| |
The Compass plans |
| Benefits |
$500
Deductible |
$1,750
Deductible |
$2,500
Deductible |
$5,000
Deductible |
Annual
Deductible
The amount a member
pays for services before coinsurance applies. Deductible
does not apply to Out-of-Pocket Limit |
$500 per person
$1,500 per family |
$1,750 per person
$4,500 per family |
$2,500 per person
$7,500 per family |
$5,000 per person
$15,000 per family |
Plan Coinsurance
The percentage amounts
the plan pays after Annual Deductible unless otherwise
noted. |
80% |
80% |
50% |
70% |
Out-of-Pocket
Limit
The maximum amount of coinsurance, and expenses
incurred and paid for covered services, during the
calendar year. Does not include deductible |
$2,000 per person
$6,000 per family |
$4,000 per person
$12,000 per family |
$6,000 per person
$18,000 per family |
$10,000 per person
$30,000 per family |
| Lifetime Maximum
Benefits |
$2,000,000 |
$2,000,000 |
$2,000,000 |
$2,000,000 |
| Benefits |
After deductible,
member pays |
After deductible,
member pays |
After deductible,
member pays |
After deductible,
member pays |
Outpatient Care
|
Applicable cost shares
apply as described below. |
Applicable cost shares
apply as described below. |
Applicable cost shares
apply as described below. |
Applicable cost shares
apply as described below. |
| Office visits |
20% |
20% |
50% |
30% |
Preventive Care
For children and adults, including physicals and immunizations, as
established in Group Health's preventive care schedule. |
20%. Not subject to
annual deductible. |
20%. Not subject to
annual deductible. |
50%. Not subject to
annual deductible. |
30%. Not subject to
annual deductible. |
| Alternative
medicine |
20% |
20% |
50% |
30% |
| Manuiplative therapy |
Up to 10 visits per calendar
year |
Up to 10 visits per calendar
year |
Up to 10 visits per calendar
year |
Up to 10 visits per calendar
year |
| Acupuncture |
Up to 8 visits per diagnosis
per year. |
Up to 8 visits per diagnosis
per year. |
Up to 8 visits per diagnosis
per year. |
Up to 8 visits per diagnosis
per year. |
| Naturopathy |
Up to 3 visits per diagnosis
per year. |
Up to 3 visits per diagnosis
per year. |
Up to 3 visits per diagnosis
per year. |
Up to 3 visits per diagnosis
per year. |
Maternity
care
Prenatal and postpartum visits; delivery and hospital
care. |
20% |
Not covered |
Not covered |
Not covered |
Mental health services
Inpatient services
Outpatient services |
20% up to
12 days PCY
20% up to 12 visits PCY |
20% up to
12 days PCY
20% up to 12 visits PCY |
50% up to
12 days PCY
50% up to 12 visits PCY |
30% up to
12 days PCY
30% up to 12 visits PCY |
Rehabilitation
services
Inpatient physical, occupational, and restorative
speech-therapy services combined. |
20%
Up to 60 days per
calendar year. |
20%
Up to 60 days per
calendar year. |
50%
Up to 60 days per
calendar year. |
30%
Up to 60 days per
calendar year. |
Outpatient physical, occupational,
and restorative speech-therapy services combined |
20%
Up to 30 days per
calendar year. |
20%
Up to 30 days per
calendar year. |
50%
Up to 30 days per
calendar year. |
30%
Up to 30 days per
calendar year. |
| Lab/X-ray Services |
20% |
20% |
50% |
30% |
Hospital
Visits - Inpatient
Hospital room and board; inpatient surgery; anesthesia;
intensive and coronary care; laboratory tests; radiology
services; drugs while in hospital. |
20% |
20% |
50% |
30% |
Prescription
drugs - Outpatient
Drugs and medicines
that require a prescription, including injectables,
contraceptive drugs, devices, and supplies. Mental
health drugs are excluded from coverage. |
$20 copay generic/ $40 copay
brand for a 30-day supply or less. $2,000 annual
benefit maximum. Not subject to the annual deductible.
Mail order; $5 discount for each 30-day supply. |
Not covered |
Not covered |
Not covered |
Ambulance
Services
Emergency ground/air transportation. |
20% |
20% |
50% |
30% |
| Ambulance
Services Nonemergency
ground/air interfacility transfer. |
20% for Group Health–
initiated transfers, except
hospital-to-hospital ground
transfers covered in full. |
20% for Group Health–
initiated transfers, except
hospital-to-hospital ground
transfers covered in full. |
50% for Group Health–
initiated transfers, except
hospital-to-hospital ground
transfers covered in full. |
30% for Group Health–
initiated transfers, except
hospital-to-hospital ground
transfers covered in full. |
Chemical
Dependency Treatment
Inpatient, limited to acute
detoxification only.
Outpatient, limited to diagnostic evaluation only. |
20%
(does not apply to out of pocket max)
|
20%
(does not apply to out of pocket max) |
50%
(does not apply to out of pocket max) |
30%
(does not apply to out of pocket max) |
Devices,
equipment, and supplies(for home use)
Orthopedic appliances, durable
medical equipment, glucose monitors, ostomy supplies,
etc. |
50% up to $5,000
($2,500 max benefit). |
50% up to $5,000
($2,500 max benefit). |
50% up to $5,000
($2,500 max benefit). |
50% up to $5,000
($2,500 max benefit). |
| Prosthetics |
50% up to $40,000
($20,000 max benefit). |
50% up to $40,000
($20,000 max benefit). |
50% up to $40,000
($20,000 max benefit). |
50% up to $40,000
($20,000 max benefit). |
Emergency
care
Provided at Group Health or Group Health–designated
hospital emergency departments. |
$75 copay per incident |
$100 copay per incident |
$100 copay per incident
+ 50% |
$100 copay per incident |
Emergency
care
Provided at non-Group Health facilities. |
$125 copay per incident |
$150 copay per incident |
$125 copay per incident
+50% |
$150 copay per incident |
Hearing
Exams - Routine
To determine hearing loss. |
20% |
20% |
50% |
30% |
Home Health
No visit limit. |
20% |
20% |
50% |
30% |
| Hospice |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
| Organ Transplant |
Covered subject to the applicable cost
share up to $250,000 lifetime maximum
(including organ acquisition, matching,
and donor costs, up to $50,000), and a six-month
benefit wait period. |
Covered subject to the applicable cost
share up to $250,000 lifetime maximum
(including organ acquisition, matching,
and donor costs, up to $50,000), and a six-month
benefit wait period. |
Covered subject to the applicable cost
share up to $250,000 lifetime maximum
(including organ acquisition, matching,
and donor costs, up to $50,000), and a six-month
benefit wait period. |
Covered subject to the applicable cost
share up to $250,000 lifetime maximum
(including organ acquisition, matching,
and donor costs, up to $50,000), and a six-month
benefit wait period. |
| Skilled
Nursing Facility Care |
20% up to 60 days per calendar year. |
20% up to 60 days per calendar year. |
50% up to 60 days per calendar year. |
30% up to 60 days per calendar year. |
Tobacco
cessation
Individual/group sessions |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
| Approved pharmacy
products |
Covered subject to pharmacy
copay. |
Subject to charge. |
Subject to charge. |
Subject to charge. |
Vision
Care
Routine eye exam. |
20%
One visit every 12 months |
20%
One visit every 12 months |
Not covered |
30%
One visit every 12 months |
| Vision
Hardware |
Not covered |
Not covered |
Not covered |
Not covered |
| Work related
conditions |
Covered as for any other
condition (limited) |
Covered as for any other
condition (limited) |
Covered as for any other
condition (limited) |
Covered as for any other
condition (limited) |
| Pre-existing
conditions |
Group Health will apply credit for pre-existing
conditions if the person enrolling has been covered
by a group or individual health benefit plan with
no more than $1,750 deductible and with maternity
and prescription drug benefits, at any time during
the 63 (sixty-three) day period immediately preceding
the receipt date of the application. If credit
is not applied, pre-existing conditions will not
be covered until a member has been continuously
enrolled under this plan for 9 months (nine months).
Maternity services for prenatal and postpartum
care are covered even if the member has a pre-existing
condition wait time. Delivery of the baby may
be considered a pre-existing condition and the
financial responsibility of the member. |
Group Health will apply credit for pre-existing
conditions if the person enrolling has been covered
by a group or individual health benefit plan with
no more than $1,750 deductible and with maternity
and prescription drug benefits, at any time during
the 63 (sixty-three) day period immediately preceding
the receipt date of the application. If credit
is not applied, pre-existing conditions will not
be covered until a member has been continuously
enrolled under this plan for 9 months (nine months).
Maternity services not covered under this plan. |
Group Health will apply credit for pre-existing
conditions if the person enrolling has been covered
by a group or individual health benefit plan with
no more than $1,750 deductible and with maternity
and prescription drug benefits, at any time during
the 63 (sixty-three) day period immediately preceding
the receipt date of the application. If credit
is not applied, pre-existing conditions will not
be covered until a member has been continuously
enrolled under this plan for 9 months (nine months).
Maternity services not covered under this plan. |
Group Health will apply credit for pre-existing
conditions if the person enrolling has been covered
by a group or individual health benefit plan with
no more than $1,750 deductible and with maternity
and prescription drug benefits, at any time during
the 63 (sixty-three) day period immediately preceding
the receipt date of the application. If credit
is not applied, pre-existing conditions will not
be covered until a member has been continuously
enrolled under this plan for 9 months (nine months).
Maternity services not covered under this plan. |
Asuris
NW Health
