PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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Coinsurance Once you meet the annual deductible, your PPO/ DRP coverage will pay a certain percentage of eligible charges toward the cost of covered services. This percentage—the coinsurance amount—is: 80% of the cost of most services received from a participating provider. (When you receive services from an Advocate facility, Advocate will waive 10% of the cost of the covered services; you will be responsible for the remaining 10%.) 60% of the reasonable and customary charge for most services received from a nonparticipating provider. Coinsurance does not apply to any preventive care services (as determined by federal law) that are provided by a participating provider. Note: Each visit to an emergency room is subject to a copayment as shown in the At-A-Glance (which does not apply against the deductible); however, this copayment will be waived if you are subsequently admitted to the hospital. Also, you will be responsible for any expenses greater than the reasonable and customary charge for services you receive from a nonparticipating provider). 16 Annual Out-of-Pocket Coinsurance Limit When you or your eligible dependents have expenses for covered services that meet the annual out-of-pocket coinsurance limit, all further eligible expenses will be 100% paid for the rest of the year, except for copayments and non-covered charges (see PPO/DRP At-A-Glance, page 6). For services provided by a nonparticipating provider, you will be responsible for any charges that are in excess of the maximum allowance. Expenses for covered services will not apply toward your annual out-of-pocket limit if they: Apply against any deductibles or copayments Are for any penalties that result from failure to have services pre-certified when precertification is required Are in excess of the rmaximum allowance charge—for out-of-network services Are for services, supplies and treatments not covered by your plan, or Exceed the eligible charge. Expenses for services that are not covered under the PPO/DRP also do not apply to your out-ofpocket limit (see Services That Are Not Covered, page 28).
Medically Necessary Services A procedure or supply is considered medically necessary if it is determined to be: Appropriate and consistent with the patient’s symptoms and could not have been omitted without adversely affecting the patient’s condition or the quality of the care rendered Supplied or performed in accordance with current U.S. standards of medical practice Not primarily for the convenience of the patient or the patient’s family or health care provider, and An appropriate supply or level of service that can be safely provided. The term “medically necessary” is usually used to determine whether a medical or insurance plan covers a procedure. Important! The fact that a physician prescribes, orders, recommends or approves a procedure or supply does not make the procedure or supply medically necessary. Your PPO/DRP coverage will not pay the cost of any procedure or supply that is not medically necessary. How do I obtain pre-certification—and the maximum benefits available under my coverage? To obtain pre-certification—and the maximum benefits available under the plan— you or your physician must call the PPO/DRP administrator at the number shown on your coverage ID card. The number is also on your ID card. Note: Inpatient services for treatment of behavioral health disorders—behavioral illness and substance abuse—also are subject to pre-certification, but this pre-certification must be provided through the Behavioral Health Certification unit. The number is on the back of your ID card. 17 Health Care Management Program To make sure that services are provided in the most effective and cost-efficient manner possible, your PPO/DRP coverage includes the Health Care Management Program. The PPO/ DRP administrator must review and pre-certify certain covered services before these services are provided. In some cases, however, services may be reviewed for medical necessity, proper length of stay or appropriateness while—or even after—you receive them. To ensure full payment of benefits, pre-certification is required for: All hospital admissions Home health care services, and Admissions to a skilled nursing facility. Important! If you have care that is medically necessary but is not pre-certified, you will pay out of your own pocket 50% of the maximum allowance for these services up-front. The proper benefit percentage will then be applied to the remaining 50% of the cost. You may be required to pay the entire cost of services you receive if certification is denied or if it is later determined that the services were not medically necessary.
Page 1 and 2: PPO/DRP Medical Plan
Page 3 and 4: PPO/DRP Medical Plan If you are an
Page 5 and 6: You also may be invited to particip
Page 7 and 8: Services In-Network Out-of-Network
Page 9 and 10: Type of Services In-Network Out-of-
Page 11 and 12: Incapacitated Dependents A child wi
Page 13 and 14: You may be able to enroll yourself
Page 15: PPO/DRP Benefits The PPO/DRP covera
Page 19 and 20: You must call to schedule a non-urg
Page 21 and 22: Chiropractic Care The Plan will pay
Page 23 and 24: The PPO/DRP pays benefits if hospic
Page 25 and 26: Benefits for Newborns When you or a
Page 27 and 28: Other Covered Services Besides the
Page 29 and 30: Weight reduction or treatment of ob
Page 31 and 32: Making a Claim Filing a Claim Any c
Page 33 and 34: However, if a claim is submitted th
Page 35 and 36: The consulting health care professi
Page 37 and 38: If the claimant’s request is comp
Page 39 and 40: Other Plan Information When Medical
Page 41 and 42: Reimbursement/Subrogation You and y
Page 43 and 44: Assignment of Benefits A Qualified
Page 45 and 46: Your Benefits If you elect to conti

PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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