Human Resource Services

Benefits

Network/Non-Network Benefits Comparison

Please note that network providers may not always be available, particularly with respect to radiologists, anethesiologists, pathologists, and emergency room physicians.

Health Plan Benefits

Using Network Providers You Pay:

Using Non-Network Providers You Pay:

Hospital Admissions

$250 per admission

$500 per admission

Outpatient and All Other Services

$250 per person per calendar year (maximum two per family)

$750 per person per calendar year (maximum two per family)

Primary Care Physician Office Visits

$15 per visit

No per-visit fee; 40 percent of non-network allowance plus difference between the actual charge and the allowance

Specialist Office Visits

$25 per visit

No per-visit fee; 40 percent of non-network allowance plus difference between the actual charge and the allowance

Other Physician Services
(including but not limited to pathology, radiology, outpatient or inpatient surgery, anesthesia, hospital visits/consultations, outpatient visits/consultations, and maternity care)

20 percent of the network allowed amount after the $250 calendar year deductible is met

40 percent of the non-network allowance plus difference between the actual charge and the allowance after the $750 calendar year deductible is met

Outpatient Facility Services
(including but not limited to outpatient hospitals, ambulatory surgical centers, and rehabilitative facilities)

20 percent of the network allowed amount after the $250 calendar year deductible is met

40 percent of the non-network allowance plus difference between the actual charge and the allowance after the $750 calendar year deductible is met

Emergency Room Services

$50 per visit; waived if admitted

No deductible; 40 percent of the non-network allowance plus difference between the actual charge and the allowance

Inpatient Acute Care Facility Services

$250 per admission deductible plus 20 percent of the network allowed amount

$500 per admission deductible plus 40 percent of the non-network allowance plus amount above non-network daily room and board allowances plus difference between the actual charge and the allowance plus hospital stay certification penalties if the admission is not properly certified

Skilled Nursing Facility Services

30 percent of the network allowed amount plus amount above the daily room and board allowance

30 percent of the non-network allowance plus amount above the non-network daily room and board allowances plus difference between the actual charge and the allowance

Specialty Institution

 

 

Outpatient

20 percent of the network allowed amount after the $250 calendar year deductible is met

Alcohol/drug treatment only: 40 percent of the non-network allowance plus difference between the actual charge and the allowance after the $750 calendar year deductible is met

Inpatient

20 percent of the network allowed amount after the $250 calendar year deductible is met

Alcohol/drug treatment only: must be requested by the employing agency and approved by DSGI--$500 per admission deductible plus 40 percent of the non-network allowance plus amount above the non-network daily room and board allowances plus difference between the actual charge and the allowance

Mammograms

20 percent of the network allowed amount after the $250 calendar year deductible is met

40 percent of the non-network allowance plus difference between the actual charge and the allowance after the $750 calendar year deductible is met

Physical and Massage Therapy

20 percent of the network allowed amount after the $250 calendar year deductible is met

40 percent of the non-network allowance plus difference between the actual charge and the allowance after the $750 calendar year deductible is met

Manipulative Services

20 percent of the network allowed amount after the $250 calendar year deductible is met

40 percent of the non-network allowance plus difference between the actual charge and the allowance after the $750 calendar year deductible is met

Home Health Care

20 percent of the network allowed amount after the $250 calendar year deductible is met

40 percent of the non-network allowance plus difference between the actual charge and the allowance after the $750 calendar year deductible is met

Ambulance Transportation

no charge

no charge

Durable Medical Equipment
(oxygen therapy, prosthetic appliances, medical supplies, wheelchairs, hospital-type beds)

20 percent of the network allowed amount after the $250 calendar year deductible is met

40 percent of the non-network allowance plus difference between the actual charge and the allowance after the $750 calendar year deductible is met

Hospice Care

 

 

Inpatient

30 percent of network allowed amount

30 percent of non-network allowance plus difference between the actual charge and the allowance

Outpatient/Home

 

20 percent of non-network allowance plus difference between the actual charge and the allowance

Health Screening Exam
(provides coverage for routine physical exams and related testing for active employees covered under the plan and former active employees with COBRA coverage--the benefit covers up to $100 toward the cost of physical exams, gynecological exams, routine eye tests, routine hearing tests, tests associated with routine exams, prostate specific antigen tests for males age 50 years and over)

You pay for the charges in excess of the $100 annual allowance

You pay for the charges in excess of the $100 annual allowance

Contraceptive Services and Supplies

Paid according to the type of service rendered as noted above for physical office visits, other physician services, and durable medical equipment

Paid according to the type of service rendered as noted above for physical office visits, other physician services, and durable medical equipment

Benefit Exclusion
Benefit Exclusions include, but are not limited to: medically unnecessary or unauthorized treatment; custodial care; war or acts of war; complications from non-covered surgery; contraceptive supplies; cosmetic surgery except as a result of covered illness or injury; occupational injuries or conditions; dental care, unless medically necessary to alleviate condition caused by an accident; experimental or investigative treatments; routine eye care; hearing aids; infertility treatment or supplies; marriage or family counseling; non-prescription (over the counter) drugs and supplies; Hepatitis B vaccines; obesity or weight reduction (certain exceptions); reversal of voluntary sterility; intersex surgery; sexual disorders; artificial insemination or in-vitro fertilization; smoking cessation programs; sleep, occupation, recreation, education, speech therapy; and work-related conditions.