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Asuris Northwest Health - Online
Application
Index | Exclusions
& Limitations | Provider
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Benefit Schedules:
Preferred Catastrophic | Clarity
50 | Clarity 70 | Clarity
80 | HSA | HSA Comprehensive
Rate Schedules:
Preferred Catastrophic | Clarity 50 | Clarity
70 | Clarity 80 | HSA | HSA Comprehensive
SUMMARY OF BENEFITS
Individual Preferred Catastrophic Plan
For medically necessary services rendered by
a Preferred Plan or participating provider, or recognized provider in the service
area, the benefits of this plan will be provided at the percentage of the allowed
amount specified below after the deductible has been met. Unless otherwise specified,
all benefits are subject to the annual deductible in addition to any copays
and coinsurance. When you have reached the annual out-of-pocket coinsurance
maximum for Preferred Plan or out-of-area provider services only, this plan
will provide benefits at 100% of the allowed amount for Preferred Plan or out-of-area
provider services for the remainder of the calendar year, unless otherwise specified.
Any balances of charges not covered by this plan will be your responsibility
to pay. Coinsurance amounts on Preferred Plan or out-of-area provider services
apply toward the out-of-pocket coinsurance maximum, unless otherwise specified.
The annual deductible, copays, prescription drugs, rehabilitative care, smoking
cessation program, vision hardware, and most services provided by participating
or recognized providers do not apply to the annual out-of-pocket amount.
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Benefits
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Preferred Plan
Provider
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Participating/Recognized
Provider
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Annual Deductible
Copays, prescription drugs, preventive
care, and the routine eye exam do not count toward the deductible.
Family deductible is met when three or more covered
family members incur the equivalent of three individual deductible amounts
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$1,750 per individual
$5,250 per family
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Lifetime maximum
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$1,000,000 per individual
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Annual Out-of-Pocket Coinsurance Amount
Family out-of-pocket coinsurance amount is met
when three or more covered family members reach the"per person"
out-of-pocket coinsurance amount in a calendar year
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$3,500 per person
$10,500 per family
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No out-of-pocket
maximum
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Professional Services
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80%
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50%
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Including diagnostic x-ray and laboratory. Coverage includes the services
of physicians, osteopaths, naturopathic providers, and other eligible
health care professional providers
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(unless specified otherwise)
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Hospital Facility (Inpatient & Outpatient)
Including diagnostic x-ray and laboratory
$100 copay per emergency room visit (waived if admitted)
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80%
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50%
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Acupuncture
12 visits per calendar year maximum
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80%
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50%
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Ambulance Services**
Ground services: $2,000 per calendar year
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80%*
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80%
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Blood Bank**
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80%
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80%
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Home Health and Hospice
Home Health – 130 visits per calendar year maximum
Hospice – 6 months maximum
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80%*
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80%
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Home Medical Equipment
$2,500 per calendar year maximum
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80%
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50%
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Home Phototherapy
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80%*
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80%
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Infusion Therapy
Growth hormone only treatment is limited to $25,000
per calendar year
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80%
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50%
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Mammography
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80%
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50%
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Maternity
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80%
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50%
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Phenylketonuria (PKU) Formulas
Not subject to waiting periods
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80%
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50%
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Prostheses and Orthotics
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80%
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50%
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Rehabilitative Care**
Inpatient – $4,000 per calendar year maximum
Outpatient – $2,000 per calendar year maximum
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80%
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50%
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Skilled Nursing Facility
30 days per calendar year maximum
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*
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80%
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Smoking Cessation
$500 lifetime maximum
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80%
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80%
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Special Equipment and Supplies
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80%
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80%
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Spinal Manipulations
10 visits per calendar year maximum
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80%
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50%
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Transplants
$250,000 lifetime maximum; $50,000 per transplant donor
organ procurement maximum; $2,500 per transplant travel and lodging
maximum; 12-month waiting period
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80%
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see contract
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*At this time, these services are provided only by Participating
Providers.
**At this time, these services are provided only by Recognized Providers.
Cost Containment Provisions: All hospital
and skilled nursing facility admissions must be medically necessary. When outside
the service area, preadmission approvalshould be obtained to ensure that full
plan benefits will be provided.
Emergency Care: Emergency benefits will
be provided at the level specified for a Preferred Plan provider. Benefits for
recognized providers will be based on the recognized provider's actual charge
for the service. Outside the service area, benefits will be provided at the
level specified below..
Care Outside the Service Area: All care
received outside the service area , whether or not a medical emergency, will
be covered at 80% of the allowed amount, except benefits for prescription drugs
and vision hardware will be provided at the levels specified. Any balances of
charges not covered by this plan will be your responsibility.
Waiting Periods: No benefits are provided
for treatment relating to a transplant until you have been covered under this
or a prior plan with the Company (Asuris Northwest Health) or it's parent company
for 12 consecutive months. No benefits will be provided for preexisting conditions,
including maternity, until you have been covered under this plan for nine consecutive
months, unless you were continuously covered for at least nine months under
the immediately preceding creditable plan.
This is a brief summary of benefits, it is
not a certificate of coverage. For full coverage provisions, including a description
of waiting periods, limitations, and exclusions, refer to the plan contract.
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Asuris
NW Health