|
Plan Features |
Heritage Providers |
Non Heritage Providers |
|
How the plan works |
For Heritage Providers, the plan pays 90% of eligible charges after you meet the annual deductible. |
You may choose to receive care from any licensed provider in Alaska or Washington.
For non Heritage hospital or hospital-based chemical dependency programs, the plan pays 60% after you meet the annual deductible.
For all other non Heritage facility and professional services, the plan pays 90% after you meet the annual deductible. |
|
Annual deductible |
Individual: $250
Family: $750 |
|
Annual out-of- pocket maximum |
When your 10% of eligible charges reaches $1,000, the plan will pay 100% of eligible charges for most services for the remainder of the year. The annual deductible and copays do not count toward the out-of-pocket maximum. Some benefits are not subject to the out-of-pocket maximum. |
|
Lifetime maximum benefit per person |
$2,000,000 |
| Care management |
A voluntary service that coordinates care with your program benefits and helps you and your physician consider effective alternatives to hospitalization and other high cost care. |
| BlueCard Program |
A national program available to enrollees who receive care outside of Alaska and Washington. If you see a Provider who has contracted with the local Blue Cross and/or Blue Shield Licensee in the are you are receiving care, your cost for services may be less. |
| Covered services |
Plan Pays |
| Ambulance |
90% after deductible |
90% after deductible |
| Chemical dependency treatment |
90% up to $14,495 per 24 consecutive-month period; $28,985 lifetime maximum benefit (this applies to the $2 million lifetime benefit) |
60% up to $14,495 per 24 consecutive-month period; $28,985 lifetime maximum benefit (this applies to the $2 million lifetime benefit) |
Diabetes health education
(outpatient only) |
100%; not subject to deductible or coinsurance |
100%; not subject to deductible or coinsurance |
| Emergency room |
90% after you pay a $100 emergency room copay (copay waived if admitted or if emergency room care is for treatment of an accidental injury within two days of injury) |
60% after you pay a $100 emergency room copay (copay waived if admitted or if emergency room care is for treatment of an accidental injury within two days of injury). Covered services received by a Non Heritage Provider are provided at the Heritage Provider benefit level if medical emergency |
| Home health care |
90% after deductible for home health agency services; up to 130 visits per calendar year |
90% after deductible for home health agency services; up to 130 visits per calendar year |
Home medical equipment
(includes respiratory equipment/medical supplies) |
90% after deductible up to $5,000 per calendar year |
90% after deductible up to $5,000 per calendar year |
| Home nursing care and therapy services |
90%, after deductible up to $1,500 per calendar year for professional services by a registered nurse (2 hours per day) and home respiratory therapy and photo therapy. |
90%, after deductible up to $1,500 per calendar year for professional services by a registered nurse (2 hours per day) and home respiratory therapy and photo therapy. |
| Hospice |
90% after deductible, not to exceed 6 months |
90% after deductible, not to exceed 6 months |
| Hospital visit |
Inpatient: 90% after deductible for semiprivate room
Outpatient: 90% after deductible |
Inpatient: 60% after deductible for semiprivate room
Outpatient: 60% after deductible |
Immunizations
(outpatient only) |
100%; not subject to deductible or coinsurance |
100%; non subject to deductible or coinsurance |
| Mental health care |
Inpatient: 90% after deductible
Outpatient: Constant 50% after deductible (does not apply to out-of-pocket maximum); maximum of 20 visits per enrollee each calendar year |
Inpatient: 60% after deductible
Outpatient: Constant 50% after deductible (does not apply to out-of-pocket maximum); maximum of 20 visits per enrollee each calendar year |
| Orthoptic therapy |
90%, after deductible up to $55 per visit, up to a maximum of 24 visits per calendar year |
90%, after deductible up to $55 per visit, up to a maximum of 24 visits per calendar year |
Physician visits
(Does not include mental health care, rehabilitation, or neurodevelopmental therapy) |
100% after $25 copay; not subject to deductible or coinsurance |
100% after $25 copay; not subject to deductible or coinsurance |
Preventive care
(Routine physicals, lab and X-ray, screenings) |
100% after $25 copay; not subject to deductible or coinsurance |
100% after $25 copay; not subject to deductible or coinsurance |
Rehabilitative care
(includes physical, occupational and speech therapy) |
Inpatient: 90% after deductible, up to 60 days per calendar year
Outpatient: Constant 80% after deductible (does not apply to out-of-pocket maximum)
|
Inpatient: 60% after deductible, up to 60 days per calendar year
Outpatient: Constant 80% after deductible (does not apply to out-of-pocket maximum) |
| Round-trip air transportation |
Maximum of 3 round trip transports per calendar year; see Benefit Booklet for details and limitations |
| Skilled nursing facility |
90% after deductible for semiprivate room, up to 60 days per calendar year |
60% after deductible for semiprivate room, up to 60 days per calendar year |
Surgical Services
|
90% after deductible |
90% after deductible |
| Transplants |
90% up to $250,000 lifetime maximum for all covered organ, bone marrow, and stem cell transplants combined |
N/A |
| Well-baby care |
100% after $25 copay; not subject to deductible or coinsurance |
100% after $25 copay; not subject to deductible or coinsurance |
| X-rays and lab tests |
90% after deductible |
90% after deductible |
You are responsible for any applicable deductibles, copayments, coinsurance, charges in excess of stated benefit maximums, and charges for services and supplies not covered under this plan.
