PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II Medical Chapter Benefi 4: Medical ts Chart Benefi ts Chart (what is covered and what you pay) Medical Benefi ts Chart Services that are covered for you Abdominal aortic aneurysm screening A one-time screening ultrasound for people at risk. Th e plan only covers this screening if you get a referral for it as a result of your “Welcome to Medicare” preventive visit. Ambulance services * Prior Authorization required for non-emergent ambulance services. • Covered ambulance services include fi xed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care only if they are furnished to a member whose medical condition is such that other means of transportation are contraindicated (could endanger the person’s health) or if authorized by the plan. • Non-emergency transportation by ambulance is appropriate if it is documented that the member’s condition is such that other means of transportation are contraindicated (could endanger the person’s health) and that transportation by ambulance is medically required. Annual wellness visit If you’ve had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. Th is is covered once every 12 months. Note: Your fi rst annual wellness visit can’t take place within 12 months of your “Welcome to Medicare” preventive visit. However, you don’t need to have had a “Welcome to Medicare” visit to be covered for annual wellness visits after you’ve had Part B for 12 months. What you must pay when you get these services In Network: $0 copayment for each Medicare-covered service Out of Network: 25% of the Medicare allowable amount for each Medicare-covered service In Network: $125 copayment for each Medicare-covered one-way trip Out of Network: $125 copayment for each Medicare-covered one-way trip In Network: Th ere is no coinsurance, copayment, or deductible for the annual wellness visit. Out of Network: 25% of the Medicare allowable amount for each Medicare-covered visit 51
52 2011 Evidence of Coverage for 2013 HMO Evidence Medicare of Coverage Supplement for PPO (cost) II Chapter 4: Medical Benefi ts Chart (what is covered Medical and what Benefi you ts Chart pay) Services that are covered for you Bone mass measurement For qualifi ed individuals (generally, this means people at risk of losing bone mass or at risk of osteoporosis), the following services are covered every 24 months or more frequently if medically necessary: procedures to identify bone mass, detect bone loss, or determine bone quality, including a physician’s interpretation of the results. Breast cancer screening (mammograms) Covered services include: • One baseline mammogram between the ages of 35 and 39 • One screening mammogram every 12 months for women age 40 and older • Clinical breast exams once every 24 months Cardiac rehabilitation services * Prior Authorization is required after the fi rst visit. Comprehensive programs of cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor’s order. Th e plan also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs. What you must pay when you get these services In Network: $0 copayment for each Medicare-covered service Out of Network: 25% of the Medicare allowable amount for each Medicare-covered service In Network: $0 copayment for each Medicare-covered service Out of Network: 25% of the Medicare allowable amount for each Medicare-covered service If you reside in New York, Queens, Kings, Richmond, Bronx, Westchester, Rockland and Nassau, you pay: In Network: $30 copayment for each Medicare-covered service If you reside in Suff olk, you pay: In Network: $25 copayment for each Medicare-covered service
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PPO II - EmblemHealth

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