Under the Traditional Indemnity benefits program, benefits
include coverage for both facility and professional services. Most Major
Medical benefits are subject to deductible and coinsurance provisions, which
require you to share a portion of the medical costs. Below are specific benefit
levels.
|
BENEFITS |
TRADITIONAL
PROFESSIONAL
PROGRAM |
TRADITIONAL
FACILITY
PROGRAM |
TRADITIONAL
MAJOR MEDICAL
PROGRAM |
|
Deductible
Per Calendar Year |
None |
None |
$500 Individual
$1,500 Family Aggregate |
|
Payment Level
Based on
Provider’s Reasonable Charge (PRC) |
100% PRC |
100% PRC |
80% PRC after deductible until
out-of-pocket is met; then 100% PRC |
|
Out-of-Pocket
Limit
Includes
Coinsurance – See benefit booklet for exclusions/details |
None |
None |
$350 per Individual
|
|
Lifetime Maximum |
None |
None |
$1,075,000/person |
|
Ambulance |
Not Covered |
100% PRC
Facility-billed only
|
80% PRC after deductible |
|
Assisted
Fertilization Procedures |
Not Covered |
Not Covered |
Not Covered |
|
Dental Services
Related to an Accidental Injury |
100% PRC |
Not Covered |
80% PRC after deductible |
|
Diabetes
Treatment |
100% PRC |
100% PRC |
80% PRC after deductible |
|
Diagnostic
Services
Lab, X-ray, and
Medical Tests
|
100% PRC |
100% PRC |
80% PRC after deductible |
|
Durable Medical
Equipment
Orthotics and
Prosthetics |
Not Covered |
Not Covered |
80% PRC after deductible |
|
Elective Abortion
Includes Dependent
Daughters
|
Not Covered
(except in cases of rape, incest, or to
avert death of the mother) |
Not Covered
(except in cases of rape, incest, or to
avert death of the mother) |
Not Covered
(except in cases of rape, incest, or to
avert death of the mother) |
|
Emergency Care
Professional
Services
|
100% PRC |
Not Covered |
80% PRC after deductible |
|
Emergency Room
Services
Facility Services –
within 72 hours
|
Not Covered |
100% PRC |
80% PRC after deductible |
|
Enteral Formulae |
100% PRC |
100% PRC |
80% PRC no deductible |
|
BENEFITS |
TRADITIONAL
PROFESSIONAL
PROGRAM |
TRADITIONAL
FACILITY
PROGRAM |
TRADITIONAL
MAJOR MEDICAL
PROGRAM |
|
Home Health Care
Excludes Respite
Care
|
Not Covered |
100% PRC |
80% PRC after deductible |
|
60 visits per 90 day period |
|
Hospice
Includes Respite
Care
|
Not Covered
|
100% PRC |
Not Covered |
|
$12,500 lifetime max |
|
Hospital Expenses
Inpatient and
Outpatient |
Not Covered |
100% PRC |
80% PRC after deductible |
|
365 days
2 pint blood deductible/calendar year |
2 pint blood deductible/calendar year |
|
Infertility
Counseling, Testing and Treatment |
100% PRC
Excludes Office Visits |
100% PRC |
80% PRC after deductible |
|
Maternity
Excludes Dependent
Daughters
|
100% PRC |
100% PRC |
80% PRC after deductible |
|
Medical Care
Includes Inpatient
Visits and Consultations
|
100% PRC |
Not Covered |
80% PRC after deductible |
|
Mental Health –
Inpatient *
Includes Partial
Hospitalization (every 3 units equals 1 day) |
100% PRC |
100% PRC |
50% PRC after deductible |
|
60 days per 12 month period |
60 days per 12 month period |
|
Mental Health –
Outpatient |
Not Covered |
Not Covered |
50% PRC after deductible;
$50 maximum per visit |
|
Office Visits
Employee only |
21 visits per 12 month period, subject to
$25 deductible |
Not Covered |
80% PRC after deductible |
|
Oral Surgery |
100% PRC |
100% PRC |
80% PRC after deductible |
|
Physical Therapy
Outpatient
|
100% PRC
unlimited |
100% PRC |
80% PRC after deductible |
|
unlimited |
unlimited |
|
Preventive Care
Adult Preventive Care includes:
Physical Exam
Immunizations
Diagnostic Screening, including
Mammography
Gynecological Exam & Pap Test |
Not Covered
Not Covered
Not Covered, except Mammography 100% PRC
100% PRC |
Not Covered
Not Covered
Not Covered, except Mammography 100% PRC
100% PRC |
Not Covered
Not Covered
Not Covered, except Mammography 80% PRC
after deductible
80% PRC no deductible/lifetime maximum |
|
Pediatric
Preventive Care includes:
Physical Exams
Pediatric Immunizations
Diagnostic Screening |
Not Covered
100% PRC
Not Covered |
Not Covered
100% PRC
Not Covered |
Not Covered
80% PRC no deductible/lifetime maximum
Not Covered |
|
Private Duty
Nursing |
Not Covered |
Not Covered |
80% PRC after deductible |
|
240 hours/calendar year |
|
BENEFITS |
TRADITIONAL
PROFESSIONAL
PROGRAM |
TRADITIONAL
FACILITY
PROGRAM |
TRADITIONAL
MAJOR MEDICAL
PROGRAM |
|
Skilled Nursing
Facility Care |
100% PRC |
Not Covered |
80% PRC after deductible |
|
Speech and
Occupational Therapy
Outpatient
|
Not Covered |
100% PRC |
80% PRC after deductible |
|
unlimited |
unlimited |
|
Spinal
Manipulations |
Not Covered |
Not Covered |
80% PRC after deductible |
|
30 visits/calendar year |
|
Substance Abuse –
Detoxification |
Not Covered |
100% PRC |
Not Covered |
|
7 days/admission; 4 admissions/lifetime |
|
Substance Abuse –
Inpatient Rehabilitation |
100% PRC |
100% PRC |
Not Covered |
|
60 days per 12 month period |
30 days/calendar year; no lifetime
maximum |
|
Substance Abuse –
Outpatient |
Not Covered |
100% PRC |
50% PRC after deductible;
$50 maximum per visit |
|
30 visits/calendar year; 120
visits/lifetime |
|
Surgical Expenses
Includes
Assistant Surgery, Anesthesia, Sterilization and Reversal Procedures
Excludes Neonatal
Circumcision |
100% PRC |
100% PRC |
80% PRC after deductible |
|
Therapy Services
Chemotherapy,
Radiation Therapy, Dialysis, Infusion Therapy, Respiration Therapy |
100% PRC |
100% PRC |
80% PRC after deductible |
|
Transplant
Services |
100% PRC |
100% PRC |
80% PRC after deductible |
|
Preadmission
Requirements for Inpatient Admissions
No Penalty for
Non-compliance |
Performed by Provider |
Performed by Provider |
Performed by Provider |
|
Condition
Management |
Case Management, Blues on Call, and
Disease State Management |
Case Management, Blues on Call, and
Disease State Management |
Case Management, Blues on Call, and
Disease State Management |
