is listed as a percentage of
charges or coinsurance is based on the network provider's discounted charges, calculated
at the time the claim is processed, which may include an agreed upon fee schedule rate
for case rate or withhold arrangements.
For services provided by a non - network provider:
Any copayment or coinsurance is applied to the lesser of the provider's charges or
the usual and customary charge for a service.
A copayment or coinsurance is due at the time a service is provided, or when billed by
the provider. The copayment or coinsurance applicable for a scheduled visit with a
Network provider will be collected for each visit, late cancellation and failed
appointment.
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Deductible:
The specified dollar amount of charges incurred for covered services, which we do not
pay, but an enrollee or a family has to pay first in a calendar year. Our payment for
those services or items begins after the deductible is satisfied. If you have a family
deductible, each individual family member may only contribute up to the individual
deductible amount toward the family deductible. An individual's copayments and
coinsurance do not apply toward the family deductible. For network providers, the
amount of the charges that apply to the deductible are based on the network provider's
discounted charges, calculated at the time the claim is processed, which may include an
agreed upon fee schedule rate for case rate or withhold arrangements. For non - network
providers, the amount of charges that apply to the deductible are the lesser of the
provider's charges or the usual and customary charge for a service. The Benefits Chart
indicates which covered services are not subject to the deductible.
Formulary:
This is a current list, which may be revised from time to time, of prescription drugs,
medications, equipment and supplies covered by us as indicated in the Benefits Chart
which are covered at the highest benefit level. Some drugs on the Formulary may require
prior authorization to be covered as formulary drugs. You may be granted an exception
to the formulary that is available to you upon request. These guidelines and procedures
include exceptions to the formulary for anti- psychotic prescription drugs prescribed to
treat emotional disturbances or mental illness if your health care provider (1) indicates to
the dispensing phannacist, orally or in writing, that the prescription must be dispensed as
indicated and (2) certifies in writing to us that the prescribed drug will best treat your
condition. Also, you may continue to receive certain non - formulary prescription drugs
for diagnosed mental illness or emotional disturbance when our formulary changes or you
change health plans for up to one year following the change. The formulary, and
information on drugs that require prior authorization, are available by calling Member
Services, or logging on to your "myHealthPartners" account at www.healtbpartners.com.
Generic Drug:
A prescription drug approved by the Food and Drug Administration (FDA) that the FDA
has determined is comparable to a brand drug product in dosage form, strength, route of
administration, quality, intended use and documented bioequivalence. Generally, generic
drugs cost less than brand drugs. Some brand drugs may be covered at the generic drug
benefit level if this is indicated on the formulary.
Lifetime Maximum Benefit:
The specified coverage limit paid for all charges combined and actually paid by us for
you under that coverage. Our payment ceases for you, when that limit is reached. You
have to pay for subsequent charges.
Out -of- Pocket Expenses:
You pay the specified copayments/coinsurance and deductibles applicable for particular
services, subject to the out -of- pocket limit described below. These amounts are in
addition to the monthly premium payments.
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Out -of- Pocket Limit: You pay the copaymentsfcoinsurance and deductibles for covered services, to the
individual or family out -of- pocket limit. Thereafter we cover 100% of charges incurred
for all other covered services, for the rest of the calendar year. You pay amounts greater
than the out -of- pocket limit if any benefit maximums or the lifetime maximum are
exceeded.
Non - Network Benefits above the usual and customary charge (see definition of charge
above) do not apply to the out -of- pocket limit.
Non - Network Benefits for transplant surgery do not apply to the out -of- pocket limit.
You are responsible to keep track of the out -of- pocket expenses. Contact our Member
Services Department for assistance in determining the amount paid by the enrollee for
specific eligible services received. Claims for reimbursement under the out -of- pocket
limit provisions are subject to the same time limits and provisions described under the
"Claims Provisions" section of the Certificate.
Specialty Drug List: This is a current list, which may be revised from time to time, of prescription drugs,
medications, equipment and supplies, which are typically bio- pharmaceuticals. The
purpose of a specialty drug list is to facilitate enhanced monitoring of complex therapies
used to treat specific conditions. Specialty drugs are covered by us as indicated below.
The specialty drug list is available by calling Member Services, or logging on to your
"myHealthPartners" account at www.healthpartners.com.
Virtuwell: Virtuwell is an online service that you may use to receive a diagnosis and treatment for
certain routine conditions, such as a cold and flu, ear pain and sinus infections. You may
access the virtuwell website at www.virtuwell.com.
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(NI -HDHP -2600- 90003 -16) 4
Individual Calendar Year Deductible
Network Benefits Non - Network Benefits
$2,600 $2,600
Family Calendar Year Deductible
Network Benefits Non - Network Benefits
$5,200 $5,200
Deductibles under the Network Benefits and the Non - Network Benefits are combined.
Individual Calendar Year Out -of- Pocket Limit
Network Benefits Non - Network Benefits
$2,600 $4,000
Family Calendar Year Out -of- Pocket Limit
Network Benefits Non - Network Benefits
$5,200 $8,000
The Out -of- Pocket Limits under the Network Benefits and the Non - Network Benefits are combined.
Any reduction in benefits for failure to comply with CareChecko requirements will not apply toward the Out -of-
Pocket Limit.
Non - Network Benefits above the usual and customary charge will not apply toward the individual or family out -
of- pocket limit.
Lifetime Maximum Benefit for Transplant Surgery
Network Benefits Non - Network Benefits
Unlimited. $25,000
Lifetime Maximum Benefit
Network Benefits Non - Network Benefits
Unlimited. $2,000,000
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 5
Notice: Some benefits listed in this Benefits Chart require precertification. See section I.K. "CareCheck @"
of your Certificate for details.
A. AMBULANCE AND MEDICAL TRANSPORTATION
Covered Services:
We cover ambulance and medical transportation for medical emergencies and as shown below.
For Network Benefits. Transfers between network hospitals for treatment by network physicians are covered, if initiated by a
network physician. Transfers from a hospital or to home or to other facilities are covered, if medical supervision is required en
route.
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefits.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
B. AUTISM BENEFIT
Covered Services:
We cover Applied Behavioral Therapy (ABA), Intensive Early Intervention Behavioral Therapy (IEIBT), and Lovaas for children
under age 18. For other autism services covered under this Certificate, see the habilitative benefit under Physical Therapy,
Occupational Therapy and Speech Therapy.
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
or dental directors. These medical policies (medical coverage criteria) are available on -line at www,healthpartners.com or by
calling Member Services.
Network Benefits Non - Network Benefits
100% of the charges incurred. No Coverage.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
C. BEHAVIORAL HEALTH SERVICES
Covered Services:
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
directors. These medical policies (medical coverage criteria) are available by calling Member Services, or logging on to your
"niyHealthPartners" account at www.healthpartners.com.
Mental Health Services
We cover services for mental health diagnoses as described in the Diagnostic and Statistical Manual of Mental Disorders — Fifth
Edition (DSMV) (most recent edition).
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We also provide coverage for mental health treatment ordered by a Minnesota court under a valid court order that is issued on the
basis of a behavioral care evaluation perforined by a licensed psychiatrist or doctoral level licensed psychologist, which includes a
diagnosis and an individual treatment plan for care in the most appropriate, least restrictive environment. We must be given a
copy of the court order and the behavioral care evaluation, and the service must be a covered benefit under this plan, and the
service must be provided by a network provider, or other provider as required by law. We cover the evaluation upon which the
court order was based if it was provided by a network provider. We also provide coverage for the initial mental health evaluation
of a child, regardless of whether that evaluation leads to a court order for treatment, if the evaluation is ordered by a Minnesota
juvenile court.
a. Outpatient Services including intensive outpatient and day treatment services: We cover medically necessary outpatient
professional mental health services for evaluation, crisis intervention, and treatment of mental health disorders.
A comprehensive diagnostic assessment will be made of each patient as the basis for a determination by a mental
health professional, concerning the appropriate treatment and the extent of services required.
Outpatient services we cover for a diagnosed mental health condition include the following:
(1) Individual, group, family, and multi- family therapy;
(2) Medication management provided by a physician, certified nurse practitioner, or physician's assistant;
(3) Psychological testing services for the purposes of determining the differential diagnoses and treatment planning for
patients currently receiving behavioral health services;
(4) Day treatment and intensive outpatient services in a licensed program;
(5) Partial hospitalization services in a licensed hospital or community mental health center; and
(6) Psychotherapy and nursing services provided in the home if authorized by us.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Group Therapy
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
b. Inpatient Services, including psychiatric residential treatment for emotionally disabled children: We cover medically
necessary inpatient services in a hospital and professional services for treatment of mental health disorders. Medical
stabilization is covered under inpatient hospital services in the "Hospital and Skilled Nursing Facility Services" section.
We cover residential care for the treatment of eating disorders in a licensed facility, as an alternative to inpatient care, when it
is medically necessary and your physician obtains authorization from us.
We also cover medically necessary psychiatric residential treatment for emotionally disabled children as diagnosed by a
physician. This care must be authorized by us and provided by a hospital or residential treatment center licensed by the local
state or Health and Human Services Department. The child must be under 18 years of age and an eligible dependent
according to the terms of this Certificate. Services not covered under this benefit include shelter services, correctional
services, detention services, transitional services, group residential services, foster care services and wilderness programs.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
BCH- 900.34
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Chemical Health Services
We cover medically necessary services for assessments by a licensed alcohol and drug counselor and treatment of Substance -
Related Disorders as defined in the latest edition of the DSM V.
a. Outpatient Services including intensive outpatient and day treatment services: We cover medically necessary
outpatient professional services for the diagnosis and treatment of chemical dependency. Chemical dependency treatment
services must be provided by a program licensed by the local Health and Human Services Department.
Outpatient services we cover for a diagnosed chemical dependency condition include the following:
(1) Individual, group, family, and multi - family therapy provided in an office setting;
(2) We cover opiate replacement therapy including methadone and buprenorphine treatment; and
(3) Day treatment and intensive outpatient services in a licensed program.
Network Benefits Non- Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Network Benefits
Non - Network Benefits
We cover supervised lodging at a contracted We cover supervised lodging at a contracted
organization for insureds actively involved in an organization for insureds actively involved in an
affiliated licensed chemical dependency day treatment affiliated licensed chemical dependency day
or intensive outpatient program for treatment of treatment or intensive outpatient program for
alcohol or drug abuse. treatment of alcohol or drug abuse.
b. Inpatient Services: We cover medically necessary inpatient services in a hospital or primary residential treatment in a
licensed chemical health treatment center. Primary residential treatment is an intensive residential treatment program of
limited duration, typically 30 days or less.
We cover services provided in a hospital that is licensed by the local state and accredited by Medicare.
Detoxification Services. We cover detoxification services in a hospital or community detoxification facility if it is licensed
by the local Health and Human Services Department.
Covered services are based on established medical policies, which are subject to periodic review and modification by the
medical directors. These medical policies (medical coverage criteria) are available by calling Member Services, or logging
on to your "myHealthPartners" account at www.healthpartners.com.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Not Covered:
• Rest and respite services and custodial care, except as respite services are specifically described in this Benefits Chart under
the section "Home Hospice Services ". This includes all services, medical equipment and drugs provided for such care.
• Halfway houses, extended care facilities, or comparable facilities, residential treatment.
• Foster care, adult foster care and any type of family child care provided or arranged by the local state or county.
• Religious counseling; marital /relationship counseling and sex therapy.
• Professional services associated with substance abuse interventions. A "substance abuse intervention" is a gathering of
family and/or friends to encourage a person covered under this certificate to seek substance abuse treatment.
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• Court ordered treatment, except as described in this Benefits Chart section C. subsection "Mental Health Services" and
section Q. "Office Visits for Illness or Injury" or as otherwise required by law.
• Vagus nerve stimulator treatment for the treatment of depression.
• Quantitative Electroencephalogram treatment for the treatment of behavioral health conditions.
• See Services Not Covered in the Group Certificate Section III.
D. CHIROPRACTIC SERVICES
Covered Services:
We cover chiropractic services for rehabilitative care. Chiropractic services are adjustments to any abnormal articulations of the
human body, especially those of the spinal column, for the purpose of giving freedom of action to impinged nerves that may cause
pain or deranged function.
Massage therapy which is performed in conjunction with other treatment /modalities by a chiropractor, is part of a prescribed
treatment plan and is not billed separately is covered.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80°, o of the charges incurred.
Limit of 20 visits per calendar year.
Not Covered:
• Massage therapy for the purpose of comfort or convenience of the insured.
• See Services Not Covered in the Group Certificate Section III.
E. CLINICAL TRIALS
Covered Services:
We cover certain routine services if you participate in a Phase I, Phase II, Phase III or Phase IV clinical trial that is conducted in
relation to the prevention, detection, or treatment of cancer or other life - threatening disease or condition as defined in the
Affordable Care Act. We cover routine patient costs for services that would be eligible under this Certificate if the service were
provided outside of a clinical trial.
Network Benefits
Coverage level is same as corresponding Network
Benefit, depending on type of service provided such as
Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
Not Covered:
Non- Network Benefits
Coverage level is same as corresponding Non - Network
Benefit, depending on type of service provided such as
Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
• The investigative item, device or service itself.
• Items or services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct
clinical management of the patient.
• A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(NI -HDHP -2600- 90003 -16)
F. DENTAL SERVICES
Covered Services:
We cover services described below.
Accidental Dental Services: We cover dentally necessary services to treat and restore damage done to sound, natural, unrestored
teeth as a result of an accidental injury. Coverage is for damage caused by external trauma to face and mouth only, not for
cracked or broken teeth which result from biting or chewing. We cover restorations, root canals, crowns and replacement of teeth
lost that are directly related to the accident in which the insured was involved. We cover initial exams, x -rays, and palliative
treatment including extractions, and other oral surgical procedures directly related to the accident. Subsequent treatment must be
initiated within the Certificate's time - frame and must be directly related to the accident. We do not cover restoration and
replacement of teeth that are not "sound and natural" at the time of the accident.
Full mouth rehabilitation to correct occlusion (bite) and malocclusion (misaligned teeth not due to the accident) are not covered.
When an implant - supported dental prosthetic treatment is pursued, the accidental dental benefit will be applied to the prosthetic
procedure. Benefits are limited to the amount that would be paid toward the placement of a removable dental prosthetic appliance
that could be used in the absence of implant treatment. Care must be provided or pre- authorized by a HealthPartners dentist.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
For all accidental dental services, treatment and /or restoration must be initiated within six months of the date of
the injury. Coverage is limited to the initial course of treatment and /or initial restoration. Services must be
provided within twenty-four months of the date of injury to be covered.
Medical Referral Dental Services
a. Medically Necessary Outpatient Dental Services: We cover medically necessary outpatient dental services. Coverage is
limited to dental services required for treatment of an underlying medical condition, e.g., removal of teeth to complete
radiation treatment for cancer of the jaw, cysts and lesions.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
b. Medically Necessary Hospitalization and Anesthesia for Dental Care: We cover medically necessary hospitalization
and anesthesia for dental care. This is limited to charges incurred by an insured who: (1) is a child under age 5; (2) is
severely disabled; (3) has a medical condition, and requires hospitalization or general anesthesia for dental care treatment;
or (4) is a child between age 5 and 12 and care in dental offices has been attempted unsuccessfully and usual methods of
behavior modification have not been successful, or when extensive amounts of restorative care, exceeding 4 appointments,
are required. The requirement of a hospital setting must be due to an insured's underlying medical condition. Coverage is
limited to facility and anesthesia charges. Anesthesia is covered in a hospital or a dental office. Oral surgeon/dentist
professional fees are not covered. The following are examples, though not all- inclusive, of medical conditions which may
require hospitalization for dental services: severe asthma, severe airway obstruction or hemophilia. Hospitalization
required due to the behavior of the insured or due to the extent of the dental procedure is not covered.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 10
c. Medical Complications of Dental Care: We cover medical complications of dental care. Treatment must be medically
necessary care and related to medical complications of non - covered dental care, including complications of the head, neck,
or substructures.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Oral Surgery: We cover oral surgery. Coverage is limited to treatment of medical conditions requiring oral surgery, such as
treatment of oral neoplasm, non - dental cysts, fracture of the jaws, trauma of the mouth and jaws, and any other oral surgery
procedures provided as medically necessary dental services.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Orthognathic Surgery Benefit: We cover orthognathic surgery for the treatment of severe skeletal dysmorphia where a
functional occlusion cannot be achieved through non - surgical treatment alone and where a demonstrable functional impairment
exists. Functional impairments include but are not limited to significant impairment in chewing, breathing or swallowing.
Associated dental or orthodontic services (pre- or postoperatively including surgical rapid palatal expansion) are not covered as
part of this benefit.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Treatment of Cleft Lip and Cleft Palate of a Dependent Child: We cover treatment of cleft lip and cleft palate of a
dependent child, to the limiting age in the definition of an "Eligible Dependent', including orthodontic treatment and oral
surgery directly related to the cleft. Benefits for individuals age 26 up to the limiting age for coverage of the dependent are
limited to inpatient or outpatient expenses arising from medical and dental treatment that was scheduled or initiated prior to the
dependent turning age 19. Dental services which are not required for the treatment of cleft lip or cleft palate are not covered. If
a dependent child covered under this Certificate is also covered under a dental plan which includes orthodontic services, that
dental plan shall be considered primary for the necessary orthodontic services. Oral appliances are subject to the same
copayment, conditions and limitations as durable medical equipment.
Network Benefits Non- Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Treatment of Temporomandibular Disorder (TMD) and Craniomandibular Disorder (CMD): We cover surgical and non-
surgical treatment of temporomandibular disorder (TMD) and craniomandibular disorder (CMD), which is medically necessary
care. Dental services which are not required to directly treat TMD or CMD are not covered.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Not Covered:
• Dental treatment, procedures or services not listed in this Benefits Chart.
• Accident related dental services if treatment is (1) provided to teeth which are not sound and natural, (2) to teeth which have
been restored, (3) initiated beyond six months from the date of the injury, (4) received beyond the initial treatment or
restoration or (5) received beyond twenty -four months from the date of injury.
• Oral surgery to remove wisdom teeth.
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(N1 -HDHP -2600- 90003 -16) 11
HOW
31lW104I 10 '7111
G. DIAGNOSTIC IMAGING SER`'ICES
Covered Services:
We cover diagnostic imaging, when ordered by a provider and provided in a clinic or outpatient hospital facility.
For Network Benefits, non - emergent, scheduled outpatient Magnetic Resonance Imaging (MRI) and computing Tomography
(CT) must be provided at a designated facility. Your physician or facility will obtain or verify prior authorization for these
services, as needed.
We cover services provided in a clinic or outpatient hospital facility (to see the benefit level for inpatient hospital or skilled
nursing facility services, see benefits under Inpatient Hospital and Skilled Nursing Facility Services).
(a) Outpatient Magnetic Resonance Imaging (MRI) and Computing Tomography (CT)
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
(b) All other outpatient diagnostic imaging services
Services for illness or injury
Network Benefits Non- Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Preventive services (MRI /CT procedures are not considered preventive)
Diagnostic imaging for preventive services is covered at the benefit level shown in the Preventive Services
section.
Not Covered:
• See Services Not Covered in the Group Certificate Section I11.
H. DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES
Covered Services:
We cover equipment and services, as described below.
We cover durable medical equipment and services, prosthetics, orthotics, and supplies, subject to the limitations below, including
certain disposable supplies, enteral feedings and the following diabetic supplies and equipment: glucose monitors, insulin pumps,
syringes, blood and urine test strips and other diabetic supplies as deemed medically appropriate and necessary, for insureds with
gestational, Type I or Type II diabetes.
We cover special dietary treatment of Phenylketonuria (PKU) and oral amino acid based elemental formula if it meets our
medical coverage criteria.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 12
External hearing aids (including osseointegrated or bone anchored) for insureds age 18 or younger who have hearing loss that is
not correctable by other covered procedures. Coverage is limited to one hearing aid for each ear every three years.
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Wigs, for hair loss resulting from alopecia areata are limited to one per calendar year. No more than a 90 -day
supply of diabetic supplies are covered and dispensed at a time.
Special dietary treatment for Phenylketonuria (PKU) if it is recommended by a physician
Network Benefits Non- Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Oral amino acid based elemental formula if it meets our medical coverage criteria
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Limitations:
Coverage of durable medical equipment is limited by the following.
• Payment will not exceed the cost of an alternate piece of equipment or service that is effective and medically necessary.
• For prosthetic benefits, other than hair prostheses (i.e., wigs) for hair loss resulting from alopecia areata and oral appliances
for cleft lip and cleft palate, payment will not exceed the cost of an alternate piece of equipment or service that is effective,
medically necessary and enables insureds to conduct standard activities of daily living.
• We reserve the right to determine if an item will be approved for rental vs. purchase.
• Diabetic supplies and equipment are limited to certain models and brands.
• Durable medical equipment and supplies must be obtained from or repaired by approved vendors.
• Covered services and supplies are based on established medical policies which are subject to periodic review and
modification by the medical or dental directors. Our coverage policy for diabetic supplies includes information on our
required models and brands. These medical policies (medical coverage criteria) are available by calling Member Services, or
logging on to your "niyHealthPartners" account at www.healthpartners.com.
Not Covered:
Items which are not eligible for coverage include, but are not limited to:
• Replacement or repair of any covered items, if the items are (i) damaged or destroyed by misuse, abuse or carelessness, (ii)
lost; or (iii) stolen.
• Duplicate or similar items.
• Labor and related charges for repair of any covered items which are more than the cost of replacement by an approved
vendor.
• Sales tax, mailing, delivery charges, service call charges.
• Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 13
I :�1►1 � �I`�1 IF.Y�17\ :7I 11
• Communication aids or devices: equipment to create, replace or augment communication abilities including, but not limited
to, hearing aids (implantable and external, including osseointegrated or bone anchored) and fitting of hearing aids except as
required by law, speech processors, receivers, communication boards, or computer or electronic assisted communication,
except as specifically described in this Certificate. This exclusion does not apply to cochlear implants, which are covered as
described in the medical coverage criteria. Medical coverage criteria are available by calling Member Services, or logging on
to your "myHealthPartners" account at www.healthpartners.com.
• Household equipment which primarily has customary uses other than medical, such as, but not limited to, exercise cycles, air
purifiers, central or unit air conditioners, water purifiers, non - allergenic pillows, mattresses or waterbeds.
• Household fixtures including, but not limited to, escalators or elevators, ramps, swimming pools and saunas.
• Modifications to the structure of the home including, but not limited to, its wiring, plumbing or charges for installation of
equipment.
• Vehicle, car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier.
• Rental equipment while owned equipment is being repaired by non - contracted vendors, beyond one month rental of
medically necessary equipment.
• Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage.
• See Services Not Covered in the Group Certificate Section II1.
I. EMERGENCY AND URGENTLY NEEDED CARE SERVICES
Covered Services:
We cover services for emergency care and urgently needed care if the services are otherwise eligible for coverage under this
Certificate.
Urgently needed care. These are services to treat an unforeseen illness or injury, which are required in order to prevent a serious
deterioration in your health, and which cannot be delayed until the next available clinic or office hours.
Urgently Needed care at clinics
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Emergency Care. These are services to treat: (1) the sudden, unexpected onset of illness or injury which, if left untreated or
unattended until the next available clinic or office hours, would result in hospitalization, or (2) a condition requiring professional
health services immediately necessary to preserve life or stabilize health. Emergency care also includes an immediate response
service available on a 24 -hour, seven - day -a -week basis for each child, or person, having a psychiatric crisis, a mental health
crisis, or a mental health emergency.
When reviewing claims for coverage of emergency services, our medical director will take into consideration a reasonable
layperson's belief that the circumstances required immediate medical care that could not wait until the next working day or next
available clinic appointment.
Emergency care in a hospital emergency room, including professional services of a physician
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefits.
Inpatient emergency care in a hospital
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefits.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 14
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
J. HEALTH EDUCATION
Covered Services:
We cover education for preventive services and education for the management of chronic health problems (such as diabetes).
Coverage includes medical nutrition therapy, that is provided by a certified, registered, or licensed health care professional
working in a program consistent with the national standards of diabetes self - management education as established by the
American Diabetes Association.
Provider office visit /session in connection with preventive services
Network Benefits Non- Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Deductible does not apply.
Provider office visit/session in connection with the management of a chronic health problem (such as diabetes)
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Deductible does not apply.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
K. HOME HEALTH SERVICES
Covered Services:
We cover skilled nursing services, physical therapy, occupational therapy, speech therapy, respiratory therapy and other therapeutic
services, non - routine prenatal and postnatal services, routine postnatal well child visits as described in the Coverage Criteria,
phototherapy services for newborns, home health aide services and other eligible home health services when provided in your home,
if you are homebound (i.e., unable to leave home without considerable effort due to a medical condition). Lack of transportation
does not constitute homebound status. For phototherapy services for newborns and high risk prenatal services, supplies and
equipment are included.
We cover total parenteral nutrition /intravenous ( "TPN/IV ") therapy, equipment, supplies and drugs in connection with IV
therapy. IV line care kits are covered under Durable Medical Equipment.
You do not need to be homebound to receive total parenteral nutrition/intravenous ( "TPN/IV ") therapy.
We cover palliative care benefits. Palliative care includes symptom management, education and establishing goals of care.
We waive the requirement that you be homebound for a limited number of home visits for palliative care (as shown in the
Benefits Chart), if you have a life - threatening, non- curable condition which has a prognosis of survival of two years or less.
Additional palliative care visits are eligible under the home health services benefit if you are homebound and meet all other
requirements defined in this section.
Home health services are eligible and covered only when they are:
1. medically necessary; and
2. provided as rehabilitative care, terminal care or maternity care; and
3. ordered by a physician, and included in the written home care plan.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 15
Limitations:
Home health services are not provided as a substitute for a primary caregiver in the home or as relief (respite) for a primary
caregiver in the home. We will not reimburse family members or residents in your home for the above services.
A service shall not be considered a skilled nursing service merely because it is performed by, or under the direct supervision of, a
licensed nurse. Where a service (such as tracheotomy suctioning or ventilator monitoring) or like services, can be safely and
effectively performed by a non - medical person (or self - administered), without the direct supervision of a licensed nurse, the
service shall not be regarded as a skilled nursing service, whether or not a skilled nurse actually provides the service. The
unavailability of a competent person to provide a non - skilled service shall not make it a skilled service when a skilled nurse
provides it. Only the skilled nursing component of so- called "blended" services (i.e. services which include skilled and non -
skilled components) are covered under this Certificate.
Physical therapy, occupational therapy, speech therapy, respiratory therapy, home health aide services and palliative care
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
TPNIIV therapy, skilled nursing services, non - routine prenatallpostnatal services, and phototherapy
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Each 24 -hour visit (or shifts of up to 24 -hour visits) equals one visit and counts toward the Maximum visits for
all other services shown below. Any visit that lasts less than 24 hours, regardless of the length of the visit, will
count as one visit toward the Maximum visits for all other services shown below. All visits must be medically
necessary and benefit eligible.
Routine postnatal well child visit
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Deductible does not apply.
Maximum visits for palliative care
If you are eligible to receive palliative care in the home and you are not homebound, there is a maximum of 8
visits per calendar year.
Maximum visits for all other services
Network Benefits Non- Network Benefits
120 visits per calendar year. 60 visits per calendar year.
Each visit provided under the Network Benefits and Non - Network Benefits counts toward the maximums shown
under both Maximum visits sections. The routine postnatal well child visit does not count toward the visit limit.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 16
Not Covered:
• Financial or legal counseling services.
• Housekeeping or meal services in your home.
• Private duty nursing services. This exclusion does not apply if covered person is also covered under Medical Assistance
under Minnesota chapter 25613.0625, subdivision 7, with the exception of section 25613.0654 subdivision 4.
• Services provided by a family member or enrollee, or a resident in the enrollee's home.
• Vocational rehabilitation and recreational or educational therapy. Recreation therapy is therapy provided solely for the
purpose of recreation, including but not limited to: (a) requests for physical therapy or occupational therapy to improve
athletic ability, and (b) braces or guards to prevent sports injuries.
• See Services Not Covered in the Group Certificate Section III.
L. HOME HOSPICE SERVICES
Applicable Definitions:
Part -time. This is up to two hours of service per day, more than two hours is considered continuous care.
Continuous Care. This is from two to twelve hours of service per day provided by a registered nurse, licensed practical nurse, or
home health aide, during a period of crisis in order to maintain a terminally ill patient at home.
Appropriate Facility. This is a nursing home, hospice residence, or other inpatient facility.
Custodial Care Related to Hospice Services. This means providing assistance in the activities of daily living and the care
needed by a terminally ill patient which can be provided by primary caregiver (i.e., family member or friend) who is responsible
for the patient's home care.
Covered Services:
Home Hospice Program. We cover the services described below if you are terminally ill and accepted as a home hospice
program participant. You must meet the eligibility requirements of the program, and elect to receive services through the home
hospice program. The services will be provided in your home, with inpatient care available when medically necessary as
described below. If you elect to receive hospice services, you do so in lieu of curative treatment for your terminal illness for the
period you are enrolled in the home hospice program.
a. Eligibility: In order to be eligible to be enrolled in the home hospice program, you must: (1) be a tenninally ill patient
(prognosis of six months or less); (2) have chosen a palliative treatment focus (i.e., emphasizing comfort and supportive
services rather than treatment attempting to cure the disease or condition); and (3) continue to meet the terminally ill
prognosis as reviewed by our medical director or his or her designee over the course of care. You may withdraw from the
home hospice program at any time.
b. Eligible Services: Hospice services include the following services provided by Medicare - certified providers, if provided in
accordance with an approved hospice treatment plan.
(1) Home Health Services:
(a) Part-time care provided in your home by an interdisciplinary hospice team (which may include a physician,
nurse, social worker, and spiritual counselor) and medically necessary home health services are covered.
(b) One or more periods of continuous care in your home or in a setting which provides day care for pain or
symptom management, when medically necessary, will be covered.
(2) Inpatient Services: We cover medically necessary inpatient services.
BCH- 900.34
(1b1 -HDHP -2600- 90003 -16) 17
l:
(3) Other Services:
(a) Respite care is covered for care in your home or in an appropriate facility, to give your primary caregivers
(i.e., family members or friends) rest and/or relief when necessary in order to maintain a terminally ill patient
at home.
(b) Medically necessary medications for pain and symptom management.
(c) Semi - electric hospital beds and other durable medical equipment are covered.
(d) Emergency and non- emergency care is covered.
Network Benefits Non- Network Benefits
1001/'o of the charges incurred. 80% of the charges incurred.
Respite care is limited to 5 days per episode, and respite care and continuous care combined are limited to 30
days.
Not Covered:
• Financial or legal counseling services; or
• Housekeeping or meal services in your home; or
• Custodial or maintenance care related to hospice services, whether provided in the home or in a nursing home; or
• Any service not specifically described as covered services under this home hospice services benefits; or
• Any services provided by members of your family or residents in your home.
• See Services Not Covered in the Group Certificate Section III.
M. HOSPITAL AND SKILLED NURSING FACILITY SERVICES
Covered Services:
We cover services as described below.
Medical or Surgical Hospital Services
Inpatient Hospital Services: We cover the following medical or surgical services, for the treatment of acute illness or
injury, which require the level of care only provided in an acute care facility. These services must be authorized by a
physician.
Inpatient hospital services include: room and board; the use of operating or maternity delivery rooms; intensive care
facilities; newborn nursery facilities; general nursing care, anesthesia, laboratory and diagnostic imaging services,
reconstructive surgery, radiation therapy, physical therapy, prescription drugs or other medications administered during
treatment, blood and blood products (unless replaced), and blood derivatives, and other diagnostic or treatment related
hospital services; physician and other professional medical and surgical services provided while in the hospital.
We cover up to 120 hours of services provided by a private duty nurse or personal care assistant who has provided home care
services to a ventilator - dependent patient, solely for the purpose of assuring adequate training of the hospital staff to
communicate with that patient.
Services for items for personal convenience, such as television rental, are not covered.
We cover, following a vaginal delivery, a minimum of 48 hours of inpatient care for the mother and newborn child. We
cover, following a caesarean section delivery, a minimum of 96 hours of inpatient care for the mother and newborn child. If
the duration of inpatient care is less than these minimums, we also cover a minimum of one home visit by a registered nurse
for post - delivery care, within 4 days of discharge of the mother and newborn child. Services provided by the registered nurse
include, but are not limited to, parent education, assistance and training in breast and bottle feeding, and conducting any
necessary and appropriate clinical tests. We shall not provide any compensation or other non- medical remuneration to
encourage a mother and newborn to leave inpatient care before the duration minimums specified.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 18
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length
of stay in connection with childbirth for the mother of newborn child to less than 48 hours following a vaginal delivery, or
less than 96 hours following a caesarean section. However, Federal law generally does not prohibit the mother's or
newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48
hours (or 96 hours as applicable). In any case plans and issuers may not, under Federal law, require that a provider obtain
authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Each insured's admission or confinement, including that of a newborn child, is separate and distinct from the
admission or c017nement of any other insured.
Outpatient Hospital, Ambulatory Care or Surgical Facility Services: We cover the following medical and surgical
services, for diagnosis or treatment of illness or injury on an outpatient basis. These services must be authorized by a
physician.
Outpatient services include: use of operating rooms, maternity delivery rooms or other outpatient departments, rooms or
facilities; and the following outpatient services: general nursing care, anesthesia, laboratory and diagnostic imaging services,
reconstructive surgery, radiation therapy, physical therapy, drugs administered during treatment, blood and blood products
(unless replaced), and blood derivatives, and other diagnostic or treatment related outpatient services; physician and other
professional medical and surgical services provided while an outpatient.
For Network Benefits, non- emergent, scheduled outpatient Magnetic Resonance Imaging (MRI) and computing Tomography
(CT) must be provided at a designated facility. Your physician or facility will obtain or verify prior authorization for these
services, as needed.
To see the benefit level for diagnostic imaging services, laboratory services and physical therapy, see the benefits under
Diagnostic Imaging Services, Laboratory Services and Physical Therapy in this Benefits Chart.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Skilled Nursing Facility Care: We cover room and board, daily skilled nursing and related ancillary services for post acute
treatment and rehabilitative care of illness or injury, following a hospital confinement.
Network Benefits
100% of the charges incurred.
Limited to 120 day maximum per period of
confinement, subject to the combined day limit.
Non - Network Benefits
80% of the charges incurred.
Limited to 120 day maximum per period of
confinement, subject to the combined day limit.
Each day of services provided under the Network and Non - Network Benefits, combined, counts toward the
maximums shown, above.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 19
Not Covered:
• Services for items for personal convenience, such as television rental, are not covered.
• See Services Not Covered in the Group Certificate Section III.
N. LABORATORY SERVICES
Covered Services:
We cover laboratory tests when ordered by a provider and provided in a clinic or outpatient hospital facility.
We cover services provided in a clinic or outpatient hospital facility (to see the benefit level for inpatient hospital or skilled
nursing facility services, see benefits under Inpatient Hospital and Skilled Nursing Facility Services).
Services for illness or injury
Network Benefits Non- Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Preventive services
Network Benefits Non - Network Benefits
Laboratory services associated with preventive services are covered at the benefit level shown in the
Preventive Services section.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
O. LYME DISEASE SERVICES
Covered Services:
We cover services for the treatment of Lyme disease.
Network Benefits
Coverage level is same as corresponding Network
Benefit, depending on type of service provided such
as Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
Not Covered:
Non - Network Benefits
Coverage level is same as corresponding Non -
Network Benefit, depending on type of service
provided such as Office Visits for Illness or Injury,
Inpatient or Outpatient Hospital Services.
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 20
P. MASTECTOMY RECONSTRUCTION BENEFIT
Covered Services:
We cover reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the other
breast to produce symmetrical appearance, and prostheses and physical complications of all stages of mastectomy, including
lymphedemas.
Network Benefits
Non - Network Benefits
Coverage level is same as corresponding Network Coverage level is same as corresponding Non - Network
Benefit, depending on type of service provided such Benefit, depending on type of service provided, such as
as Office Visits for Illness or Injury, Inpatient or Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services. Outpatient Hospital Services.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
Q. OFFICE VISITS FOR ILLNESS OR INJURY
Covered Services:
We cover the following when medically necessary: professional medical and surgical services and related supplies, including
biofeedback, of physicians and other health care providers; blood and blood products (unless replaced) and blood derivatives.
We cover diagnosis and treatment of illness or injury to the eyes. Where contact or eyeglass lenses are prescribed as medically
necessary for the post - operative treatment of cataracts or for the treatment of aphakia, or keratoconus, we cover the initial
evaluation, lenses and fitting. Insureds must pay for lens replacement beyond the initial pair.
We also provide coverage for the initial physical evaluation of a child if it is ordered by a Minnesota juvenile court.
Office visits
Network Benefits Non- Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Convenience clinics
Network Benefits Non- Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Scheduled telephone visits
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
E- visits
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 21
NIN11i
Injections administered in a physician's office, other than immunizations
Allergy injections
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
All other injections
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Not Covered:
• Court ordered treatment, except as described in this Benefits Chart section C., subsection "Mental Health Services" and
section Q. "Office Visits for Illness or Injury" or as otherwise required by law.
• See Services Not Covered in the Group Certificate Section III.
R. PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY
Covered Services:
We cover the following physical therapy, occupational therapy and speech therapy services:
1. Medically necessary rehabilitative care to correct the effects of illness or injury.
2. Habilitative care rendered for congenital, developmental or medical conditions which have significantly limited the
successful initiation of normal speech and normal motor development.
Massage therapy which is performed in conjunction with other treatment /modalities by a physical or occupational therapist, is
part of a prescribed treatment plan and is not billed separately is covered.
We cover services provided in a clinic. We also cover physical therapy provided in an outpatient hospital facility. To see the
benefit level for inpatient hospital or skilled nursing facility services, see benefits under Inpatient Hospital and Skilled Nursing
Facility Services.
Rehabilitative Care
Network Benefits
100% of the charges incurred.
Habilitative Care
Non - Network Benefits
80% of the charges incurred.
Physical and Occupational Therapy combined are
limited to 20 visits per calendar year.
Speech Therapy is limited to 20 visits per calendar
year.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Physical, Occupational and Speech Therapy
combined are limited to 20 visits per calendar year.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 22
Not Covered:
• Massage therapy for the purpose of comfort or convenience of the insured.
• See Services Not Covered in the Group Certificate Section III.
S. PORT WINE STAIN REMOVAL SERVICES
Covered Services:
We cover port wine stain removal services.
Network Benefits
Coverage level is same as corresponding Network
Benefit, depending on type of service provided such
as Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
Not Covered:
Non - Network Benefits
Coverage level is same as corresponding Non -
Network Benefit, depending on type of service
provided such as Office Visits for Illness or Injury,
Inpatient or Outpatient Hospital Services.
• See Services Not Covered in the Group Certificate Section III.
T. PRESCRIPTION DRUG SERVICES
Covered Services:
We cover prescription drugs and medications, which can be self - administered or are administered in a physician's office. We
cover off -label use of formulary drugs to treat cancer if the drug is recognized for the treatment of cancer in one of the standard
reference compendia or in one article in the medical literature as defined by Minnesota Statute 62Q.525.
For Network benefits, drugs and medications must be obtained at a Network Pharmacy.
Outpatient drugs (other than tobacco cessation, contraceptive, specialty and growth deficiency drugs)
Network Benefits
100% of the charges incurred.
Drugs for the treatment of sexual dysfunction are
limited to six doses per month.
Non - Network Benefits
60% of the charges incurred.
Drugs for the treatment of sexual dysfunction are
limited to six doses per month.
Tobacco cessation drugs are covered for all FDA - approved tobacco cessation drugs (including over - the - counter drugs) for
a minimum of 90 days.
Network Benefits
Formulary Drugs:
100% of the charges incurred.
Deductible does not apply.
Non - Network Benefits
60% of the charges incurred.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 23
BENEFITS CHART
Mail Order Drugs
Network Benefits
Non - Network Benefits
You may also get outpatient prescription drugs which See Network Mail Order Drugs Benefit.
can be self - administered through HealthPartners mail
order service. Outpatient drugs ordered through this
service are covered at the benefit percent shown in
Outpatient Drugs above.
New prescriptions to treat certain chronic conditions
and trial drugs will be limited to quantity limits
described at the end of this section.
Drugs for the treatment of sexual dysfunction are
limited to 18 doses per 90—day supply.
Specialty Drugs are not available through the mail
order service.
Specialty Drugs which are self - administered
Network Benefits Non- Network Benefits
See Network Outpatient drugs benefit. See Non - Network Outpatient Drugs benefit.
For Network Benefits, Specialty Drugs are limited to drugs on the specialty drug list and must be obtained front a
designated vendor.
Drugs for the treatment of growth deficiency
Network Benefits Non - Network Benefits
80% of the charges incurred. 80% of the charges incurred.
For Network Benefits, Growth Deficiency Drugs are limited to drugs on the specialty drug list and must be
obtained from a designated vendor.
Contraceptive drugs
Network Benefits
100% of the charges incurred for formulary drugs.
Deductible does not apply.
If a physician requests that a non - formulary
contraceptive drug be dispensed as written, the drug
will be covered at 100 %, not subject to the
deductible.
Non - Network Benefits
60% of the charges incurred.
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Unless otherwise specified in the Prescription Drug Services section, you may receive up to a 30 -day supply per
prescription. Certain drugs may require prior authorization as indicated on the formulary. HealthPartners may
require prior authorization.for the drug and also the site where the drug will be provided. Certain drugs are
subject to our utilization review process and quantity limits as indicated on our formulary. New prescriptions are
limited to a 30 -day supply. Certain non formulary drugs require prior authorization. In addition, certain drugs
may be subject to any quantity limits applied as part of our trial program. A 90 -dav supply will be covered and
dispensed only at pharmacies that participate in our extended day supply program. No more than a 30 -day supply
of Specialty Drugs will be covered and dispensed at a time.
If an insured requests a brand drug when there is a generic equivalent, the brand drug will be covered up to the
charge that would apply to the generic drug, minus any required copayment. If a physician requests that a brand
drug be dispensed as written, and we determine the brand drug is medically necessary, the drug will be paid at the
brand drug benefit.
Not Covered:
Replacement of prescription drugs, medications, equipment and supplies due to loss, damage or theft.
Nonprescription (over the counter) drugs or medications, unless listed on the formulary and prescribed by a physician or
legally authorized health care provider under applicable state law, including, but not limited to, vitamins, supplements,
homeopathic remedies, and non -FDA approved drugs. We cover off -label use of drugs to treat cancer as specified in the
"Prescription Drug Services" section of this Benefits Chart. This exclusion does not include over - the - counter contraceptives
for women as allowed under the Affordable Care Act when the insured obtains a prescription for the item. In addition, if the
insured obtains a prescription, this exclusion does not include aspirin to prevent cardiovascular disease for men and women
of certain ages; folic acid supplements for women who may become pregnant; fluoride chemoprevention supplements for
children without fluoride in their water source; and iron supplements for children ages 6 -12 who are at risk for anemia.
All drugs for the treatment of infertility.
Medical cannabis.
See Services Not Covered in the Group Certificate Section III.
U. PREVENTIVE SERVICES
Covered Services:
We cover preventive services which meet any of the requirements under the Affordable Care Act (ACA) shown in the bulleted
items below. These preventive services are covered at 100% under the network benefits with no deductible, copayments or
coinsurance. (If a preventive service is not required by the ACA and it is covered at a lower benefit level, it will be specified
below). Preventive benefits mandated under the ACA are subject to periodic review and modification. Changes would be
effective in accordance with the federal rules. Preventive services mandated by the ACA include:
• Evidence -based items or services that have in effect a rating of A or B in the current recommendations of the United
States Preventive Services Task Force with respect to the individual;
• Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the
Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the
individual;
• With respect to infants, children, and adolescents, evidence- informed preventive care and screenings provided for in
comprehensive guidelines supported by the Health Resources and Services Administration; and
• With respect to women, preventive care and screenings provided for in comprehensive guidelines supported by the
Health Resources and Services Administration.
Covered services are based on established medical policies, which are subject to periodic review, and modification by the medical
or dental directors. These medical policies (medical coverage criteria) are available by calling Member Services, or logging on to
your "myHealthPartners" account at www.healthpartners.com.
In addition to any ACA mandated preventive services referenced above, we cover the following eligible preventive services.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 25
Benefits are limited to $300 per calendar year for the following items: 1., 5., 6., 7., 9. and 10. combined
under the Non - Network Benefits.
1. Routine health exams and periodic health assessments. A physician or health care provider will counsel you as to
how often health assessments are needed based on age, sex and health status. This includes screening for tobacco use,
at least two tobacco cessation attempts per year (for those who use tobacco products), all FDA approved tobacco
cessation medications including over - the- counter drugs (as shown in the prescription drugs section) and at least four
counseling sessions of at least ten minutes each for tobacco cessation.
Network Benefits Non- Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Deductible does not apply.
2. Child health supervision services, including pediatric preventive services, routine immunizations, developmental
assessments and laboratory services appropriate to the age of the child from birth to 72 months, and appropriate
immunizations to age 18.
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefit.
Deductible does not apply.
3. Routine prenatal care and exams to include visit - specific screening tests, education and counseling.
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefit.
Deductible does not apply.
4. Routine postnatal care and exams to include health exams, assessments, education and counseling relating to the period
immediately after childbirth.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Deductible does not apply.
5. Routine screening procedures for cancer, including colorectal screening, pap smears, ovarian cancer screening and prostate
screening. Women's preventive health services below describe additional routine screening procedures for cancer.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Deductible does not apply.
BCH- 900.34
(,VI-HDHP -2600- 90003 -16) 26
s �
6. Routine eye and hearing exams
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Deductible does not apply.
7. Professional voluntary family planning services
Network Benefits Non- Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Deductible does not apply.
8. Adult immunizations
Network Benefits Non- Network Benefits
100;0 of the charges incurred. 80% of the charges incurred.
Deductible does not apply.
9. Women's preventive health services including mammograms; screenings for cervical cancer; breast pumps; human
papillomavirus (HPV) testing; counseling for sexually transmitted infections; and counseling and screening for human
immunodeficiency virus (HIV); and all FDA approved contraceptive methods as prescribed by a doctor; sterilization
procedures, education and counseling (see prescription drug services section for coverage of contraceptive drugs).
For women whose family history is associated with an increased risk for BRCAI or BRCA2 gene mutations, we cover
genetic counseling and BRCA screening without cost sharing, if appropriate and as determined by a physician.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80% of the charges incurred.
Deductible does not apply.
10. Obesity screening and management. We cover obesity screening and counseling for all ages during a routine
preventive care exam. If you are an adult age 18 or older and have a body mass index of 30 or more, we also cover
intensive obesity management to help you lose weight. Your primary care doctor can coordinate these services.
Network Benefits Non - Network Benefits
100% of the charges incurred. 80° o of the charges incurred.
Deductible does not apply.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(14'1 -HDHP -2600- 90003 -16) 27
V. SPECIFIED NON - NETWORK SERVICES
Covered Services:
We cover the following services when you elect to receive them from a non- network provider, at the same level of coverage we
provide when you elect to receive the services from a network provider:
1. Voluntary family planning of the conception and bearing of children.
2. Testing and treatment of sexually transmitted diseases (other than HIV).
3. Testing for AIDS or other HIV - related conditions.
Network Benefits Non - Network Benefits
Coverage level is same as corresponding Network See Network coverage for the services covered.
Benefit, depending on type of service provided, such as
Office Visits for Illness or Injury.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
W. TRANSPLANT SERVICES
Applicable Definitions:
Autologous. This is when the source of cells is from the individual's own marrow or stem cells.
Allogeneic. This is when the source of cells is from a related or unrelated donor's marrow or stem cells.
Autologous Bone Marrow Transplant. This is when the bone marrow is harvested from the individual and stored. The patient
undergoes treatment which includes tumor ablation with high -dose chemotherapy and /or radiation. The bone marrow is reinfused
(transplanted).
Allogeneic Bone Marrow Transplant. This is when the bone marrow is harvested from the related or unrelated donor and
stored. The patient undergoes treatment which includes tumor ablation with high -dose chemotherapy and/or radiation. The bone
marrow is reinfused (transplanted).
Autologous /Allogeneic Stem Cell Support. This is a treatment process that includes stem cell harvest from either bone marrow
or peripheral blood, tumor ablation with high -dose chemotherapy and /or radiation, stern cell reinfusion, and related care.
Autologous /allogeneic bone marrow transplantation and high dose chemotherapy with peripheral stem cell rescue /support are
considered to be autologous /allogeneic stem cell support.
Designated Transplant Center. This is any health care provider, group or association of health care providers designated by us
to provide services, supplies or drugs for specified transplants for our insureds.
Transplant Services. This is transplantation (including retransplants) of the human organs or tissue listed below, including all
related post - surgical treatment, follow -up care and drugs and multiple transplants for a related cause. Transplant services do not
include other organ or tissue transplants or surgical implantation of mechanical devices functioning as a human organ, except
surgical implantation of an FDA approved Ventricular Assist Device (VAD) or total artificial heart, functioning as a temporary
bridge to heart transplantation.
Covered Services:
We cover eligible transplant services (as defined above) while you are covered under this Certificate. Transplants that will be
considered for coverage are limited to the following:
1. Kidney transplants for end -stage disease.
2. Cornea transplants for end -stage disease.
3. Heart transplants for end -stage disease.
4. Lung transplants or heart /lung transplants for: (1) primary pulmonary hypertension; (2) Eisenmenger's syndrome; (3) end -
stage pulmonary fibrosis; (4) alpha 1 antitrypsin disease; (5) cystic fibrosis; and (6) emphysema.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 28
5. Liver transplants for: (1) biliary atresia in children; (2) primary biliary cirrhosis; (3) post -acute viral infection (including
hepatitis A, hepatitis B antigen e negative and hepatitis C) causing acute atrophy or post - necrotic cirrhosis; (4) primary
sclerosing cholangitis; (5) alcoholic cirrhosis; and (6) hepatocellular carcinoma.
6. Allogeneic bone marrow transplants or peripheral stem cell support associated with high dose chemotherapy for: (1) acute
myelogenous leukemia; (2) acute lymphocytic leukemia; (3) chronic myelogenous leukemia; (4) severe combined
immunodeficiency disease; (5) Wiskott- Aldrich syndrome; (6) aplastic anemia; (7) sickle cell anemia; (8) non - relapsed or
relapsed non - Hodgkin's lymphoma; (9) multiple myeloma; and (10) testicular cancer.
7. Autologous bone marrow transplants or peripheral stem cell support associated with high -dose chemotherapy for: (1) acute
leukemias; (2) non - Hodgkin's lymphoma; (3) Hodgkin's disease; (4) Burkitt's lymphoma; (5) neuroblastoma; (6) multiple
myeloma; (7) chronic myelogenous leukemia; and (8) non - relapsed non - Hodgkin's lymphoma.
8. Pancreas transplants for simultaneous pancreas- kidney transplants for diabetes, pancreas after kidney, living related
segmental simultaneous pancreas kidney transplantation and pancreas transplant alone.
To receive Network Benefits, charges for transplant services must be incurred at a Designated Transplant Center. The transplant -
related treatment provided, including the expenses incurred for directly related donor services, shall be subject to and in
accordance with the provisions, limitations, maximums and other terms of this Certificate.
Medical and hospital expenses of the donor are covered only when the recipient is an insured and the transplant and directly
related donor expenses have been prior authorized for coverage. Treatment of medical complications that may occur to the donor
are not covered. Donors are not considered insureds, and are therefore not eligible for the rights afforded to insureds under this
Certificate.
The list of eligible transplant services and coverage determinations are based on established medical policies, which are subject to
periodic review and modification by the medical director.
Network Benefits Non - Network Benefits
See Network Inpatient Hospital Services Benefit. See Non - Network Inpatient Hospital Services Benefit.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Not Covered:
• We consider the following transplants to be investigative and do not cover them: surgical implantation of mechanical devices
functioning as a permanent substitute for human organ, non -human organ implants and/or transplants and other transplants
not specifically listed in the Certificate.
• See Services Not Covered in the Group Certificate Section 111.
BCH- 900.34
(1V1 -HDHP -2600- 90003 -16) 29
X. ADDITIONAL SERVICES COVERED UNDER THE PLAN
Covered Services:
We cover the following additional program:
Medication Therapy Disease Management Program. If you meet our criteria for coverage, you may qualify for our
Medication Therapy Disease Management program.
The program covers consultations with a designated pharmacist.
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
directors. These medical policies (medical coverage criteria) are available by logging on to your "my HealthPartners" account at
www.healthpartners.com or by calling Member Services.
Network Benefits Non - Network Benefits
100% of the charges incurred. No Coverage.
Deductible does not apply.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
Y. WEIGHT LOSS SURGERY OR BARIATRIC SURGERY
Covered Services:
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
directors. These medical policies (medical coverage criteria) are available on -line by logging on to your "myHealthPartners"
account at www.healthpartners.com or by calling Member Services.
Network Benefits Non- Network Benefits
No Coverage. No Coverage.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(NI -HDHP -2600- 90003 -16) 30
NationalONEsm Plan
Benefits Chart
Group Policyholder: City of Columbia Heights
Group Number: 90003
Effective Date: The later of January 1, 2016 and your effective date of coverage under the Group Policy.
HealthPartners Insurance Company agrees to cover the services described below. The Benefits Chart
describes the level of payment that applies for each of the covered services. To be covered under this
section, the medical or dental services or items described below must be medically or dentally necessary.
Coverage for eligible services is subject to the exclusions, limitations, and other conditions of this Benefits
Chart and Group Certificate.
Covered services and supplies are based on established medical policies, which are subject to periodic
review and modification by the medical or dental directors. These medical policies (medical coverage
criteria) are available by calling Member Services, or logging on to your "myHealthPartners" account at
www.healthpartners.com.
The Network Benefits constitute a Non - Qualified Plan. The Non - Network Benefits constitute a Non -
qualified plan.
Benefits are underwritten by HealthPartners Insurance Company.
Coverage may vary depending on whether you select a network provider or a non - network provider.
The amount that we pay for covered services is listed below. You are responsible for the specified dollar
amount and /or percentage of charges that we do not pay.
When you use Non - Network providers, benefits are substantially reduced and you will likely incur
significantly higher out -of- pocket expenses. A Non- Network provider does not usually have an
agreement with HealthPartners to provide services at a discounted fee. In addition, Non - Network
Benefits are restricted to the usual and customary amount under the definition of "Charge." The usual
and customary amount can be significantly lower than a Non - Network provider's billed charges. If the
Non - Network provider's billed charges are over the usual and customary amount, you pay the difference,
in addition to any required deductible, copayment and /or coinsurance, and these charges do not apply to
the out -of- pocket limit. The only exceptions to this requirement are described below in the "Emergency
and Urgently Needed Care Services" section. This section describes what benefits are covered at the
Network Benefit level regardless of who provides the service.
These definitions apply to the Benefits Chart. They also apply to the Certificate.
Biosimilar Drug: A prescription drug, approved by the Food and Drug Administration (FDA), that the FDA
has determined is biosimilar to and interchangeable with a biological brand drug.
Biosimilar drugs are not considered generic drugs and are not covered under the generic
drug benefit.
BCH- 900.34
(,VI 90003 -16)
Brand Drug:
A prescription drug, approved by the Food and Drug Administration (FDA), that is
manufactured, sold, or licensed for sale under a trademark by the pharmaceutical
company that originally researched and developed the drug. Brand drugs have the same
active - ingredient formula as the generic version of the drug. However, generic drugs are
manufactured and sold by other drug manufacturers and are generally not available until
after the patent on the brand drug has expired. A few brand drugs may be covered at the
generic drug benefit level if this is indicated on the formulary.
Charge:
For covered services delivered by participating network providers, is the provider's
discounted charge for a given medical /surgical service, procedure or item.
For covered services delivered by non - network providers, is the provider's charge for a
given medical /surgical service procedure or item, according to the usual and customary
charge allowed amount.
The Usual and Customary Charge is the maximum amount allowed we consider in the
calculation of payment of charges incurred for certain covered services. It is consistent
with the charge of other providers of a given service or item in the same region. You
must pay for any charges above the usual and customary charge, and they do not apply to
the out -of- pocket limit.
A charge is incurred for covered ambulatory medical and surgical services, on the date
the service or item is provided. A charge is incurred for covered inpatient services, on
the date of admission to a hospital. To be covered, a charge must be incurred on or after
your effective date and on or before the termination date.
Combined Day Limit:
Your total benefit is combined, for inpatient hospitalization, skilled nursing facility care
services and inpatient mental and chemical health services, and limited to 365 days per
period of confinement. Each day of such services provided under the Network Benefits
and Non - Network Benefits counts toward this combined day limit, for the same period of
confinement.
Copayment /Coinsurance:
The specified dollar amount, or percentage, of charges incurred for covered services,
which we do not pay, but which you must pay, each time you receive certain medical
services, procedures or items. Our payment for those covered services or items begins
after the copayment or coinsurance is satisfied. Covered services or items requiring a
copayment or coinsurance are specified in this Certificate.
For services provided by a network provider:
An amount which is listed as a flat dollar copayment is applied to a network provider's
discounted charges for a given service. However, if the network provider's discounted
charge for a service or item is less than the flat dollar copayment, you will pay the
network provider's discounted charge. An amount which is listed as a percentage of
charges or coinsurance is based on the network provider's discounted charges, calculated
at the time the claim is processed, which may include an agreed upon fee schedule rate
for case rate or withhold arrangements.
For services provided by a non- network provider:
Any copayment or coinsurance is applied to the lesser of the provider's charges or
the usual and customary charge for a service.
A copayment or coinsurance is due at the time a service is provided, or when billed by
the provider. The copayment or coinsurance applicable for a scheduled visit with a
Network provider will be collected for each visit, late cancellation and failed
appointment.
BCH- 900.34
(N] 90003 -16)
Deductible:
The specified dollar amount of charges incurred for covered services, which we do not
pay, but an enrollee or a family has to pay first in a calendar year. Our payment for
those services or items begins after the deductible is satisfied. If you have a family
deductible, each individual family member may only contribute up to the individual
deductible amount toward the family deductible. An individual's copayments and
coinsurance do not apply toward the family deductible. For network providers, the
amount of the charges that apply to the deductible are based on the network provider's
discounted charges, calculated at the time the claim is processed, which may include an
agreed upon fee schedule rate for case rate or withhold arrangements. For non - network
providers, the amount of charges that apply to the deductible are the lesser of the
provider's charges or the usual and customary charge for a service.
Formulary:
This is a current list, which may be revised from time to time, of prescription drugs,
medications, equipment and supplies covered by us as indicated in the Benefits Chart
which are covered at the highest benefit level. Some drugs on the Formulary may require
prior authorization to be covered as formulary drugs. You may be granted an exception
to the formulary that is available to you upon request. These guidelines and procedures
include exceptions to the formulary for anti - psychotic prescription drugs prescribed to
treat emotional disturbances or mental illness if your health care provider (1) indicates to
the dispensing phannacist, orally or in writing, that the prescription must be dispensed as
indicated and (2) certifies in writing to us that the prescribed drug will best treat your
condition. Also, you may continue to receive certain non - formulary prescription drugs
for diagnosed mental illness or emotional disturbance when our formulary changes or you
change health plans for up to one year following the change. The formulary, and
information on drugs that require prior authorization, are available by calling Member
Services, or logging on to your "myHealthPartners" account at www.healthpartners.com.
Generic Drug:
A prescription drug approved by the Food and Drug Administration (FDA) that the FDA
has determined is comparable to a brand drug product in dosage form, strength, route of
administration, quality, intended use and documented bioequivalence. Generally, generic
drugs cost less than brand drugs. Some brand drugs may be covered at the generic drug
benefit level if this is indicated on the formulary.
Lifetime Maximum Benefit:
The specified coverage limit paid for all charges combined and actually paid by us for
you under that coverage. Our payment ceases for you, when that limit is reached. You
have to pay for subsequent charges.
Non - Formulary Drug:
This is a prescription drug, approved by the Food and Drug Administration (FDA), that
is not on the formulary, is medically necessary and is not investigative or otherwise
excluded under this Certificate.
Out -of- Pocket Expenses:
You pay the specified copayments /coinsurance and deductibles applicable for particular
services, subject to the out -of- pocket limit described below. These amounts are in
addition to the monthly premium payments.
BCH- 900.34
(1421 90003 -16)
Out -of- Pocket Limit: You pay the copaymentslcoinsurance and deductibles for covered services, to the
individual or family out -of- pocket limit. Thereafter we cover 100% of charges incurred
for all other covered services, for the rest of the calendar year. You pay amounts greater
than the out -of- pocket limit if any benefit maximums or the lifetime maximum are
exceeded.
Non- Network Benefits above the usual and customary charge (see definition of charge
above) do not apply to the out -of- pocket limit.
Non - Network Benefits for transplant surgery do not apply to the out -of- pocket limit.
You are responsible to keep track of the out -of- pocket expenses. Contact our Member
Services Department for assistance in determining the amount paid by the enrollee for
specific eligible services received. Claims for reimbursement under the out -of- pocket
limit provisions are subject to the same time limits and provisions described under the
"Claims Provisions" section of the Certificate.
Specialty Drug List: This is a current list, which may be revised from time to time, of prescription drugs,
medications, equipment and supplies, which are typically bio- pharmaceuticals. The
purpose of a specialty drug list is to facilitate enhanced monitoring of complex therapies
used to treat specific conditions. Specialty drugs are covered by us as indicated below.
The specialty drug list is available by calling Member Services, or logging on to your
"rnyHealthPartners" account at www.healthpartners.com.
Virtuwell: Virtuwell is an online service that you may use to receive a diagnosis and treatment for
certain routine conditions, such as a cold and flu, ear pain and sinus infections. You may
access the vrtuwell website at www.virtuwell.com.
BCH- 900.34
(N1 90003 -16)
Individual Calendar Year Deductible
Network Benefits Non - Network Benefits
None. $2,000
Family Calendar Year Deductible
Network Benefits Non - Network Benefits
None. $5,000
Individual Calendar Year Out -of- Pocket Limit
Network Benefits Non- Network Benefits
$2,000 $9,000
Family Calendar Year Out -of- Pocket Limit
Network Benefits Non- Network Benefits
$5,000 None.
The Out -of- Pocket Limits under the Network Benefits and the Non- Network Benefits are combined.
Any reduction in benefits far failure to comply with CareChece requirements will not apply toward the Out -of-
Pocket Limit.
Non - Network Benefits above the usual and customary charge will not apply toward the individual orfamily out -
of- pocket limit.
Lifetime Maximum Benefit for Transplant Surgery
Network Benefits Non - Network Benefits
Unlimited. $25,000
Lifetime Maximum Benefit
Network Benefits Non - Network Benefits
Unlimited. $2,000,000
BCH- 900.34
(NI 90003 -16) 5
BENEFITS CHART
Notice: Some benefits listed in this Benefits Chart require precertification. See section I.K. "CareCheck�"
of your Certificate for details.
A. AMBULANCE AND MEDICAL TRANSPORTATION
Covered Services:
We cover ambulance and medical transportation for medical emergencies and as shown below.
For Network Benefits. Transfers between network hospitals for treatment by network physicians are covered, if initiated by a
network physician. Transfers from a hospital or to home or to other facilities are covered, if medical supervision is required en
route.
Network Benefits Non- Network Benefits
100% of the charges incurred. See Network Benefits.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
B. AUTISM BENEFIT
Covered Services:
We cover Applied Behavioral Therapy (ABA), Intensive Early Intervention Behavioral Therapy (IEIBT), and Lovaas for children
under age 18. For other autism services covered under this Certificate, see the habilitative benefit under Physical Therapy,
Occupational Therapy and Speech Therapy.
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
or dental directors. These medical policies (medical coverage criteria) are available on -line at www.healthpartners.com or by
calling Member Services.
Network Benefits Non - Network Benefits
100% of the charges incurred, subject to your No Coverage.
copayment of $15 per visit.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
C. BEHAVIORAL HEALTH SERVICES
Covered Services:
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
directors. These medical policies (medical coverage criteria) are available by calling Member Services, or logging on to your
"myHealthPartners" account at www.healthpartners.com.
Mental Health Services
We cover services for mental health diagnoses as described in the Diagnostic and Statistical Manual of Mental Disorders — Fifth
Edition (DSMV) (most recent edition).
BCH- 900.34
(AT] 90003 -16)
We also provide coverage for mental health treatment ordered by a Minnesota court under a valid court order that is issued on the
basis of a behavioral care evaluation performed by a licensed psychiatrist or doctoral level licensed psychologist, which includes a
diagnosis and an individual treatment plan for care in the most appropriate, least restrictive environment. We must be given a
copy of the court order and the behavioral care evaluation, and the service must be a covered benefit under this plan, and the
service must be provided by a network provider, or other provider as required by law. We cover the evaluation upon which the
court order was based if it was provided by a network provider. We also provide coverage for the initial mental health evaluation
of a child, regardless of whether that evaluation leads to a court order for treatment, if the evaluation is ordered by a Minnesota
juvenile court.
a. Outpatient Services including intensive outpatient and day treatment services: We cover medically necessary outpatient
professional mental health services for evaluation, crisis intervention, and treatment of mental health disorders.
A comprehensive diagnostic assessment will be made of each patient as the basis for a determination by a mental
health professional, concerning the appropriate treatment and the extent of services required.
Outpatient services we cover for a diagnosed mental health condition include the following:
(1) Individual, group, family, and multi - family therapy;
(2) Medication management provided by a physician, certified nurse practitioner, or physician's assistant;
(3) Psychological testing services for the purposes of determining the differential diagnoses and treatment planning for
patients currently receiving behavioral health services;
(4) Day treatment and intensive outpatient services in a licensed program;
(5) Partial hospitalization services in a licensed hospital or community mental health center; and
(6) Psychotherapy and nursing services provided in the home if authorized by us.
Network Benefits
Non - Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $15 per visit.
For family therapy, only one copayment will be
charged, regardless of the number of insureds
primarily involved in the therapy.
Group Therapy
Network Benefits Non - Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $7.50 per visit.
BCH- 900.34
(NI 90003 -16)
b. Inpatient Services, including psychiatric residential treatment for emotionally disabled children: We cover medically
necessary inpatient services in a hospital and professional services for treatment of mental health disorders. Medical
stabilization is covered under inpatient hospital services in the "Hospital and Skilled Nursing Facility Services" section.
We cover residential care for the treatment of eating disorders in a licensed facility, as an alternative to inpatient care, when it
is medically necessary and your physician obtains authorization from us.
We also cover medically necessary psychiatric residential treatment for emotionally disabled children as diagnosed by a
physician. This care must be authorized by us and provided by a hospital or residential treatment center licensed by the local
state or Health and Human Services Department. The child must be under 18 years of age and an eligible dependent
according to the terms of this Certificate. Services not covered under this benefit include shelter services, correctional
services, detention services, transitional services, group residential services, foster care services and wilderness programs.
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Chemical Health Services
We cover medically necessary services for assessments by a licensed alcohol and drug counselor and treatment of Substance -
Related Disorders as defined in the latest edition of the DSM V.
a. Outpatient Services including intensive outpatient and day treatment services: We cover medically necessary
outpatient professional services for the diagnosis and treatment of chemical dependency. Chemical dependency treatment
services must be provided by a program licensed by the local Health and Human Services Department.
Outpatient services we cover for a diagnosed chemical dependency condition include the following:
(1) Individual, group, family, and multi - family therapy provided in an office setting;
(2) We cover opiate replacement therapy including methadone and buprenorphine treatment; and
(3) Day treatment and intensive outpatient services in a licensed program.
Network Benefits
100% of the charges incurred, subject to your
copayment of $15 per visit.
For family therapy, only one copayment will be
charged, regardless of the number of insureds
primarily involved in the therapy.
Network Benefits
Non - Network Benefits
50% of the charges incurred.
Non - Network Benefits
We cover supervised lodging at a contracted We cover supervised lodging at a contracted
organization for insureds actively involved in an organization for insureds actively involved in an
affiliated licensed chemical dependency day treatment affiliated licensed chemical dependency day
or intensive outpatient program for treatment of treatment or intensive outpatient program for
alcohol or drug abuse. treatment of alcohol or drug abuse.
BCH- 900.34
(NI 90003 -16)
BENEFITS CHART
b. Inpatient Services: We cover medically necessary inpatient services in a hospital or primary residential treatment in a
licensed chemical health treatment center. Primary residential treatment is an intensive residential treatment program of
limited duration, typically 30 days or less.
We cover services provided in a hospital that is licensed by the local state and accredited by Medicare.
Detoxification Services. We cover detoxification services in a hospital or community detoxification facility if it is licensed
by the local Health and Human Services Department.
Covered services are based on established medical policies, which are subject to periodic review and modification by the
medical directors. These medical policies (medical coverage criteria) are available by calling Member Services, or logging
on to your "myHealthPartners" account at www.healthpartners.com.
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Not Covered:
• Rest and respite services and custodial care, except as respite services are specifically described in this Benefits Chart under
the section "Home Hospice Services ". This includes all services, medical equipment and drugs provided for such care.
• Halfway houses, extended care facilities, or comparable facilities, residential treatment.
• Foster care, adult foster care and any type of family child care provided or arranged by the local state or county.
• Religious counseling; marital /relationship counseling and sex therapy.
• Professional services associated with substance abuse interventions. A "substance abuse intervention" is a gathering of
family and /or friends to encourage a person covered under this certificate to seek substance abuse treatment.
• Court ordered treatment, except as described in this Benefits Chart section C. subsection "Mental Health Services" and
section Q. "Office Visits for Illness or Injury" or as otherwise required by law.
• Vagus nerve stimulator treatment for the treatment of depression.
• Quantitative Electroencephalogram treatment for the treatment of behavioral health conditions.
• See Services Not Covered in the Group Certificate Section III.
D. CHIROPRACTIC SERVICES
Covered Services:
We cover chiropractic services for rehabilitative care. Chiropractic services are adjustments to any abnormal articulations of the
human body, especially those of the spinal column, for the purpose of giving freedom of action to impinged nerves that may cause
pain or deranged function.
Massage therapy which is performed in conjunction with other treatment /modalities by a chiropractor, is part of a prescribed
treatment plan and is not billed separately is covered.
Network Benefits Non- Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $15 per office visit.
Limit of 20 visits per calendar year.
Not Covered:
• Massage therapy for the purpose of comfort or convenience of the insured.
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(NI 90003 -16)
[JIMIN El ;1
E. CLINICAL TRIALS
Covered Services:
We cover certain routine services if you participate in a Phase I, Phase II, Phase III or Phase IV clinical trial that is conducted in
relation to the prevention, detection, or treatment of cancer or other life - threatening disease or condition as defined in the
Affordable Care Act. We cover routine patient costs for services that would be eligible under this Certificate if the service were
provided outside of a clinical trial.
Network Benefits
Coverage level is same as corresponding Network
Benefit, depending on type of service provided such as
Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
Not Covered:
• The investigative item, device or service itself.
Non - Network Benefits
Coverage level is same as corresponding Non - Network
Benefit, depending on type of service provided such as
Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
• Items or services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct
clinical management of the patient.
• A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.
• See Services Not Covered in the Group Certificate Section III.
F. DENTAL SERVICES
Covered Services:
We cover services described below.
Accidental Dental Services: We cover dentally necessary services to treat and restore damage done to sound, natural, unrestored
teeth as a result of an accidental injury. Coverage is for damage caused by external trauma to face and mouth only, not for
cracked or broken teeth which result from biting or chewing. We cover restorations, root canals, crowns and replacement of teeth
lost that are directly related to the accident in which the insured was involved. We cover initial exams, x -rays, and palliative
treatment including extractions, and other oral surgical procedures directly related to the accident. Subsequent treatment must be
initiated within the Certificate's time -frame and must be directly related to the accident. We do not cover restoration and
replacement of teeth that are not "sound and natural" at the time of the accident.
Full mouth rehabilitation to correct occlusion (bite) and malocclusion (misaligned teeth not due to the accident) are not covered.
When an implant - supported dental prosthetic treatment is pursued, the accidental dental benefit will be applied to the prosthetic
procedure. Benefits are limited to the amount that would be paid toward the placement of a removable dental prosthetic appliance
that could be used in the absence of implant treatment. Care must be provided or pre- authorized by a HealthPartners dentist.
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
For all accidental dental services, treatment andlor restoration must be initiated within six months of the date of
the injury. Coverage is limited to the initial course of treatment and/or initial restoration. Services must be
provided within twenty-four months of the date of injury to be covered.
BCH- 900.34
(VZ 90003 -16) 10
Medical Referral Dental Services
a. Medically Necessary Outpatient Dental Services: We cover medically necessary outpatient dental services. Coverage is
limited to dental services required for treatment of an underlying medical condition, e.g., removal of teeth to complete
radiation treatment for cancer of the jaw, cysts and lesions.
Network Benefits Non - Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $15 per office visit.
b. Medically Necessary Hospitalization and Anesthesia for Dental Care: We cover medically necessary hospitalization
and anesthesia for dental care. This is limited to charges incurred by an insured who: (1) is a child under age 5; (2) is
severely disabled; (3) has a medical condition, and requires hospitalization or general anesthesia for dental care treatment;
or (4) is a child between age 5 and 12 and care in dental offices has been attempted unsuccessfully and usual methods of
behavior modification have not been successful, or when extensive amounts of restorative care, exceeding 4 appointments,
are required. The requirement of a hospital setting must be due to an insured's underlying medical condition. Coverage is
limited to facility and anesthesia charges. Anesthesia is covered in a hospital or a dental office. Oral surgeon/dentist
professional fees are not covered. The following are examples, though not all - inclusive, of medical conditions which may
require hospitalization for dental services: severe asthma, severe airway obstruction or hemophilia. Hospitalization
required due to the behavior of the insured or due to the extent of the dental procedure is not covered.
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
c. Medical Complications of Dental Care: We cover medical complications of dental care. Treatment must be medically
necessary care and related to medical complications of non - covered dental care, including complications of the head, neck,
or substructures.
Network Benefits Non- Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred,
copayment of $15 per office visit.
Oral Surgery: We cover oral surgery. Coverage is limited to treatment of medical conditions requiring oral surgery, such as
treatment of oral neoplasm, non - dental cysts, fracture of the jaws, trauma of the mouth and jaws, and any other oral surgery
procedures provided as medically necessary dental services.
Network Benefits Non - Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $15 per office visit.
BCH- 900.34
(] 90003 -16) 11
Orthognathic Surgery Benefit: We cover orthognathic surgery for the treatment of severe skeletal dysmorphia where a
functional occlusion cannot be achieved through non - surgical treatment alone and where a demonstrable functional impairment
exists. Functional impairments include but are not limited to significant impairment in chewing, breathing or swallowing.
Associated dental or orthodontic services (pre- or postoperatively including surgical rapid palatal expansion) are not covered as
part of this benefit.
Network Benefits Non- Network Benefits
80% of the charges incurred. 50% of the charges incurred.
Treatment of Cleft Lip and Cleft Palate of a Dependent Child: We cover treatment of cleft lip and cleft palate of a
dependent child, to the limiting age in the definition of an "Eligible Dependent ", including orthodontic treatment and oral
surgery directly related to the cleft. Benefits for individuals age 26 up to the limiting age for coverage of the dependent are
limited to inpatient or outpatient expenses arising from medical and dental treatment that was scheduled or initiated prior to the
dependent turning age 19. Dental services which are not required for the treatment of cleft lip or cleft palate are not covered. If
a dependent child covered under this Certificate is also covered under a dental plan which includes orthodontic services, that
dental plan shall be considered primary for the necessary orthodontic services. Oral appliances are subject to the same
copayment, conditions and limitations as durable medical equipment.
Network Benefits Non - Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred,
copayment of $15 per office visit.
Treatment of Temporomandibular Disorder (TMD) and Craniomandibular Disorder (CMD): We cover surgical and non-
surgical treatment of temporomandibular disorder (TMD) and craniomandibular disorder (CMD), which is medically necessary
care. Dental services which are not required to directly treat TMD or CMD are not covered.
Network Benefits Non - Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $15 per office visit.
Not Covered:
• Dental treatment, procedures or services not listed in this Benefits Chart.
• Accident related dental services if treatment is (1) provided to teeth which are not sound and natural, (2) to teeth which have
been restored, (3) initiated beyond six months from the date of the injury, (4) received beyond the initial treatment or
restoration or (5) received beyond twenty -four months from the date of injury.
• Oral surgery to remove wisdom teeth.
• See Services Not Covered in the Group Certificate Section III.
G. DIAGNOSTIC IMAGING SERVICES
Covered Services:
We cover diagnostic imaging, when ordered by a provider and provided in a clinic or outpatient hospital facility.
For Network Benefits, non - emergent, scheduled outpatient Magnetic Resonance Imaging (MRI) and computing Tomography
(CT) must be provided at a designated facility. Your physician or facility will obtain or verify prior authorization for these
services, as needed.
We cover services provided in a clinic or outpatient hospital facility (to see the benefit level for inpatient hospital or skilled
nursing facility services, see benefits under Inpatient Hospital and Skilled Nursing Facility Services).
BCH- 900.34
(N7 90003 -16) 12
i -.:
(a) Outpatient Magnetic Resonance Imaging (MRI) and Computing Tomography (CT)
Network Benefits Non- Network Benefits
100% of the charges incurred. 50% of the charges incurred.
(b) All other outpatient diagnostic imaging services
Services for illness or injury
Network Benefits Non- Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Preventive services (MRIICT procedures are not considered preventive)
Diagnostic imaging for preventive services is covered at the benefit level shown in the Preventive Services
section.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
H. DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES
Covered Services:
We cover equipment and services, as described below.
We cover durable medical equipment and services, prosthetics, orthotics, and supplies, subject to the limitations below, including
certain disposable supplies, enteral feedings and the following diabetic supplies and equipment: glucose monitors, insulin pumps,
syringes, blood and urine test strips and other diabetic supplies as deemed medically appropriate and necessary, for insureds with
gestational, Type I or Type II diabetes.
We cover special dietary treatment of Phenylketonuria (PKU) and oral amino acid based elemental formula if it meets our
medical coverage criteria.
External hearing aids (including osseointegrated or bone anchored) for insureds age 18 or younger who have hearing loss that is
not correctable by other covered procedures. Coverage is limited to one hearing aid for each ear every three years.
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
Network Benefits Non - Network Benefits
80% of the charges incurred. 50% of the charges incurred.
Wigs.for hair loss resulting from alopecia areata are limited to one per calendar year. No more than a 90 -day
supply of diabetic supplies are covered and dispensed at a time.
Special dietary treatment for Phenylketonuria (PKU) if it is recommended by a physician
Network Benefits I Non - Network Benefits
80% of the charges incurred. 50% of the charges incurred.
BCH- 900.34
(N190003 -1 b) 13
Oral amino acid based elemental formula if it meets our medical coverage criteria
Network Benefits Non - Network Benefits
80% of the charges incurred. 50% of the charges incurred.
Limitations:
Coverage of durable medical equipment is limited by the following.
• Payment will not exceed the cost of an alternate piece of equipment or service that is effective and medically necessary.
• For prosthetic benefits, other than hair prostheses (i.e., wigs) for hair loss resulting from alopecia areata and oral appliances
for cleft lip and cleft palate, payment will not exceed the cost of an alternate piece of equipment or service that is effective,
medically necessary and enables insureds to conduct standard activities of daily living.
• We reserve the right to determine if an item will be approved for rental vs. purchase.
• Diabetic supplies and equipment are limited to certain models and brands.
• Durable medical equipment and supplies must be obtained from or repaired by approved vendors.
• Covered services and supplies are based on established medical policies which are subject to periodic review and
modification by the medical or dental directors. Our coverage policy for diabetic supplies includes information on our
required models and brands. These medical policies (medical coverage criteria) are available by calling Member Services, or
logging on to your "myHealthPartners" account at www.healthpartners.com.
Not Covered:
Items which are not eligible for coverage include, but are not limited to:
• Replacement or repair of any covered items, if the items are (i) damaged or destroyed by misuse, abuse or carelessness, (ii)
lost; or (iii) stolen.
• Duplicate or similar items.
• Labor and related charges for repair of any covered items which are more than the cost of replacement by an approved
vendor.
• Sales tax, mailing, delivery charges, service call charges.
• Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation.
• Communication aids or devices: equipment to create, replace or augment communication abilities including, but not limited
to, hearing aids (implantable and external, including osseointegrated or bone anchored) and fitting of hearing aids except as
required by law, speech processors, receivers, communication boards, or computer or electronic assisted communication,
except as specifically described in this Certificate. This exclusion does not apply to cochlear implants, which are covered as
described in the medical coverage criteria. Medical coverage criteria are available by calling Member Services, or logging on
to your "myHealthPartners" account at www.healthpartners.com.
• Household equipment which primarily has customary uses other than medical, such as, but not limited to, exercise cycles, air
purifiers, central or unit air conditioners, water purifiers, non - allergenic pillows, mattresses or waterbeds.
• Household fixtures including, but not limited to, escalators or elevators, ramps, swimming pools and saunas.
• Modifications to the structure of the home including, but not limited to, its wiring, plumbing or charges for installation of
equipment.
• Vehicle, car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier.
• Rental equipment while owned equipment is being repaired by non - contracted vendors, beyond one month rental of
medically necessary equipment.
• Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage.
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(NI 90003 -16) 14
I. EMERGENCY AND URGENTLY NEEDED CARE SERVICES
Covered Services:
We cover services for emergency care and urgently needed care if the services are otherwise eligible for coverage under this
Certificate.
Urgently needed care. These are services to treat an unforeseen illness or injury, which are required in order to prevent a serious
deterioration in your health, and which cannot be delayed until the next available clinic or office hours.
Urgently Needed care at clinics
Network Benefits Non - Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $15 per office visit.
Emergency Care. These are services to treat: (1) the sudden, unexpected onset of illness or injury which, if left untreated or
unattended until the next available clinic or office hours, would result in hospitalization, or (2) a condition requiring professional
health services immediately necessary to preserve life or stabilize health. Emergency care also includes an immediate response
service available on a 24 -hour, seven- day -a -week basis for each child, or person, having a psychiatric crisis, a mental health
crisis, or a mental health emergency.
When reviewing claims for coverage of emergency services, our medical director will take into consideration a reasonable
layperson's belief that the circumstances required immediate medical care that could not wait until the next working day or next
available clinic appointment.
Emergency care in a hospital emergency room, including professional services of a physician
Network Benefits
Non - Network Benefits
100% of the charges incurred, subject to your See Network Benefits.
copayment of $95 per visit.
Emergency room copayment is waived if admitted for
the same condition within 24 hours.
Inpatient emergency care in a hospital
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefits.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(A'1 90003 -16) 15
J. HEALTH EDUCATION
Covered Services:
We cover education for preventive services and education for the management of chronic health problems (such as diabetes).
Coverage includes medical nutrition therapy, that is provided by a certified, registered, or licensed health care professional
working in a program consistent with the national standards of diabetes self - management education as established by the
American Diabetes Association.
Provider office visit /session in connection with preventive services
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Provider office visit /session in connection with the management of a chronic health problem (such as diabetes)
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
K. HOME HEALTH SERVICES
Covered Services:
We cover skilled nursing services, physical therapy, occupational therapy, speech therapy, respiratory therapy and other therapeutic
services, non - routine prenatal and postnatal services, routine postnatal well child visits as described in the Coverage Criteria,
phototherapy services for newborns, home health aide services and other eligible home health services when provided in your home,
if you are homebound (i.e., unable to leave home without considerable effort due to a medical condition). Lack of transportation
does not constitute homebound status. For phototherapy services for newborns and high risk prenatal services, supplies and
equipment are included.
We cover total parenteral nutrition /intravenous ( "TPN /IV ") therapy, equipment, supplies and drugs in connection with IV
therapy. IV line care kits are covered under Durable Medical Equipment.
You do not need to be homebound to receive total parenteral nutrition,z "intravenous ( "TPN /IV ") therapy.
We cover palliative care benefits. Palliative care includes symptom management, education and establishing goals of care.
We waive the requirement that you be homebound for a limited number of home visits for palliative care (as shown in the
Benefits Chart), if you have a life - threatening, non- curable condition which has a prognosis of survival of two years or less.
Additional palliative care visits are eligible under the home health services benefit if you are homebound and meet all other
requirements defined in this section.
Home health services are eligible and covered only when they are:
1. medically necessary; and
2. provided as rehabilitative care, terminal care or maternity care; and
3. ordered by a physician, and included in the written home care plan.
BCH- 900.34
(NI 90003 -16) 16
Fff _ .! . \...
Limitations:
Home health services are not provided as a substitute for a primary caregiver in the home or as relief (respite) for a primary
caregiver in the home. We will not reimburse family members or residents in your home for the above services.
A service shall not be considered a skilled nursing service merely because it is performed by, or under the direct supervision of, a
licensed nurse. Where a service (such as tracheotomy suctioning or ventilator monitoring) or like services, can be safely and
effectively performed by a non - medical person (or self - administered), without the direct supervision of a licensed nurse, the
service shall not be regarded as a skilled nursing service, whether or not a skilled nurse actually provides the service. The
unavailability of a competent person to provide a non - skilled service shall not make it a skilled service when a skilled nurse
provides it. Only the skilled nursing component of so- called "blended" services (i.e. services which include skilled and non -
skilled components) are covered under this Certificate.
Physical therapy, occupational therapy, speech therapy, respiratory therapy, home health aide services and palliative care
Network Benefits Non- Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $15 per visit.
If more than one home health visit occurs in a day, a separate copayment applies to each. For example, if a nurse
and a physical therapist visit an insured in the same day, a separate copayment will be charged for each visit.
TPN /IV therapy, skilled nursing services, non - routine prenatal /postnatal services, and phototherapy
Network Benefits Non- Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Each 24 -hour visit (or shifts of up to 24 -hour visits) equals one visit and counts toward the Maximum visits for
all other services shown below. Any visit that lasts less than 24 hours, regardless of the length of the visit, will
count as one visit toward the Maximum visits for all other services shown below. All visits must be medically
necessary and benefit eligible.
BCH- 900.34
(NI 90003 -16) 17
Routine postnatal well child visit
Network Benefits Non - Network Benefits
100% of the charges incurred. - 50% of the charges incurred.
Maximum visits for palliative care
If you are eligible to receive palliative care in the home and you are not homebound, there is a maximum of 8
visits per calendar year.
Maximum visits for all other services
Network Benefits Non - Network Benefits
120 visits per calendar year. 60 visits per calendar year.
Each visitprovided under the Network- Benefits and Non- Network Beneftts counts toward the maximums shown
under both Maximum visits sections. The routine postnatal well child visit does not count toward the visit limit.
Not Covered:
• Financial or legal counseling services.
• Housekeeping or meal services in your home.
• Private duty nursing services. This exclusion does not apply if covered person is also covered under Medical Assistance
under Minnesota chapter 25613.0625, subdivision 7, with the exception of section 25613.0654 subdivision 4.
• Services provided by a family member or enrollee, or a resident in the enrollee's home.
• Vocational rehabilitation and recreational or educational therapy. Recreation therapy is therapy provided solely for the
purpose of recreation, including but not limited to: (a) requests for physical therapy or occupational therapy to improve
athletic ability, and (b) braces or guards to prevent sports injuries.
• See Services Not Covered in the Group Certificate Section Ill.
L. HOME HOSPICE SERVICES
Applicable Definitions:
Part -time. This is up to two hours of service per day, more than two hours is considered continuous care.
Continuous Care. This is from two to twelve hours of service per day provided by a registered nurse, licensed practical nurse, or
home health aide, during a period of crisis in order to maintain a terminally ill patient at home.
Appropriate Facility. This is a nursing home, hospice residence, or other inpatient facility.
Custodial Care Related to Hospice Services. This means providing assistance in the activities of daily living and the care
needed by a terminally ill patient which can be provided by primary caregiver (i.e., family member or friend) who is responsible
for the patient's home care.
BCH- 900.34
(NI 90003 -16) 18
Covered Services:
Home Hospice Program. We cover the services described below if you are terminally ill and accepted as a home hospice
program participant. You must meet the eligibility requirements of the program, and elect to receive services through the home
hospice program, The services will be provided in your home, with inpatient care available when medically necessary as
described below. If you elect to receive hospice services, you do so in lieu of curative treatment for your terminal illness for the
period you are enrolled in the home hospice program.
a. Eligibility: In order to be eligible to be enrolled in the home hospice program, you must: (1) be a terminally ill patient
(prognosis of six months or less); (2) have chosen a palliative treatment focus (i.e., emphasizing comfort and supportive
services rather than treatment attempting to cure the disease or condition); and (3) continue to meet the terminally ill
prognosis as reviewed by our medical director or his or her designee over the course of care. You may withdraw from the
home hospice program at any time.
b. Eligible Services: Hospice services include the following services provided by Medicare - certified providers, if provided in
accordance with an approved hospice treatment plan.
(1) Home Health Services:
(a) Part-time care provided in your home by an interdisciplinary hospice team (which may include a physician,
nurse, social worker, and spiritual counselor) and medically necessary home health services are covered.
(b) One or more periods of continuous care in your home or in a setting which provides day care for pain or
symptom management, when medically necessary, will be covered.
(2) Inpatient Services: We cover medically necessary inpatient services.
(3) Other Services:
(a) Respite care is covered for care in your home or in an appropriate facility, to give your primary caregivers
(i.e., family members or friends) rest and /or relief when necessary in order to maintain a terminally ill patient
at home.
(b) Medically necessary medications for pain and symptom management.
(c) Semi- electric hospital beds and other durable medical equipment are covered.
(d) Emergency and non - emergency care is covered.
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Respite care is limited to 5 days per episode, and respite care and continuous care combined are limited to 30
days.
Not Covered:
• Financial or legal counseling services; or
• Housekeeping or meal services in your home; or
• Custodial or maintenance care related to hospice services, whether provided in the home or in a nursing home; or
• Any service not specifically described as covered services under this home hospice services benefits; or
• Any services provided by members of your family or residents in your home.
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(N] 90003 -16) 19
is
M. HOSPITAL AND SKILLED NURSING FACILITY SERVICES
Covered Services:
We cover services as described below.
Medical or Surgical Hospital Services
Inpatient Hospital Services: We cover the following medical or surgical services, for the treatment of acute illness or
injury, which require the level of care only provided in an acute care facility. These services must be authorized by a
physician.
Inpatient hospital services include: room and board; the use of operating or maternity delivery rooms; intensive care
facilities; newborn nursery facilities; general nursing care, anesthesia, laboratory and diagnostic imaging services,
reconstructive surgery, radiation therapy, physical therapy, prescription drugs or other medications administered during
treatment, blood and blood products (unless replaced), and blood derivatives, and other diagnostic or treatment related
hospital services; physician and other professional medical and surgical services provided while in the hospital.
We cover up to 120 hours of services provided by a private duty nurse or personal care assistant who has provided home care
services to a ventilator- dependent patient, solely for the purpose of assuring adequate training of the hospital staff to
communicate with that patient.
Services for items for personal convenience, such as television rental, are not covered.
We cover, following a vaginal delivery, a minimum of 48 hours of inpatient care for the mother and newborn child. We
cover, following a caesarean section delivery, a minimum of 96 hours of inpatient care for the mother and newborn child. If
the duration of inpatient care is less than these minimums, we also cover a minimum of one home visit by a registered nurse
for post - delivery care, within 4 days of discharge of the mother and newborn child. Services provided by the registered nurse
include, but are not limited to, parent education, assistance and training in breast and bottle feeding, and conducting any
necessary and appropriate clinical tests. We shall not provide any compensation or other non - medical remuneration to
encourage a mother and newborn to leave inpatient care before the duration minimums specified.
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length
of stay in connection with childbirth for the mother of newborn child to less than 48 hours following a vaginal delivery, or
less than 96 hours following a caesarean section. However, Federal law generally does not prohibit the mother's or
newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48
hours (or 96 hours as applicable). In any case plans and issuers may not, under Federal law, require that a provider- obtain
authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Network Benefits Non- Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Each insured's admission or confinement, including that of a newborn child, is separate and distinct from the
admission or confinement of anv other insured.
BCH- 900.34
('V1 90003 -16) 20
Outpatient Hospital, Ambulatory Care or Surgical Facility Services: We cover the following medical and surgical
services, for diagnosis or treatment of illness or injury on an outpatient basis. These services must be authorized by a
physician.
Outpatient services include: use of operating rooms, maternity delivery rooms or other outpatient departments, rooms or
facilities; and the following outpatient services: general nursing care, anesthesia, laboratory and diagnostic imaging services,
reconstructive surgery, radiation therapy, physical therapy, drugs administered during treatment, blood and blood products
(unless replaced), and blood derivatives, and other diagnostic or treatment related outpatient services; physician and other
professional medical and surgical services provided while an outpatient.
For Network Benefits, non - emergent, scheduled outpatient Magnetic Resonance Imaging (MRI) and computing Tomography
(CT) must be provided at a designated facility. Your physician or facility will obtain or verify prior authorization for these
services, as needed.
To see the benefit level for diagnostic imaging services, laboratory services and physical therapy, see the benefits under
Diagnostic Imaging Services, Laboratory Services and Physical Therapy in this Benefits Chart.
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Skilled Nursing Facility Care: We cover room and board, daily skilled nursing and related ancillary services for post acute
treatment and rehabilitative care of illness or injury, following a hospital confinement.
Network Benefits
100% of the charges incurred.
Limited to 120 day maximum per period of
confinement, subject to the combined day limit
Non - Network Benefits
50% of the charges incurred.
Limited to 120 day maximum per period of
confinement, subject to the combined day limit.
Each day of services provided under the Network and Non - Network Benefits, combined, counts toward the
rnaximurns shown above.
Not Covered:
• Services for items for personal convenience, such as television rental, are not covered.
• See Services Not Covered in the Group Certificate Section III.
N. LABORATORY SERVICES
Covered Services:
We cover laboratory tests when ordered by a provider and provided in a clinic or outpatient hospital facility.
We cover services provided in a clinic or outpatient hospital facility (to see the benefit level for inpatient hospital or skilled
nursing facility services, see benefits under Inpatient Hospital and Skilled Nursing Facility Services).
Services for illness or injury
Network Benefits Non- Network Benefits
100% of the charges incurred. 50% of the charges incurred.
BCH- 900.34
(NI 90003 -16) 21
Preventive services
Network Benefits Non - Network Benefits
Laboratory services associated with preventive services are covered at the benefit level shown in the
Preventive Services section.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
O. LYME DISEASE SER`710ES
Covered Services:
We cover services for the treatment of Lyme disease.
Network Benefits
Coverage level is same as corresponding Network
Benefit, depending on type of service provided such
as Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
Not Covered:
Non - Network Benefits
Coverage level is same as corresponding Non -
Network Benefit, depending on type of service
provided such as Office Visits for Illness or Injury,
Inpatient or Outpatient Hospital Services.
• See Services Not Covered in the Group Certificate Section III.
P. MASTECTOMY RECONSTRUCTION BENEFIT
Covered Services:
We cover reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the other
breast to produce symmetrical appearance, and prostheses and physical complications of all stages of mastectomy, including
lymphedemas.
Network Benefits
Coverage level is same as corresponding Network
Benefit, depending on type of service provided such
as Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
Not Covered:
Non- Network Benefits
Coverage level is same as corresponding Non - Network
Benefit, depending on type of service provided, such as
Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(NI 90003 -16) 22
Q. OFFICE VISITS FOR ILLNESS OR INJURY
Covered Services:
We cover the following when medically necessary: professional medical and surgical services and related supplies, including
biofeedback, of physicians and other health care providers; blood and blood products (unless replaced) and blood derivatives.
We cover diagnosis and treatment of illness or injury to the eyes. Where contact or eyeglass lenses are prescribed as medically -
necessary for the post- operative treatment of cataracts or for the treatment of aphakia, or keratoconus, we cover the initial
evaluation, lenses and fitting. Insureds must pay for lens replacement beyond the initial pair.
We also provide coverage for the initial physical evaluation of a child if it is ordered by a Minnesota juvenile court.
Office visits
Network Benefits Non - Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $15 per office visit.
Convenience clinics
Network Benefits Non - Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $10 per office visit.
Scheduled telephone visits
Network Benefits Non- Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $10 per office visit.
E- visits
a. Access To Online Care through virtuwell at www.virtuwell.com
Network Benefits
Non - Network Benefits
The first three online visits to virtuwell in a calendar No Coverage.
year are paid at 100 %. Then all virtuwell services
will be paid at 100% of the charges incurred, subject
to your copayment of $10 per visit.
b. All other E- visits
Network Benefits Non - Network Benefits
100% of the charges incurred, subject to your 50% of the charges incurred.
copayment of $10 per visit.
BCH- 900.34
(NI 90003 -16) 23
Injections administered in a physician's office, other than immunizations
Allergy injections
Network Benefits Non- Network Benefits
100% of the charges incurred. 50% of the charges incurred.
All other injections
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Not Covered:
• Court ordered treatment, except as described in this Benefits Chart section C., subsection "Mental Health Services" and
section Q. "Office Visits for Illness or Injury" or as otherwise required by law.
• See Services Not Covered in the Group Certificate Section III.
R. PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY
Covered Services:
We cover the following physical therapy, occupational therapy and speech therapy services:
1. Medically necessary rehabilitative care to correct the effects of illness or injury.
2. Habilitative care rendered for congenital, developmental or medical conditions which have significantly limited the
successful initiation of normal speech and normal motor development.
Massage therapy which is performed in conjunction with other treatment /modalities by a physical or occupational therapist, is
part of a prescribed treatment plan and is not billed separately is covered.
We cover services provided in a clinic. We also cover physical therapy provided in an outpatient hospital facility. To see the
benefit level for inpatient hospital or skilled nursing facility services, see benefits under Inpatient Hospital and Skilled Nursing
Facility Services.
Rehabilitative Care
Network Benefits
100% of the charges incurred, subject to your
copayment of $15 per visit.
Habilitative Care
Network Benefits
100% of the charges incurred, subject to your
copayment of $15 per visit.
BCH- 900.34
(A'] 90003 -16)
Non- Network Benefits
50% of the charges incurred.
Physical and Occupational Therapy combined are
limited to 20 visits per calendar year.
Speech Therapy is limited to 20 visits per calendar
year.
Non - Network Benefits
50% of the charges incurred.
Physical, Occupational and Speech Therapy
combined are limited to 20 visits per calendar year.
24
Not Covered:
• Massage therapy for the purpose of comfort or convenience of the insured.
• See Services Not Covered in the Group Certificate Section III.
S. PORT WINE STAIN REMOVAL SERVICES
Covered Services:
We cover port wine stain removal services.
Network Benefits
Coverage level is same as corresponding Network
Benefit, depending on type of service provided such
as Office Visits for Illness or Injury, Inpatient or
Outpatient Hospital Services.
Not Covered:
Non - Network Benefits
Coverage level is same as corresponding Non -
Network Benefit, depending on type of service
provided such as Office Visits for Illness or Injury,
Inpatient or Outpatient Hospital Services.
• See Services Not Covered in the Group Certificate Section III.
T. PRESCRIPTION DRUG SERVICES
Covered Services:
We cover prescription drugs and medications, which can be self - administered or are administered in a physician's office. We
cover off -label use of formulary drugs to treat cancer if the drug is recognized for the treatment of cancer in one of the standard
reference compendia or in one article in the medical literature as defined by Minnesota Statute 62Q.525.
For Network benefits, drugs and medications must be obtained at a Network Pharmacy.
Outpatient drugs (other than tobacco cessation, contraceptive, specialty and growth deficiency drugs)
Network Benefits
100% of the charges incurred, subject to your
copayment of $12 for generic formulary drugs and $50
for brand formulary drugs. Non - formulary drugs are
covered at 100% of the charges incurred, subject to
your copayment of $90.
Drugs for the treatment of sexual dysfunction are
limited to six doses per month.
Non - Network Benefits
60% of the charges incurred.
Drugs for the treatment of sexual dysfunction are
limited to six doses per month.
Tobacco cessation drugs are covered for all FDA - approved tobacco cessation drugs (including over - the - counter drugs) for
a minimum of 90 days.
Network Benefits Non - Network Benefits
Formulary Drugs: 60% of the charges incurred.
100% of the charges incurred.
BCH- 900.34
(NI 90003 -16) 25
Mail Order Drugs
Network Benefits
Non - Network Benefits
You may also get outpatient prescription drugs which See Network Mail Order Drugs Benefit.
can be self - administered through Healthl'artners mail
order service. Outpatient drugs ordered through this
service are covered at the benefit percent shown in
Outpatient Drugs above, subject to two copayments
for each 90 -day supply, or portion thereof.
New prescriptions to treat certain chronic conditions
and trial drugs will be limited to quantity limits
described at the end of this section. You will have to
pay one copayment for your initial 30 -day supply.
Drugs for the treatment of sexual dysfunction are
limited to 18 doses per 90—day supply.
Specialty Drugs are not available through the mail
order service.
Specialty Drugs which are self - administered
Network Benefits Non- Network Benefits
80% of the charges incurred, up to a maximum See Non - Network Outpatient Drugs benefit.
copayment of $200.
For Network Benefits, Specialty Drugs are limited to drugs on the specialty drug list and must be obtained from a
designated vendor.
Drugs for the treatment of growth deficiency
Network Benefits Non - Network Benefits
80% of the charges incurred. 50% of the charges incurred.
For Network Benefits, Growth Deficiency Drugs are limited to drugs on the specialty drug list and must be
obtained from a designated vendor.
Contraceptive drugs
Network Benefits Non - Network Benefits
100% of the charges incurred for formulary drugs. 60% of the charges incurred.
If a physician requests that a non - formulary
contraceptive drug be dispensed as written, the drug
will be covered at 100 %.
BCH- 900.34
(N1 90003 -16) 26
Unless otherwise specified in the Prescription Drug Services section, you may receive up to a 30 -day supply per
prescription. Certain drugs may requirepr for authorization as indicated on the forrnula7y. HealthPartners may
require prior authorization for the drug and also the site where the drug will be provided. Certain drugs are
subject to our utilization review process and quantity limits as indicated on our formulary. New prescriptions are
limited to a 30 -day supply. Certain non formulary drugs require prior authorization. In addition, certain drugs
may be subject to any quantity limits applied as part of our trial program. A 90 -day supply will be covered and
dispensed only at phar niacies that participate in our extended day supply program. No more than a 30 -day supply
of Specialty Drugs will be covered and dispensed at a time.
If an insured requests a brand drug when there is a generic equivalent, the brand drug will be covered up to the
charge that would apply to the generic drug, minus any required copayment. If a physician requests that a brand
drug be dispensed as written, the drug will be paid at the non formulary benefit.
If a copayment is required, you must pay one copayment for each 30 -day supply, or portion thereof, except as
follows:
For Mail Order Drugs, see benefit above.
Not Covered:
Replacement of prescription drugs, medications, equipment and supplies due to loss, damage or theft.
Nonprescription (over the counter) drugs or medications, unless listed on the formulary and prescribed by a physician or
legally authorized health care provider under applicable state law, including, but not limited to, vitamins, supplements,
homeopathic remedies, and non -FDA approved drugs. We cover off -label use of drugs to treat cancer as specified in the
"Prescription Drug Services" section of this Benefits Chart. This exclusion does not include over - the - counter contraceptives
for women as allowed under the Affordable Care Act when the insured obtains a prescription for the item. In addition, if the
insured obtains a prescription, this exclusion does not include aspirin to prevent cardiovascular disease for men and women
of certain ages; folic acid supplements for women who may become pregnant; fluoride chemoprevention supplements for
children without fluoride in their water source; and iron supplements for children ages 6 -12 who are at risk for anemia.
All drugs for the treatment of infertility.
Medical cannabis.
See Services Not Covered in the Group Certificate Section III.
U. PREVENTIVE SERVICES
Covered Services:
We cover preventive services which meet any of the requirements under the Affordable Care Act (ACA) shown in the bulleted
items below. These preventive services are covered at 100% under the network benefits with no deductible, copayments or
coinsurance. (If a preventive service is not required by the ACA and it is covered at a lower benefit level, it will be specified
below). Preventive benefits mandated under the ACA are subject to periodic review and modification. Changes would be
effective in accordance with the federal rules. Preventive services mandated by the ACA include:
• Evidence -based items or services that have in effect a rating of A or B in the current recommendations of the United
States Preventive Services Task Force with respect to the individual;
• Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the
Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the
individual;
• With respect to infants, children, and adolescents, evidence - informed preventive care and screenings provided for in
comprehensive guidelines supported by the Health Resources and Services Administration; and
• With respect to women, preventive care and screenings provided for in comprehensive guidelines supported by the
Health Resources and Services Administration.
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
or dental directors. These medical policies (medical coverage criteria) are available by calling Member Services, or logging on to
your "myHealthPartners" account at www.healthpartners.com.
In addition to any ACA mandated preventive services referenced above, we cover the following eligible preventive services.
BCH- 900.34
(NI 90003 -16) 27
Benefits are limited to $300 per calendar year for the following items: 1., 5., 6., 7., 9. and 10. combined
under the Non - Network Benefits.
1. Routine health exams and periodic health assessments. A physician or health care provider will counsel you as to
how often health assessments are needed based on age, sex and health status. This includes screening for tobacco use,
at least two tobacco cessation attempts per year (for those who use tobacco products), all FDA approved tobacco
cessation medications including over - the - counter drugs (as shown in the prescription drugs section) and at least four
counseling sessions of at least ten minutes each for tobacco cessation.
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
2. Child health supervision services, including pediatric preventive services, routine immunizations, developmental
assessments and laboratory services appropriate to the age of the child from birth to 72 months, and appropriate
immunizations to age 18.
Network Benefits Non- Network Benefits
100% of the charges incurred. See Network Benefit.
3. Routine prenatal care and exams to include visit - specific screening tests, education and counseling.
Network Benefits Non - Network Benefits
100% of the charges incurred. See Network Benefit.
4. Routine postnatal care and exams to include health exams, assessments, education and counseling relating to the period
immediately after childbirth.
Network Benefits Non- Network Benefits
100% of the charges incurred. 50% of the charges incurred.
5. Routine screening procedures for cancer, including colorectal screening, pap smears, ovarian cancer screening and prostate
screening. Women's preventive health services below describe additional routine screening procedures for cancer.
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
BCH- 900.34
(N1 90003 -16) 28
6. Routine eye and hearing exams
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
7. Professional voluntary family planning services
Network Benefits Non- Network Benefits
100% of the charges incurred. 50% of the charges incurred.
8. Adult immunizations
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
9. Women's preventive health services including mammograms; screenings for cervical cancer; breast pumps; human
papillomavirus (HPV) testing; counseling for sexually transmitted infections; and counseling and screening for human
immunodeficiency virus (HIV); and all FDA approved contraceptive methods as prescribed by a doctor; sterilization
procedures, education and counseling (see prescription drug services section for coverage of contraceptive drugs).
For women whose family history is associated with an increased risk for BRCAI or BRCA2 gene mutations, we cover
genetic counseling and BRCA screening without cost sharing, if appropriate and as determined by a physician.
Network Benefits Non- Network Benefits
100% of the charges incurred. 50% of the charges incurred.
10. Obesity screening and management. We cover obesity screening and counseling for all ages during a routine
preventive care exam. If you are an adult age 18 or older and have a body mass index of 30 or more, we also cover
intensive obesity management to help you lose weight. Your primary care doctor can coordinate these services.
Network Benefits Non - Network Benefits
100% of the charges incurred. 50% of the charges incurred.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(N1 90003 -16) 29
1013#101y n4%�
V. SPECIFIED NON - NETWORK SERVICES
Covered Services:
We cover the following services when you elect to receive them from a non - network provider, at the same level of coverage we
provide when you elect to receive the services from a network provider:
1. Voluntary family planning of the conception and bearing of children.
2. Testing and treatment of sexually transmitted diseases (other than HIV).
3. Testing for AIDS or other HIV- related conditions.
Network Benefits Non - Network Benefits
Coverage level is same as corresponding Network See Network coverage for the services covered.
Benefit, depending on type of service provided, such as
Office Visits for Illness or Injury.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
W. TRANSPLANT SERVICES
Applicable Definitions:
Autologous. This is when the source of cells is from the individual's own marrow or stem cells.
Allogeneic. This is when the source of cells is from a related or unrelated donor's marrow or stem cells.
Autologous Bone Marrow Transplant. This is when the bone marrow is harvested from the individual and stored. The patient
undergoes treatment which includes tumor ablation with high -dose chemotherapy and/or radiation. The bone marrow is reinfused
(transplanted).
Allogeneic Bone Marrow Transplant. This is when the bone marrow is harvested from the related or unrelated donor and
stored. The patient undergoes treatment which includes tumor ablation with high -dose chemotherapy and/or radiation. The bone
marrow is reinfused (transplanted).
Autologous /Allogeneic Stem Cell Support. This is a treatment process that includes stem cell harvest from either bone marrow
or peripheral blood, tumor ablation with high -dose chemotherapy and/or radiation, stem cell reinfusion, and related care.
Auto] ogous /allogeneic bone marrow transplantation and high dose chemotherapy with peripheral stem cell rescue /support are
considered to be auto]ogous /allogeneic stem cell support.
Designated Transplant Center. This is any health care provider, group or association of health care providers designated by us
to provide services, supplies or drugs for specified transplants for our insureds.
Transplant Services. This is transplantation (including retransplants) of the human organs or tissue listed below, including all
related post- surgical treatment, follow -up care and drugs and multiple transplants for a related cause. Transplant services do not
include other organ or tissue transplants or surgical implantation of mechanical devices functioning as a human organ, except
surgical implantation of an FDA approved Ventricular Assist Device (VAD) or total artificial heart, functioning as a temporary
bridge to heart transplantation.
Covered Services:
We cover eligible transplant services (as defined above) while you are covered under this Certificate. Transplants that will be
considered for coverage are limited to the following:
1. Kidney transplants for end -stage disease.
2. Cornea transplants for end -stage disease.
3. Heart transplants for end -stage disease.
4. Lung transplants or heart/lung transplants for: (1) primary pulmonary hypertension; (2) Eisenmenger's syndrome; (3) end -
stage pulmonary fibrosis; (4) alpha 1 antitrypsin disease; (5) cystic fibrosis; and (6) emphysema.
BCH- 900.34
(N] 90003 -16) 30
5. Liver transplants for: (1) biliary atresia in children; (2) primary biliary cirrhosis; (3) post -acute viral infection (including
hepatitis A, hepatitis B antigen e negative and hepatitis C) causing acute atrophy or post - necrotic cirrhosis; (4) primary
sclerosing cholangitis; (5) alcoholic cirrhosis; and (6) hepatocellular carcinoma.
6. Allogeneic bone marrow transplants or peripheral stem cell support associated with high dose chemotherapy for: (1) acute
myelogenous leukemia; (2) acute lymphocytic leukemia; (3) chronic myelogenous leukemia; (4) severe combined
immunodeficiency disease; (5) Wiskott- Aldrich syndrome; (6) aplastic anemia; (7) sickle cell anemia; (8) non - relapsed or
relapsed non - Hodgkin's lymphoma; (9) multiple myeloma; and (10) testicular cancer.
7. Autologous bone marrow transplants or peripheral stem cell support associated with high -dose chemotherapy for: (1) acute
leukemias; (2) non - Hodgkin's lymphoma; (3) Hodgkin's disease; (4) Burkitt's lymphoma; (5) neuroblastoma; (6) multiple
myeloma; (7) chronic myelogenous leukemia; and (8) non - relapsed non- Hodgkin's lymphoma.
8. Pancreas transplants for simultaneous pancreas - kidney transplants for diabetes, pancreas after kidney, living related
segmental simultaneous pancreas kidney transplantation and pancreas transplant alone.
To receive Network Benefits, charges for transplant services must be incurred at a Designated Transplant Center. The transplant -
related treatment provided, including the expenses incurred for directly related donor services, shall be subject to and in
accordance with the provisions, limitations, maximums and other terms of this Certificate.
Medical and hospital expenses of the donor are covered only when the recipient is an insured and the transplant and directly
related donor expenses have been prior authorized for coverage. Treatment of medical complications that may occur to the donor
are not covered. Donors are not considered insureds, and are therefore not eligible for the rights afforded to insureds under this
Certificate.
The list of eligible transplant services and coverage determinations are based on established medical policies, which are subject to
periodic review and modification by the medical director.
Network Benefits Non - Network Benefits
See Network Inpatient Hospital Services Benefit, See Non- Network Inpatient Hospital Services Benefit.
Limited to 365 day maximum per period of confinement, subject to the combined day limit.
Not Covered:
• We consider the following transplants to be investigative and do not cover them: surgical implantation of mechanical devices
functioning as a permanent substitute for human organ, non -human organ implants and /or transplants and other transplants
not specifically listed in the Certificate.
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(NI 90003 -16) 31
► �l I�I.Y�1:El.7111
X. ADDITIONAL SERVICES COVERED UNDER THE PLAN
Covered Services:
We cover the following additional program:
Medication Therapy Disease Management Program. If you meet our criteria for coverage, you may qualify for our
Medication Therapy Disease Management program.
The program covers consultations with a designated pharmacist.
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
directors. These medical policies (medical coverage criteria) are available by logging on to your "my HealthPartners" account at
www.healthpartners.com or by calling Member Services.
Network Benefits Non - Network Benefits
100% of the charges incurred. No Coverage.
Not Covered:
• See Services Not Covered in the Group Certificate Section IIl.
Y. WEIGHT LOSS SURGERY OR BARIATRIC SURGERY
Covered Services:
Covered services are based on established medical policies, which are subject to periodic review and modification by the medical
directors. These medical policies (medical coverage criteria) are available on -line by logging on to your "myHealthPartners"
account at www.healthpartners.com or by calling Member Services.
Network Benefits Non - Network Benefits
No Coverage. No Coverage.
Not Covered:
• See Services Not Covered in the Group Certificate Section III.
BCH- 900.34
(NI 90003 -16) 32