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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

Preventive Physical Exam

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

Annual Gynecological Exam

Covered

Annual Pap Smear Screening

Covered

Annual Mammography Screening

Covered

Well Baby and Child Care

Covered

ACIP Required/Recommended Immunizations – pediatric and adult

Covered

Prostate Specific Antigen (PSA) screening

Covered

Hearing Screening

Covered

 

Physician Office Visits

Office Visits

Covered - $20.00 co-pay

Specialist Visits

Covered - $30.00 co-pay

 

Prescription Drugs

Generic Drugs

Covered - $10.00 co-pay per prescription

Brand Name Drugs

Covered - $20.00co-pay per prescription

Psychotherapeutics

Covered – 50% of each prescription drug

 

Emergency Care

Hospital Emergency Visit

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.

Urgent Care Center (24 hour access)

Covered - $25.00 co-pay per visit

Ambulance Services – medically necessary

Covered if admitted - $50.00 co-pay if not admitted

 

Mental Health and Substance Abuse Services

Inpatient Mental Health and/or Substance Abuse Services*

Covered - $200.00 co-pay per admission. Subject to limitations indicated in the Subscriber’s Certificate

 

Outpatient Mental Health and Substance Abuse /Professional Services

Covered - $20.00 co-pay

*- Requires Prior Authorization

 

Diagnostic and Therapeutic Services

Radiology

Covered – No co-pay

Diagnostic Laboratory

Covered – No co-pay

Physical Therapy

Covered - $20.00 co-pay (30 visits/year limit)

Durable Medical Equipment

Covered – 50% per prescribed equipment

 

Maternity Services Provided by a Physician

Pre-Natal and Post-Natal Care

Covered - $20.00 co-pay

Delivery and Nursery Care

Covered –$200.00 co-pay per admission

 

Hospital Care

Inpatient physician care, general nursing care,

Hospital Services and Supplies

Covered – $200.00 co-pay per admission.

Subject to limitations indicated in the Subscriber’s Certificate

 

Outpatient Hospital Services

Covered - $50.00 co-pay

 

Alternatives to Hospital Care

Home Health Care

Covered - $20.00 per visit

 Surgical Services

Surgery – includes all related services and anesthesia. See member certificate for specifics

Covered – (see hospital care co-pay above)

 

Other Rider Services

Vision Exam & Glasses

Covered subject to Co-payments set forth on Appendix I and exclusions set forth on Appendix J.

Dental

Covered subject to co-payments set forth on Appendix D and exclusions set forth on Appendix E.