Huntington Ingalls Newport News Anthem Key ... - Benefits Connect

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2 - Summary of benefits In-network Out-of-network Detail Copayment Coinsurance Coinsurance Page number (after calendar year deductible) (after calendar year deductible) Visits to an out-of-network emergency room for emergency services will be covered at in-network benefit levels and apply the in-network cost shares. The facility and provider may balance bill for any amounts in excess of the maximum allowed amount. The out-of-network benefit shown reflects the cost shares for visits to an out-of-network emergency room for services that are not emergency services. Hearing aids and tests Home care services 90-visit calendar year limit for home health services Copayment/coinsurance determined by service received. $0 10% 20% 19 Home private duty nurses services $0 10% ** 19 $500 calendar year limit Hospice care services $0 10% 20% 19 Hospital services Inpatient treatment Facility services $0 per stay 10% 20% 20 Professional provider services $0 10% 20% 20 Outpatient treatment Facility services $0 10% 20% 20 Professional provider services Primary Care Physicians $15 0% 20% 20 Specialty Care Providers $25 0% 20% 20 calendar year deductible does not apply Infusion services - outpatient services *** Facility services $0 10% 20% 21 Professional provider services $0 10% 20% 21 Home services $0 10% 20% 21 Infusion medications Outpatient settings $0 10% 20% 21 Home settings $0 10% 20% 21 Maternity Professional provider services Prenatal and postnatal follow-up care Primary Care Physicians $15 0% 20% 21 Specialty Care Providers $25 0% 20% 21 calendar year deductible does not apply Delivery $0 10% 20% 21 Hospital services for delivery delivery room, anesthesia, nursing care for newborn $0 per stay 10% 20% 21 Diagnostic tests $0 10% 20% 21 Medical equipment (durable), prosthetics, appliances, formulas, supplies, and medications $0 10% 20% 22 Mental health or substance abuse treatment 23 Inpatient treatment 23 Facility services $0 per stay 10% 20% 23 ** Since there is no network required for these services, benefits will be paid as if rendered on an in-network basis. *** See Hospital services for payment amounts for inpatient therapy. Summary of benefits continued
Summary of benefits - 3 In-network Out-of-network Detail Copayment Coinsurance Coinsurance Page number (after calendar year deductible) (after calendar year deductible) Professional provider services $0 10% 20% 23 Partial day program $0 10% 20% 24 Outpatient treatment Primary Care Physicians $15 0% 20% 24 Specialty Care Providers $25 0% 20% 24 calendar year deductible does not apply Shots (injections) $0 10% 20% 29 at a doctor’s office, emergency room or outpatient hospital department Skilled nursing facility stays 29 100-day per stay limit Facility services $0 10% 20% 29 per stay Professional provider services $0 10% 20% 29 Spinal manipulations and other manual medical interventions 30-visit calendar year limit per member Primary Care Physicians $15 0% 20% 29 Specialty Care Providers $25 0% 20% 29 calendar year deductible does not apply Surgery 29 Inpatient Facility services $0 10% 20% 29 per stay Professional provider services $0 10% 20% 29 Outpatient Facility services $0 10% 20% 29 per visit Professional provider services Primary Care Physicians $15 0% 20% 29 Specialty Care Providers $25 0% 20% 29 calendar year deductible does not apply Therapy – outpatient services *** Cardiac rehabilitation therapy Hospital services $0 10% 20% 31 Professional provider services $0 10% 20% 31 Chemotherapy Hospital services $0 10% 20% 31 Professional provider services $0 10% 20% 31 Occupational therapy visits 30 – visit calendar year limit per member (combined with physical therapy visits) Hospital services $0 10% 20% 31 Professional provider services Primary Care Physicians $15 0% 20% 31 Specialty Care Providers $25 0% 20% 31 calendar year deductible does not apply *** See Hospital services for payment amounts for inpatient therapy. Summary of benefits continued
Page 1 and 2: Huntington Ingalls Industries, Inc.
Page 3 and 4: SUMMARY PLAN DESCRIPTION KEYCARE 15
Page 5 and 6: SECTION I - MEMBER CERTIFICATE This
Page 7: STEELWORKERS HEALTH AND WELFARE FUN
Page 10 and 11: Helpful tip: Look for these icons t
Page 12 and 13: Index. . . . . . . . . . . . . . .
Page 16 and 17: 4 - Summary of benefits In-network
Page 18 and 19: 6 How your health plan works Your h
Page 20 and 21: 8 - How your health plan works Choo
Page 22 and 23: 10 - How your health plan works All
Page 24 and 25: 12 - How your health plan works Bef
Page 26 and 27: 14 - How your health plan works •
Page 28 and 29: 16 What is covered Your health plan
Page 30 and 31: 18 - What is covered • nuclear ca
Page 32 and 33: 20 - What is covered • services o
Page 34 and 35: 22 - What is covered If your doctor
Page 36 and 37: 24 - What is covered How your healt
Page 38 and 39: 26 - What is covered We have establ
Page 40 and 41: 28 - What is covered Services of no
Page 42 and 43: 30 - What is covered Morbid obesity
Page 44 and 45: 32 - What is covered Physical thera
Page 46 and 47: 34 - What is covered Your health pl
Page 48 and 49: 36 - What is not covered This exclu
Page 50 and 51: 38 - What is not covered However, i
Page 52 and 53: 40 - What is not covered Your cover
Page 54 and 55: 42 - What is not covered W Your cov
Page 56 and 57: 44 - Claims and payments Out-of-net
Page 58 and 59: 46 - Claims and payments Providers
Page 60 and 61: 48 - Claims and payments • the ou
Page 62 and 63: 50 - Claims and payments In additio
Page 64 and 65:
52 When you are covered by more tha
Page 66 and 67:
54 - When you are covered by more t
Page 68 and 69:
56 - Eligibility for coverage Chang
Page 70 and 71:
58 - Eligibility for coverage will
Page 72 and 73:
60 - Eligibility for coverage Depen
Page 74 and 75:
62 - Eligibility for coverage Conti
Page 76 and 77:
64 - Eligibility for coverage When
Page 78 and 79:
66 - Eligibility for coverage A qua
Page 80 and 81:
68 - Important information about yo
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
76 - Member’s rights and responsi
Page 90 and 91:
78 - Definitions Emergency services
Page 92 and 93:
80 - Definitions Out-of-network is
Page 94 and 95:
82 - Definitions Skilled nursing fa
Page 96 and 97:
84 - Exhibit A Clinical trial costs
Page 98 and 99:
86 page Newborn . . . . . . . . . .
Page 100 and 101:
88 - Special features and programs
Page 102:
Anthem Blue Cross and Blue Shield 2
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