CHCGA - Coventry Health Care of Georgia

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Medical PlansGHS offers two medical plans from which to choose: the HMO Plan and thePatient Driven Health Plan (formerly the Definity Health Plan). In 2007, both ofthe plans will be administered by Coventry Health Care of Georgia. Please referto pages 8-10 for a detailed comparison chart. Important additional informationabout each plan follows:Coventry HMO PlanThe Coventry HMO Plan offers low co-pays for covered services and no annualdeductibles to meet. You must select a Primary Care Physician (PCP) from eitherthe GHS ASO Network or Coventry Network. Your PCP will manage and coordinateall of your health care. (Your choice of a PCP may be Family Practice,General Practice, Internal Medicine or Pediatrics). If necessary, your PCP willrefer you to a specialist within the networks. You do not need a referral forOB-GYN, Dermatology or Ophthalmology participating providers. There are noout-of-network benefits, except in certain urgent, emergency care situations. Youcan access a listing of network providers at the following Coventry web address:www.chcga.com or, upon request, in the Human Resources Department.Coventry Patient Driven Health PlanAnother healthcare option is the Patient Driven Health Plan, a consumer drivenplan designed to give you more control over your healthcare. GHS providesbenefit dollars to your Healthcare Reimbursement Account (HRA). The amountcontributed to your HRA depends upon your level of coverage. These dollars maybe used to pay for your covered medical needs and prescription drug co-pays. Ifyou use all of your HRA, then you must meet the remainder of a plan deductible,after which the plan begins sharing costs with you. If you don’t use all of yourHRA within the plan year, the remaining balance rolls over to the following year.For current members of the Definity Health Plan, if you have unused HRA dollarsleft in your account at the end of 2006, and if you elect to participate in the CoventryPatient Driven Health Plan for 2007, your HRA dollars will be rolled overand added to your 2007 HRA balances. You can access a listing of networkproviders at the following web address: www.chcga.com.The Patient Driven Health Plan emphasizes the importance of preventive care byproviding 100% coverage for well child and adult preventive care, includingannual routine physical, immunizations, annual Pap smear, and cancer screenings.You can find more details about the Patient Driven Health Plan in the Addendumsection.7
HEALTH PLANS COMPARISONSUMMARY HMO PLAN PATIENT DRIVEN HEALTH PLANGHS ASO Network You Pay Coventry In Network You Pay Coventry Out of Network You Pay*In Network You PayPreventive Health ServicesRoutine physical exams• PCP Office Visit $25 per visit $40 per visit $0 40% after HRA dollars• Specialist Office Visit $35 per visit $50 per visit used and deductible metRoutine vision exam $30 $50 Covered at 100% 40% after HRA dollars(limit 1 in 12 months) used and deductible metPhysician ServicesInpatient, extended care, No charge No charge 10% after HRA dollars 40% after HRA dollarsrehab/skilled nursing services and deductible met and deductible metby physician (includessurgeon, assistant surgeon,anesthesiologist, pathologist,and radiologist)Office visits & outpatientservices by PCP or specialistphysician:• PCP Office Visit $25 per visit $40 per visit 10% after HRA dollars 40% after HRA dollars• Specialist Office Visit $35 per visit $50 per visit and deductible met and deductible met• Lab, X-ray, diagnostics No charge No chargePregnancy & Maternity CarePrenatal & postnatal physician $400 per pregnancy $800 per pregnancy 10% after HRA dollars 40% after HRAoffice visits and delivery (includes all services) (includes all services) and deductible met dollars and deductible met(requires precertification in1 st trimester). All necessaryinpatient hospital services fornormal delivery, profession fees,cesarean section, andcomplication of pregnancy.Midwife services must beperformed under directsupervision of a participatingobstetrician.Allergy Testing & TreatmentOffice visits, serum, & testing• PCP office visit $25 per visit $40 per visit 10% after HRA dollars 40% after HRA• Specialist office visit $35 per visit $50 per visit and deductible met dollars and deductible met• Allergy injections only $0 co-pay $0 co-payHospital ServicesInpatient services including $300 per admission $600 per admission 10% after HRA dollars 40% after HRAsemi-private room & board, and deductible met dollars and deductible metoperating room, ICU, generalnursing care, medications,oxygen, blood and bloodplasmaOutpatient hospital services $200 per admission $400 per admission 10% after HRA dollars 40% after HRAor surgery including and deductible met dollars and deductible metnecessary suppliesSpecialty FacilityServicesInpatient skilled nursing $300 per admission $400 per admission 10% after HRA dollars 40% after HRAservices, extended care and deductible met dollars and deductible metfacility services, rehabfacility services and othernecessary services(combined maximum of 100days per benefit year).Custodial care not covered.Hospice inpatient (maximum $300 per admission $400 per admission 10% after HRA dollars 40% after HRA180 hospital days) and deductible met dollars and deductible metOutpatient services and $200 per admission $400 per admission 10% after HRA dollars 40% after HRAsurgery including and deductible met dollars and deductible metnecessary supplies8* Patient Driven Health Plan out-of-network benefits pay at 60% of the out-of-network rate after the deductible has been met.Your provider may charge you more than the out-of network rate. You will be responsible for any charges over the out-ofnetworkrate and these charges will not apply to your deductible, coinsurance maximum or maximum out-of-pocket.
Page 2 and 3: TABLE OF CONTENTSWhat’s New for 2
Page 4 and 5: Vision Plan Changes• Beginning in
Page 6 and 7: CHANGES DURING A PLAN YEARThe decis
Page 10 and 11: HEALTH PLANS COMPARISONSUMMARY HMO
Page 12 and 13: PRESCRIPTION DRUG BENEFITIf you enr
Page 14 and 15: VISION CAREIf you enroll in the Cov
Page 16 and 17: Other Important Information• IRS
Page 18 and 19: • $1 per $1 on the first 1% of pa
Page 20: ADDENDUMCoventry Patient Driven Hea
Page 24 and 25: Patient Driven Health Plan continue
Page 26 and 27: ExpressScripts Prescription Drug Pl
Page 30 and 31: Dental Plan One continued...29
Page 38: For Dental Plans Two and Three cont
Page 43 and 44: 42Note: Patient Driven Health Plan
Page 45: 44NOTES

CHCGA - Coventry Health Care of Georgia

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