|
|
|
|
|
|
|
|
Site Map Glossary Employee Book of Benefits OneCall: 1-877-861-2255 |
Home > Medical Plan > How Indemnity Plan Works
Under the Indemnity Plan, you may receive care from any provider you choose. After you meet your annual deductible, the plan pays 80% of reasonable and customary charges for medically necessary services and supplies until you reach the annual out-of-pocket maximum. (Note: The Indemnity Plan does not cover routine physical exams except for mammograms.) The out-of-pocket maximum protects you from excessive medical costs by establishing a ceiling on the amount you pay for covered medical expenses during a year. Once you reach the out-of-pocket maximum, the plan pays 100% of reasonable and customary charges for eligible medical expenses for the rest of that year. You must file claims to be reimbursed for your eligible expenses. Claim forms are available from the Benefit Plans Office. You must also call Intracorp to precertify any non-emergency hospitalization. If you do not call, your benefit will be subject to a penalty. Reasonable and CustomaryAll Indemnity Plan benefit payments are subject to reasonable and customary limits. Any charges above reasonable and customary are not covered by the plan, and you will not be reimbursed for them. Also, these amounts will not count toward the deductible or out-of-pocket maximum.The Deductible The individual deductible is 0.5% of your annual pension ($200 minimum). The maximum family deductible is 1.5% of your annual pension ($400 minimum). The Family Deductible Although the deductible applies separately to each covered family member, the plan contains a provision — called the family — deductible that limits the amount you pay in deductibles each year. The most you pay to meet deductibles for your entire family in a year is three individual deductibles (0.5% + 0.5% + 0.5% = 1.5%). You can also meet the family deductible with any combination of individual expenses. However, once one family member meets his or her individual deductible, any further expenses incurred by that person may not be applied to the family deductible. Once the family deductible is met, no other family member needs to meet the deductible for that year. Common Accident Deductible Only one deductible applies to all covered medical expenses resulting from an accident where two or more family members are injured.
The Out-of-Pocket MaximumThe out-of-pocket maximum limits the amount you pay for medical expenses in one year. The individual out-of-pocket maximum is 5% of your annual pension benefit ($2,000 minimum). The family out-of-pocket maximum is 8% of your annual pension benefit ($4,000 minimum).Once you reach the out-of-pocket maximum, the plan pays 100% of covered charges for the rest of the year. Certain expenses do not count toward the out-of-pocket maximum:
Hospital PrecertificationTo help ensure that all hospital admissions are medically necessary, the Indemnity Plan uses Intracorp — a service that reviews and evaluates recommended treatment plans. You or your physician are required to call Intracorp if your physician recommends hospitalization.You should call Intracorp at least seven days before a regular non-emergency admission, or as soon as reasonably possible. You must call Intracorp by the fourth month of pregnancy to precertify a maternity admission. It is important to have your admission and length of stay confirmed before you enter the hospital.
If you do not have your admission precertified, the first $300 of hospital charges for each separate admission will not be covered under this plan. When you call Intracorp, you or your physician will discuss your proposed admission and length of stay with a registered nurse specially trained for this job. If the nurse approves your admission and hospital stay, your admission certification will be mailed to you within 24 hours. If there are questions, the nurse will refer your case to an Intracorp physician who will follow-up with your physician. If your physician and the Intracorp physician cannot agree on your treatment, a second Intracorp physician will consider your case. In the rare event that an agreement cannot be reached, your physician may appeal the decision to the Intracorp physicians and have the disputed hospitalization resolved by local physicians qualified to consult on your case. After your admission is certified and you are hospitalized, Intracorp will monitor your hospital stay by telephone calls to your physician or the hospital. Your physician must contact Intracorp to extend your hospital stay. Intracorp will approve or deny the extension. If it is denied, an Intracorp professional will contact you and your physician directly. Emergency Hospitalization If you have a medical emergency and are admitted to the hospital, someone must contact Intracorp within two days of your admission or on the first business day following your admission, if later. Reduction of Benefits You will be penalized if you do not call Intracorp or if you do not follow Intracorp's recommendations:
Second surgical opinions are not mandatory, but are covered by the plan with certain limitations. If your physician recommends surgery, the plan pays 100% of the reasonable and customary charge for a second surgical opinion, with no deductible. If additional opinions are necessary, they will be covered at 80% of reasonable and customary charges. Preadmission and Post-Confinement Testing The plan pays 100% of the cost of preadmission and post-release testing performed on an outpatient basis within 14 days before a scheduled admission or within 14 days after you leave the hospital, provided the testing is related to your surgery. If the preadmission tests are performed and your admission is later cancelled, or if the tests are duplicated while you are in the hospital, the plan will pay 80% of reasonable and customary charges for the tests, after you meet the deductible. Mental Health/Alcohol and Drug Abuse Treatment After you meet the deductible, the Indemnity Plan pays 80% of reasonable and customary charges for mental health/alcohol and drug abuse treatment, up to the limits described in the chart on the following pages. Inpatient care must be precertified by contacting Intracorp. Last updated: Thursday April 21 2005 | ||||
| |||||
