Notas a las cuentas anuales consolidadas
32 Obligaciones por prestaciones al personal
Annual Deductible
The amount of covered medical and prescription drug expenses you pay each year before the Plan pays any benefits.
Amount is per Plan year (January 1 – December 31); includes covered medical and prescription drug expenses
$1,150 per person $2,300 per family
The per person deductible applies separately to each covered person. The family deductible combines the per person deductible expenses incurred by all covered family members.
Once your family has met the family deductible for the plan year, no further deductible will be applied for any covered family member during the remainder of that year.
$1,500 for employee only coverage
$3,000 for family coverage (any level greater than employee only)
Employee only coverage has a different deductible amount than family coverage (any level greater than employee only). Family coverage has no per person deductible for each covered person. Family coverage is any coverage level that includes family members. The family deductible can be met by covered charges incurred by the various covered members of the family. Certain expenses do not apply towards the deductible, including but not limited to: services, even if recommended by a physician, not covered by the Plan; services in excess of a maximum benefit limit; fees in excess of reasonable and customary charges; penalties paid for not obtaining required prior authorization; and any copayments for the Health Reimbursement Medical Plan
Out of Pocket Maximum
The maximum amount, including deductibles, you must pay toward covered medical expenses in any Plan year (January 1 – December 31). Once the out-of-pocket maximum is met in a Plan year, the Medical plan pays 100% of any additional covered expenses in that year. With family coverage, once your family has met the family deductible out of pocket maximum for the plan year, covered expenses for any covered family member will be paid at 100% for the remainder of that Plan year.
Per person $3,300 Family $6,600
The per person out of pocket maximum applies separately to each covered person.
The family out of pocket maximum combines per person expenses incurred by all covered family members.
Employee only coverage $3,000
Family coverage $6,000
Employee only coverage has a different out of pocket maximum amount than family coverage (any level greater than employee only).
Family coverage has no per person out of pocket maximum for each covered person. Family coverage is any coverage level that includes family members. The family deductible out of pocket maximum can be met by covered charges incurred by the various covered members of the family.
Certain expenses do not apply to the out-of-pocket maximum, including but not limited to: services, even if recommended by a physician, not covered by the Plan; services in excess of a maximum benefit limit; fees in excess of reasonable and customary charges; and penalties paid for not obtaining required prior authorization.
type exclusions listed in the Benefit Summary.
The following table summarizes two preferred provider medical options. Information on HMO plans or legacy plans can be found in the appendix. The claims administrator for employees of the Western Montana region is Allegiance Benefit Plan Management, Inc.; a separate medical summary plan description will be provided.
Benefit
Health Reimbursement Medical Plan
Health Savings Medical Plan
Acupuncture
Care by licensed acupuncturist:
-Office visits
May include Medically Necessary adjunctive therapy when provided with acupuncture course of treatment for neuromuscloskeletal disorders, nausea or pain
Subject to the deductible
Any licensed acupuncturist: Plan pays 80% of the covered amount, you pay
remainder of the invoice
In combination with any care by a chiropractor and/or naturopathic physician, maximum of $1,500 in covered expenses allowable in a Plan year.
Amounts that apply to the deductible also apply to the benefit limit
Exclusions: Emergency care; preventive care; adjunctive therapy not associated with acupuncture; acupuncture performed with reusable needles; treatment of alcohol, drug or chemical dependency in a specialized inpatient or residential facility
Allergy Services
Allergy shots, allergy serum, injectable
medications and total parenteral nutrition (TPN)
Subject to the deductible
Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20%
Out-of-network: Plan pays 50% of the covered amount, you pay the remainder
of the billed amount
Cancer Screening and Non-surgical Treatment Routine cancer screening
Covered as Preventive Services in accordance with the Adult Preventive Care schedule under the Plan and the Patient Protection and Affordable Care Act of 2010.
Mammogram: at any age
Prostate cancer screen: for one prostate specific antigen (PSA) or DRE per calendar year, ages 40+
Colorectal cancer screening exam or tests for fecal blood test, flexible sigmoidoscopy, colonoscopy, barium enema - beginning at age 50. (Under age 50, covered under Inpatient Surgery benefit)
See below for the deductible
In-network: Not subject to the deductible. Plan pays 100% of the covered
amount, you pay 0%
Out-of-network: Subject to the deductible. Plan pays 50% of the covered
amount, you pay the remainder of the billed amount
Colonoscopy scheduled for other than
screening exam, based on medical necessity
Subject to the deductible
Facility
Providence/Preferred Partner: Plan pays 90% of the covered amount, you
pay 10%
In-network: Plan pays 75% of the covered amount, you pay 25%
Out-of-network: Plan pays 50%of the covered amount; you pay remainder of
the billed amount
Physician/Provider
Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20%
Out-of-network: Plan pays 50% of the covered amount, you pay the remainder
Outpatient Chemotherapy or Radiation Therapy
Subject to the deductible
Facility
Providence/Preferred Partner: Plan pays 90% of the covered amount, you
pay 10%
In-network: Plan pays 75% of the covered amount, you pay 25%
Out-of-network: Plan pays 50%of the covered amount; you pay remainder of
the billed amount
Physician/Provider
Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20%
Out-of-network: Plan pays 50% of the covered amount, you pay the remainder
of the billed amount
Clinical trials relating to cancer Clinical trials are not covered under the plan.
In-network & Out-of-Network: However, for care provided by the health
care practitioners associated with the clinical trial that would otherwise be covered (preventive services, diagnosis, treatment, palliative care), coverage is available under regular plan provision. Please contact Providence Health Plan with questions.
Chiropractic Care
Care by licensed chiropractor:
- Office visits for diagnosis, evaluation and treatment planning for musculoskeletal conditions
- Related diagnostic X-rays and laboratory services for the diagnosis and evaluations of musculoskeletal conditions
- Manipulation of the spine, joints and/or musculoskeletal soft tissue, a re-evaluation, and/ or other services in various combinations. - Adjunctive physiotherapy which may include ultrasound, hot packs, cold packs, electrical muscle stimulation or other therapies and procedures which are Medically Necessary for the treatment of neuromusculoskeletal disorders, including one unit of massage therapy per visit when billed with manipulation
Subject to the deductible
Any licensed chiropractor: Plan pays 80% of the covered amount, you pay the
remainder of the billed amount.
In combination with any care by an acupuncturist and/or naturopathic physician, maximum of $1,500 in covered expenses allowable in a Plan year.
Exclusions: Emergency care; preventive care; services, exams and/or treatments for conditions other than neuromusculoskeletal disorders; all chiropractic appliances or Durable Medical Equipment; adjunctive physiotherapy not associated with chiropractic manipulation of the spine, joints, and/or musculoskeletal soft tissues; clinical laboratory studies performed in a chiropractor’s office; venipuncture; massage therapy when billed without manipulation; massage therapy in excess of one unit per visit with manipulation
Benefit
Health Reimbursement Medical Plan
Health Savings Medical Plan
Dental Services and Dental Anesthesia Dental services received after an accidental injury to natural teeth which
occurred while covered under the Plan Conditions for receiving this benefit: All treatment, except emergency services, require prior authorization by the Plan.
Conditions related to trauma must be diagnosed within six months of injury and treatment must begin within 12 months of injury.
Subject to the deductible
In-network: Plan pays 80% of the covered amount, you pay 20%
Out-of-network: Plan pays 50% of the covered amount, you pay the remainder
of the billed amount
Outpatient facility charges and related anesthesia charges for dental services for children under age six or developmentally disabled children or developmentally disabled adults (these
services are not otherwise provided under the Medical Plan)
Subject to the deductible
Facility
Providence/Preferred Partner: Plan pays 90% of the covered amount, you
pay 10%
In-network: Plan pays 75% of the covered amount, you pay 25%
Out-of-network: Plan pays 50%of the covered amount; you pay remainder of
the billed amount
Anesthesia
Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20%
Out-of-network: Plan pays 50% of the covered amount, you pay the remainder
of the billed amount Prior authorization required
Exclusions: Oral surgery (non-dental or dental) or other dental Services (all procedures involving the teeth;, wisdom teeth areas surrounding the teeth, and dental implants), except as approved by Providence Health Plan
Diabetic Care
Annual preventive exams
- Dilated retinal exams by a qualified participating eye care specialist; - Glycosylated hemoglobin (HbA1c) test; - Urine test to test kidney function; - Blood test for lipid levels as appropriate; - Visual exam of mouth and teeth by a personal physician/provider or other provider (dental visits are not covered); and
- Foot inspection without shoes or socks. NOTE: With the exception of the dilated retinal exam, all of the above may be performed in your provider’s office at the time of your annual exam. The eye exam may be done by an eye care specialist.
Exams may be performed more often than once a year if your provider decides they are medically necessary. Additional exams and tests are subject to the deductible and coinsurance
See below for the deductible
In-network: Not subject to the deductible. Plan pays 100% of the covered
amount, you pay 0%
Out-of-network: Subject to the deductible. Plan pays 50% of the covered
amount, you pay the remainder of the billed amount Additional exams billed with a medical diagnosis Subject to the deductible
Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Subject to the deductible, Plan pays 80% of the covered amount. Out-of-network: Subject to the deductible. Plan pays 50% of the covered
Diabetes supplies
(covered under preventive medication benefit) - Glucose control solution
- Pump supplies - Test strips: - Lancets: - Syringes.
See below for the deductible
In-network: Not subject to the deductible. Plan pays 100% of the covered
amount, you pay 0%
Out-of-network: Subject to the deductible. Plan pays 50% of the covered
amount, you pay the remainder of the billed amount
Diabetes self-management education program
Initial self-management education program. Your provider can recommend a Specialist or facility that provides these services. You must be enrolled on the date services are received through the program for benefits to be paid.
See below for the deductible
In-network: Not subject to the deductible. Plan pays 100% of the covered
amount, you pay 0%
Out-of-network: Subject to the deductible. Plan pays 50% of the covered
amount, you pay the remainder of the billed amount
Diagnostic X-ray and Laboratory Outpatient