BCBSM SBC Support Staff PT 0005 2000-4000 - Kellogg ...

More documents

Recommendations

Info

Common Medical Event Services You May Need Physician/surgeon fee Your cost if you use a In-Network Out-of-Network Provider Provider No Charge after deductible 20% co-insurance after deductible Limitations & Exceptions ---none--- Mental/Behavioral health outpatient services No Charge after deductible 20% co-insurance after deductible Unlimited visits If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services No Charge after deductible No Charge after deductible No Charge after deductible 20% co-insurance after deductible 20% co-insurance after deductible 20% co-insurance after deductible Unlimited days Unlimited visits Unlimited days If you are pregnant Prenatal and postnatal care Delivery and all inpatient services No Charge after deductible No Charge after deductible 20% co-insurance after deductible 20% co-insurance after deductible ---none--- ---none--- If you need help recovering or have other special health needs Home health care Rehabilitation services No Charge after deductible No Charge after deductible No Charge after deductible 20% co-insurance after deductible ---none--- Habilitation services Not Covered Not Covered ---none--- Skilled nursing care No Charge after deductible No Charge after deductible Physical, Occupational, Speech therapy is limited to a combined maximum of 60 visits per member, per calendar year. Limited to a maximum of 90 days per member per calendar year. Durable medical equipment Hospice service No Charge after deductible No Charge after ---none--- deductible No Charge No Charge ---none--- 4 of 8
Common Medical Event If your child needs dental or eye care Your cost if you use a Services You May Need In-Network Provider Out-of-Network Provider Limitations & Exceptions Eye exam Not Covered Not Covered ---none--- Glasses Not Covered Not Covered ---none--- Dental check-up Not Covered Not Covered ---none--- Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Long-term care Cosmetic surgery Routine eye care (Adult) Dental care (Adult) Routine foot care Hearing aids Weight loss programs Infertility treatment Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric surgery Chiropractic care Coverage provided outside the United States. See http://provider.bcbs.com If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, co-payments, or co-insurance, or benefits not otherwise covered. Private-duty nursing 5 of 8
Page 1 and 2: :Kellogg Community College Coverage
Page 3: Common Medical Event For more infor
Page 7 and 8: About these Coverage Examples: Thes

BCBSM SBC Support Staff PT 0005 2000-4000 - Kellogg ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?