Wayne County/Oakland County
Benefits at a Glance for HealthChoice Small Business Program
Co-pay Package
This is intended as an easy-to-read summary. It is not a contract. An official description of benefits is contained in applicable HealthChoice Subscriber certificates and riders. Payment amounts are based on the HealthChoice approved amount, less any applicable co-pay amounts required by the program. This coverage is provided pursuant to a current, signed group-operating agreement between the group and the HealthChoice Executive Director. Services must be provided by member’s primary care physician (PCP) or receive prior approval from health plan.
HEALTHCHOICE BENEFITS AT A GLANCE
Preventive Services
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Preventive Physical Exam
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Covered – No co-pay for Preventive Health Exam (1 preventive health exam is provided per calendar year for adults, as required by federal preventive care guidelines for children), Non-preventive office visits are subject to $20.00 co-pay
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Annual Gynecological Exam
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Covered
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Annual Pap Smear Screening
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Covered
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Annual Mammography Screening
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Covered
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Well Baby and Child Care
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Covered
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ACIP Required/Recommended Immunizations – pediatric and adult
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Covered
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Prostate Specific Antigen (PSA) screening
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Covered
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Hearing Screening
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Covered
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Physician Office Visits
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Office Visits
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Covered - $20.00 co-pay
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Specialist Visits
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Covered - $30.00 co-pay
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Prescription Drugs
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Generic Drugs
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Covered - $10.00 co-pay per prescription
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Brand Name Drugs
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Covered - $20.00co-pay per prescription
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Psychotherapeutics
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Covered – 50% of each prescription drug
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Emergency Care
Hospital Emergency Visit
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Covered –$100.00 co-pay if not admitted; No co-pay if admitted. Provider is only responsible for 110% of Michigan Medicaid DRG rate for Emergency Services. Members are liable for any and all charges that exceed 110% of Michigan Medicaid rates.
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Urgent Care Center (24 hour access)
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Covered - $25.00 co-pay per visit
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Ambulance Services – medically necessary
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Covered if admitted - $50.00 co-pay if not admitted
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Mental Health and Substance Abuse Services
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Inpatient Mental Health and/or Substance Abuse Services*
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Covered - $200.00 co-pay per admission. Subject to limitations indicated in the Subscriber’s Certificate
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Outpatient Mental Health and Substance Abuse /Professional Services
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Covered - $20.00 co-pay
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*- Requires Prior Authorization
Diagnostic and Therapeutic Services
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Radiology
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Covered – No co-pay
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Diagnostic Laboratory
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Covered – No co-pay
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Physical Therapy
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Covered - $20.00 co-pay (30 visits/year limit)
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Durable Medical Equipment
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Covered – 50% per prescribed equipment
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Maternity Services Provided by a Physician
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Pre-Natal and Post-Natal Care
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Covered - $20.00 co-pay
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Delivery and Nursery Care
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Covered –$200.00 co-pay per admission
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Hospital Care
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Inpatient physician care, general nursing care,
Hospital Services and Supplies
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Covered – $200.00 co-pay per admission.
Subject to limitations indicated in the Subscriber’s Certificate
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Outpatient Hospital Services
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Covered - $50.00 co-pay
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Alternatives to Hospital Care
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Home Health Care
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Covered - $20.00 per visit
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Surgical Services
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Surgery – includes all related services and anesthesia. See member certificate for specifics
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Covered – (see hospital care co-pay above)
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Other Rider Services
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Vision Exam & Glasses
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Covered subject to Co-payments set forth on Appendix I and exclusions set forth on Appendix J.
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Dental
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Covered subject to co-payments set forth on Appendix D and exclusions set forth on Appendix E.
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