HealthPartners.com - 2010 MN Advantage

2010 MN Advantage

Minnesota Advantage Health Plan 2010 Benefits Schedule

The following highlights your HealthPartners Advantage Plan coverage. For exact terms and conditions, consult a HealthPartners Summary of Benefits, or call Member Services at 952-883-7900, 1-888-343-4404 or 952-883-5127 (TTY).

	Cost Level 1 You Pay:	Cost Level 2 You Pay:	Cost Level 3 You Pay:	Cost Level 4 You Pay:
A. Preventive care services Routine medical exams, cancer screening Child health preventive services, routine immunizations Prenatal and postnatal care and exams Routine eye and hearing exams Adult immunizations	Nothing	Nothing	Nothing	Nothing
B. Annual first dollar deductible (Single/Family)	$50/$100	$140/$280	$350/$700	$600/$1200
C. Office visits for illness/injury Outpatient visits in a physician’s office Chiropractic services Outpatient mental health and chemical dependency	$17/22* copay Annual deductible applies	$22/27* copay Annual deductible applies	$27/32* copay Annual deductible applies	$37/42* copay Annual deductible applies
D. Convenience Clinics	$10 copay	$10 copay	$10 copay	$10 copay
E. Emergency Emergency care or urgent care received in a hospital emergency room in the plan’s service area	$75 copay Annual deductible applies	$75 copay Annual deductible applies	$75 copay Annual deductible applies	25% coinsurance Annual deductible applies
F. Inpatient hospital copay (waived for admission to Center of Excellence)	$85 copay Annual deductible applies	$180 copay Annual deductible applies	$450 copay Annual deductible applies	25% coinsurance Annual deductible applies
G. Outpatient surgery copay	$55 copay Annual deductible applies	$110 copay Annual deductible applies	$220 copay Annual deductible applies	25% coinsurance Annual deductible applies
H. Hospice and skilled nursing facility	Nothing	Nothing	Nothing	Nothing
I. Prosthetics, durable medical equipment, diabetic supplies	20% coinsurance	20% coinsurance	20% coinsurance	25% coinsurance Annual deductible applies
J. Lab (including allergy shots), pathology and x-ray not included as part of preventive care and not subject to office visit or facility copayments	5% coinsurance Annual deductible applies	5% acoinsurance Annual deductible applies	10% coinsurance Annual deductible applies	25% coinsurance Annual deductible applies
K. MRI/CT Scans	5% coinsurance Annual deductible applies	5% acoinsurance Annual deductible applies	10% coinsurance Annual deductible applies	25% coinsurance Annual deductible applies
L. Expenses not covered in A-J above, including but not limited to: Ambulance Home Health Care Nonsurgical Outpatient Hospital Radiation/chemotherapy Enhanced radiology services, including CT scans, MRIs Dialysis Other diagnostic or treatment-related outpatient services Day treatment for mental health & chemical dependency	5% coinsurance Annual deductible applies	5% acoinsurance Annual deductible applies	10% coinsurance Annual deductible applies	25% coinsurance Annual deductible applies
M. Prescriptions drugs ** 30-day supply of Tier 1, Tier 2, or Tier 3 prescription drugs, including insulin, or a 3- cycle supply of oral contraceptives	$10/$16/$36	$10/$16/$36	$10/$16/$36	$10/$16/$36
N. Maximum out-of-pocket expense for prescription drugs (excludes PKU, Infertility, growth hormones) (single/family)	$800/$1600	$800/$1600	$800/$1600	$800/$1600
O. . Maximum out-of-pocket expense (excluding prescription drugs) (Single/Family)	$1100/2200	$1100/2200	$1100/2200	$1100/2200

*The level of the office visit copayment for the employee and his or her family is dependent upon whether the employee has completed the Health Assessment in each Open Enrollment period, and opted-in for any indicated health coaching. Employees who have completed the Health Assessment and opted-in for health coaching are entitled to the lower copayment. Employees hired after the close of Open Enrollment will be entitled to the lower copayment. This chart applies only in-network coverage.

Emergency care or urgent care at a hospital emergency room or urgent care center out of the plan’s service area or out of network: the plan covers 80% of the first $2000 of eligible charges, then 100% per calendar year.

Out-of-Network coverage for members whose permanent residence is outside the State of Minnesota and outside the service areas of the health plans participating in Advantage (this category includes employees temporarily residing outside Minnesota on temporary assignment or paid leave [including sabbatical leaves] and all dependent children, including college students, and spouses living out of area). The members pay a $350 single or $700 family deductible and 30% coinsurance to the out-of-pocket maximum described in Section O above. Members pay the drug copayment described at Section M above to the out-of-pocket maximum described at Section N.

A standard set of benefits is offered in all SEGIP Advantage Plans. There may be some differences from plan to plan in the way that benefits are administered, including the transplant benefit and in the referral and diagnosis coding patterns of primary care clinics, and the definitions of allowed amount.

** Administered by Navitus Health Solutions