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KPS health plans
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Index | Exclusions | Provider
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Benefit Schedules:
Sound Harbor Elite | Essential Plus | Essential Five | HSA
| HSA with RX
Rate Schedules:
Sound Harbor Elite | Essential Plus | Essential Five | HSA | HSA
with RX
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Essential Plus Benefits |
| Annual Deductible - Individual |
$2,000* |
| Annual Deductible
- Family |
$6,000 |
Annual Coinsurance
Maximum - Individual**
(Does not include deductible, unless otherwise stated) |
$6,000 |
Annual Coinsurance
Maximum - Family**
(Does not include deductible, unless otherwise stated) |
$18,000 |
| Lifetime maximum |
$1,000,000/person |
Preventive Care:
(Not subject to deductible, unless otherwise stated)
Annual Routine Physical Exam
Well-Baby Exam (to 24 months of age)
Annual Routine Eye Exam
Smoking Cessation- Professional Services |
$250 maximum per year for all preventive
care
70%
70%
70%
70%
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Professional Services
Office, home, naturopath or urgent care visits
Other outpatient professional services |
100% after $30 per-visit copay for first 3 visits
combined (no deductible), subsequent visits
70% subject to deductible
70% |
Outpatient Lab & X-Ray
Mammography Services and Prostate Cancer Screening-Routine
Mammography Services and Prostate Cancer Screening-Diagnostic |
70%
70% (not subject to deductible)
70% (subject to deductible) |
Hospital
Inpatient
|
70% |
Hospital
Outpatient |
70% |
Emergency Room & Supplies
(copay waived if admitted) |
70% after $100 copay per visit |
Acupuncture
(12 treatments per year maximum) |
See Professional Services |
Ambulance Services
Air and Ground Combined - $5,000 max per year |
70% |
Home Health and Hospice
Home Health – 130 visits maximum
Hospice – 6 months maximum per year |
70%
70%
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| Maternity |
Not a Benefit |
Medical Equipment & Supplies
$2,500 per calendar year maximum |
70% |
Mental Health
Inpatient (prior authorization required)-10 days per year maximum
Outpatient-12 visits per year maximum |
70%
See Professional Services |
Nutritional Guidance
$400 maximum per year |
70% |
Outpatient
Rehabilitation
(Physical, Speech, Massage & Occupational Therapy) |
70%
($1,000 maximum per year) |
Prescriptions ($2,000 maximum per year, except for diabetes)
Tier 1: generic
Tier 2: preferred brand
name
Tier 3: non-preferred brand name |
Tier 1: $15 copay or the cost of the drug, whichever is less
Tier 2: Pharmacy Discount Program
Tier 3: Pharmacy Discount Program |
Skilled Nursing Facility
(in lieu of hospitilization) |
70% |
Spinal & Extremity Manipulations
(12 manipulations per year maximum)
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70% |
*In the case of accidental injury, charges for medically necessary covered services directly related to the treatment of the injury are exempt from the deductible for a period of up to six (6) months, provided initial treatment for the injury is received within seventy-two (72) hours of the onset of the injury. After six (6) months, the condition is considered to be chronic and charges related to the treatment of the injury would be applied to any outstanding deductible. All other applicable benefit limitations and maximums apply. |
All benefits are subject to annual deductible unless otherwise stated. This
benefit comparison contains only a brief explanation of the more important coverage
features offered. It does not constitute a contract. Complete coverage details,
including waiting periods and other limits and exclusions, are in the Benefits
Booklet. In the event of discrepancies, the Benefits Booklet shall govern.
*In the case of accidental injury, charges for medically necessary covered services directly related to the treatment of the injury are exempt from the deductible for a period of up to six (6) months, provided initial treatment for the injury is received within seventy-two (72) hours of the onset of the injury. After six (6) months, the condition is considered to be chronic and charges related to the treatment of the injury would be applied to any outstanding deductible. All other applicable benefit limitations and maximums apply.
**After member satisfies the annual deductible and coinsurance maximum, KPS pays 100% of covered benefits for the remainder of the calendar year, with some limitations. If you choose a non-participating provider, your coinsurance costs are higher. In addition, it is your responsibility to pay the difference between any amounts billed by the non-participating provider or facility and the amount paid by KPS.
Note: This summary contains a brief explanation of the
coverage features offered through KPS Health Plans. It does not constitute a
contract. Complete coverage details are in the Benefit Booklet. In the event
of discrepancies, the Benefit Booklet shall govern. There are exceptions, limitations,
and reductions which may affect your coverage.
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Asuris
NW Health