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

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Ambulance Service The PPO/DRP covers the cost of ambulance services for ground transportation for you or a covered family member from the place where an injury or serious medical accident occurs to the nearest hospital where appropriate treatment can be given. Non-emergency ambulance services are covered only if required to transport you or a covered family member to or from a hospital or between hospitals for required treatment, but only if the ambulance service is medically necessary. Note: Air ambulance services are covered only if approved by the PPO/DRP administrator. Behavioral Health Care The PPO/DRP covers hospital treatment for behavioral illness and substance abuse services; however, inpatient services must be pre-certified; to initiate the pre-certification process, call the number shown on your coverage ID card. Important! If you have inpatient behavioral health care services that are medically necessary but not pre-certified, you will pay 50% of the cost of these services up-front (out of your own pocket) based on either the negotiated rate or actual cost of the service, as appropriate; the proper benefit percentage—depending on whether you see a participating or nonparticipating provider— will then be applied to the remaining 50% of the cost. You may be required to pay the entire cost of services you have received if certification is denied or if it is later determined that the services were not medically necessary. While it is not necessary to pre-certify outpatient behavioral health services, you may contact the behavioral health certification unit for assistance in selecting a provider. 20 Behavioral Illness and Substance Abuse Treatment The PPO/DRP pays benefits for care to treat a behavioral illness or substance abuse. This type of care includes inpatient hospital confinement, psychotherapy, group therapy and psychological testing and—for treatment of a behavioral illness—electro-convulsive therapy or convulsive drug therapy and family counseling. Care must be provided by a physician, psychologist, clinical social worker or clinical professional counselor. Benefits are available if you: Are an inpatient in a hospital, skilled nursing facility or behavioral health/substance abuse facility Are a patient in a partial hospitalization treatment program or coordinated home care program, or Receive individual or group outpatient behavioral disorder/substance abuse treatment services from a physician, psychologist or clinical social worker. What is considered a behavioral illness? A behavioral illness is a disease that is commonly understood to be a mental disorder whether or not it has a physiological or organic basis. Treatment is generally provided by or under the direction of a behavioral disorder professional.
Chiropractic Care The Plan will pay the cost of chiropractic care, including initial consultation, x-rays and treatment (but not maintenance care). Spinal manipulation charges are limited to 20 manipulations per calendar year. Diagnostic Services and Supplies The PPO/DRP pays benefits toward the cost of diagnostic laboratory, pathology, ultrasound, nuclear medicine, magnetic imaging and x-ray services. Covered services include preadmission and diagnostic services performed within seven days prior to the start of an inpatient hospital stay, as long as these services are related to the condition necessitating the hospitalization. Note: Benefits will not be paid if the same diagnostic tests are performed again after you or your covered family member have entered the hospital. Benefits for diagnostic services and supplies will not be provided if you postpone or cancel an associated surgery. Durable Medical Equipment You can receive benefits for the rental or purchase of durable medical equipment prescribed by a physician and required for therapeutic use. The equipment must be primarily used to serve a medical purpose. Benefits will be paid based on the usual charge for the equipment which meets the patient’s needs. Benefits will be provided for the purchase of a piece of equipment if it is less expensive than renting. In addition, repair or replacement of purchased medically necessary durable medical equipment will be covered if required due to normal use or the growth of a child. Examples of durable medical equipment include: Internal cardiac valves Internal pacemakers Mandibular reconstruction devices not used primarily to support dental prosthesis Bone screws Wheelchairs Hospital beds, and Ventilators. 21 Emergency Care Under the PPO/DRP, you are covered for the initial treatment of an injury or medical condition that is severe and life threatening. Emergency accident and medical care must begin within 72 hours of the injury or onset of the emergency condition. Your injury or medical condition is considered an emergency if it could: Place your life in jeopardy Cause other serious medical consequences Cause serious impairment to bodily functions, or Cause serious dysfunction of any organ or body part. You will also be subject to a copayment for emergency services as shown in the At-A-Glance, but this copayment will be waived if you are admitted. Extended Care Facility Extended care facility services are covered if all of the following criteria are met: Care is pre-certified before you receive it You were first confined to a hospital for three consecutive days Your physician recommends extended care confinement for convalescence from a condition that caused that hospital stay or a related condition The extended care confinement begins within 14 days after discharge from the hospital You are under a physician’s continuous care, and Your physician certifies that you must have nursing care 24 hours a day. Extended care facility benefits will be paid for charges for: Room and board in a semiprivate room, and Other services, supplies and treatment ordered by your physician and furnished by the extended care facility for inpatient care.
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 and 16: PPO/DRP Benefits The PPO/DRP covera
Page 17 and 18: Medically Necessary Services A proc
Page 19: You must call to schedule a non-urg
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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