Summary of Benefits Prominence HealthFirst Nevada Health Link Individual & Family HSA 1 Premier All specialty care services will require a PCP or emergency care practitioner referral Type of Service Your Out-of-Pocket Expense Calendar Year Deductible (CYD)1 $5,000 single/ 2x family Out-of-Pocket Maximum - Deductibles, coinsurance and copays all accrue towards the out-of-pocket maximum.2 $6,350 single/ 2x family Physician Office Visits CYD/$0 copay per visit • Primary care practitioner (PCP)3 • Specialist office visit - will require a referral from your PCP and prior authorization 4 CYD/$0 copay per visit PCP and specialist copay applies to all services in the practitioner’s office unless the service is also listed on this summary of benefits with an additional copay. Alternative Medicine - Homeopathy, acupuncture and integrated medicine. $1,500 maximum per calendar year. No prior authorization required for initial visit. CYD/$0 copay per visit Ambulance Services - Medically necessary only. • Air ambulance CYD/$0 copay per trip • Ground ambulance CYD/$0 copay per trip Approval date: 10/07/2014 Distribution date: 01/01/2015 Diabetic Products • Generic CYD/$5 copay • Preferred Brand CYD/$15 copay • Non-Preferred Brand CYD/$30 copay 5 Durable Medical Equipment • Rental CYD/$0 copay per item • Items approved for purchase CYD/$0 copay per item Emergency Care - Includes surgeon and physician costs. • Emergency room - The copay is waived when the member is admitted as an inpatient directly from the emergency room. CYD/$0 copay per visit • Urgent care - In and 0ut-of-area urgent care services are covered for medically CYD/$0 copay per visit necessary covered services. Members should call Prominence Health Plan Member Services 800.863.7515 for assistance prior to obtaining out-of-area urgent care services. Health and Wellness Services • Online Wellness Assessment - OWA Link: prominencehealthplan.com No Charge • Telephonic health coaching - Six sessions per condition per calendar year (diabetes management, tobacco cessation and weight management) No Charge Hearing Aids - Limited to one every three years. CYD/$0 copay per item Home Healthcare - Includes private-duty nursing; maximum 30 visits per calendar year. CYD/$0 copay per visit Form #: SMHF-129601342 Hospice Care • Hospice care CYD/$0 copay • Respite inpatient - Plan CYD applies. Limited to 10 per 6 months. CYD/$0 copay per day • Respite outpatient - Limited to 10 visits per year. CYD/0% coinsurance • Bereavement services - Limited to 5 visits per year. CYD/$0 copay per visit 5XEXHSAP www.prominencehealthplan.com Page 1 Summary of Benefits Prominence HealthFirst Nevada Health Link Individual & Family HSA 1 Premier Your Out-of-Pocket Expense Type of Service Hospital/Outpatient/Ambulatory Services6 - *Includes surgeon, facility and anesthesia charges • Inpatient*- Plan CYD applies. CYD/$0 copay per day • Outpatient surgery* CYD/0% coinsurance • Observation* - No additional copay if transferred from outpatient surgery. CYD/0% coinsurance • Inpatient skilled nursing - Limited to 100 days per calendar year. Plan CYD applies. CYD/$0 copay per day • Acute rehabilitation - Limited to 60 visits per condition per member per calendar year (combined with physical occupational and speech therapies); includes outpatient rehabilitation visits. Plan CYD applies. CYD/$0 copay per day Infertility Treatment Services • Office visit evaluation - Please refer to the applicable surgical procedure copay and/or coinsurance amount for any surgical infertility procedures performed. CYD/$0 copay per visit Infusion Therapy* • Performed and billed by a physician’s office or free-standing, outpatient facility CYD/$0 copay per visit • Performed and billed by a hospital outpatient facility CYD/$0 copay per visit * Special pharmaceuticals incur 20% coinsurance Kidney Dialysis Services - Covered to the extent not covered by Medicare. CYD/$0 copay per visit Laboratory and Pathology Services CYD/$0 • Pathology CYD/$0 Mastectomy Reconstructive Services • Inpatient surgery - Plan CYD applies. CYD/$0 copay per day • Outpatient surgery CYD/0% coinsurance Maternity CYD/$0 copay per delivery • Delivery room and nursery hospital care for mother and baby - Plan CYD applies. CYD/$0 copay per day • Ancillary maternity charges CYD/$0 copay per visit Medical Nutrition Therapy Counseling - Limited to 25 visits per calendar year. CYD/$0 copay per visit Mental Health Services Severe Mental Illness CYD/$0 copay per day •Day treatment program CYD/0% coinsurance •Outpatient CYD/0% coinsurance •Outpatient office visit CYD/$0 copay per visit General Mental Health •Outpatient office visit Page 2 CYD/$0 copay per visit www.prominencehealthplan.com Distribution date: 01/01/2015 •Inpatient - Plan CYD applies. Approval date: 10/07/2014 • Physician: prenatal and delivery Form #: SMHF-129601342 • Laboratory Summary of Benefits Prominence HealthFirst Nevada Health Link Individual & Family HSA 1 Premier Your Out-of-Pocket Expense Type of Service Mental Health Services (continued) Alcohol and Drug Abuse Services •Inpatient withdrawal - Plan CYD applies. CYD/$0 copay per day •Inpatient rehabilitation - Plan CYD applies. CYD/$0 copay per day •Outpatient rehabilitation/day treatment CYD/0% coinsurance •Outpatient office visit CYD/$0 copay per visit Morbid Obesity - Includes inpatient or outpatient services. Bariatric Gastric Restrictive surgery. Plan CYD applies. One procedure every three years; includes surgical complications. CYD/$0 copay per day Nutritional Supplements - Enteral Therapy and Parenteral Nutrition. Maximum 120 days CYD/$0 copay per 30 day supply supply for special food products. Organ Transplants - Plan CYD applies. CYD/$0 copay per day Orthotics - Foot orthotics limited to one pair per year CYD/$0 copay per item Ostomy Supplies CYD/$0 copay per visit Form #: SMHF-129601342 Approval date: 10/07/2014 Distribution date: 01/01/2015 Prescription Drugs • FDA - approved oral contraceptive drugs $0 copay • Generic CYD/$5 copay • Preferred brand CYD/$15 copay • Non-preferred brand CYD/$30 copay • Special pharmaceuticals CYD/20% coinsurance Preventive Services - For a complete list of covered services, visit http://doi.nv.gov/Healthcare-Reform/Individuals-Families/Preventative-Care/ • Colorectal cancer screening, colonoscopy, sigmoidoscopy, or fecal occult blood test No Charge • Mammograms - baseline and annual No Charge • Pap and pelvic exams No Charge • Periodic health assessments for hearing and vision for ages 19 and under No Charge • BRCA genetic counseling and testing services No Charge • Prenatal well visits No Charge • Prostate screenings No Charge • Well baby and child visits, immunizations/vaccinations for children through age 17 No Charge • Preventive sterilization No Charge Prosthetic • Prosthetic devices CYD/$0 copay per item • Dental/oral orthotic appliances, TMJ and/or sleep apnea - Limited to one appliance per CYD/$0 copay per item member per calendar year. Radiation Oncology Therapy • Professional read/specialist visit CYD/$0 copay per visit • Hospital outpatient therapy – facility fee CYD/0% coinsurance www.prominencehealthplan.com Page 3 Summary of Benefits Prominence HealthFirst Nevada Health Link Individual & Family HSA 1 Premier Your Out-of-Pocket Expense Type of Service Radiology and Diagnostic Services7 Routine X-ray and Routine Diagnostic Tests •Performed and billed by a free-standing, outpatient facility CYD/$0 copay per test •Performed in and billed by a hospital outpatient facility CYD/$0 copay per test CT SCAN and MRI •Performed and billed by a free-standing, outpatient facility CYD/$0 copay per test •Performed and billed by a hospital outpatient facility CYD/$0 copay per test Complex Diagnostic Testing •Performed and billed by a free-standing, outpatient facility CYD/$0 copay per test •Performed and billed by a hospital outpatient facility CYD/$0 copay per test CYD/$0 copay per visit Spinal Manipulation Temporomandibular Joint Dysfunction • TMJ surgery - inpatient hospital - Plan CYD applies. CYD/$0 copay per day • TMJ non-surgical outpatient office visit CYD/$0 copay per visit Therapies CYD/$0 copay per visit • Habilitative - Limited to 60 visits per condition per member per calendar year. CYD/$0 copay per visit • Rehabilitative - Limited to 60 visits per condition per member per calendar year combined with acute rehabilitation visits. CYD/$0 copay per visit • Autism spectrum disorders - Limited to 200 visits per member per calendar year. CYD/$0 copay per visit Vision - Pediatric - Coverage up to age 19 No Charge • Low-vision exam - Limited to one routine eye exam per child per year. No Charge • Glasses - Limited to one pair of basic frames and lenses. No Charge • Post-cataract services - Limited to one pair of basic frames and lenses. CYD/$0 copay per item The Evidence of Coverage (EOC) sets forth in detail the rights and obligations of both you and the insurance company. It is important you review the EOC once you are enrolled. This disclosure statement provides only a brief description of some important features and limitations of your policy. Except for an emergency, all healthcare services must be coordinated and obtained by a primary care practitioner (PCP) unless otherwise authorized. All specialty care services will require a PCP or emergency care practitioner referral. 1. Deductible - a set amount of covered charges occurring each calendar year which must be paid by the member before benefits are payable under this plan. Page 4 www.prominencehealthplan.com Distribution date: 01/01/2015 If you have questions about this summary of benefits (SOB), please call Prominence Health Plan Member Services at 775.770.9310, 800.863.7515 or (TTY Operator Assistance) 800.326.6868. Our website, www.prominencehealthplan.com, also serves as an important resource and includes information about provider directories, urgent care and emergency care locations and more. Approval date: 10/07/2014 • Eye exam - Limited to one routine eye exam per child per year. Form #: SMHF-129601342 • Physical, occupational and speech - Limited to 60 visits per condition per member per calendar year combined with acute rehabilitation visits. Summary of Benefits Prominence HealthFirst Nevada Health Link Individual & Family HSA 1 Premier 2. Deductibles, coinsurance and copays accrue to the out-of-pocket maximum (OOPM). The following services cannot be used to satisfy the out-of-pocket maximum: 01. Penalty for failure to obtain prior authorization; and 02. Use of emergency room for non-emergency. 3. Each member must choose a PCP who is responsible to provide, arrange and coordinate all of the healthcare services to ensure continuity of care for you and initiating any referrals and prior authorizations for specialized care you may require. 4. Prior authorization is the standard process of receiving approval for certain procedures and medical services to ensure that the requested medical care is appropriate and necessary. Not all referrals require a prior authorization from Prominence Health Plan. Your PCP (or specialist) obtains this on your behalf. For a complete list of services that require prior authorization, please visit www.prominencehealthplan.com or call 800.863.7515 to confirm if prior authorization has been obtained if required. Form #: SMHF-129601342 Approval date: 10/07/2014 Distribution date: 01/01/2015 A referral is required when your PCP or emergency care/specialty care practitioner recommends that you be evaluated and/or treated by a specialist and it is also required if you want to see one on your own. A referral from your PCP to a specialist helps assure care continuity and coordination, and minimize the chance that you receive duplicate or unnecessary testing, imaging, or treatment. The referring practitioner is responsible for providing the consultation request and related information to the receiving specialist. 5. Durable medical equipment (DME) is covered when medically necessary, authorized by Prominence Health Plan and is in accordance with Medicare DME guidelines. 6. Ambulatory and day-surgery services performed in hospital or other facility. 7. Some invasive diagnostic procedures are treated as outpatient hospital visits. Patient Protection and Affordable Care Act (PPACA) mandatory disclosures For Prominence HealthFirst documents that are Qualified Health Plans1 Choosing your primary care practitioner (PCP) As a Prominence HealthFirst HMO member, you must select a primary care practitioner (PCP) to manage all of your medical care. If you have already selected a PCP, his or her name and contact number will appear on your member ID card. If “Call for PCP” is printed on your ID card, you must select a PCP by following the instructions below. How to locate a PCP 1.Go to www.prominencehealthplan.com 2.Select “Click here to view printable provider directories.” 3.Choose your plan’s provider directory to review the list of available PCPs. How to select or change your PCP 1.Call Member Services at 775.770.9310 or 800.863.7515 (8 a.m. - 5 p.m. Pacific Time, Monday-Friday) 2.Be prepared to indicate your PCP selection to Member Services. You must use your selected PCP to manage your care • If you see a primary care practitioner who is not your assigned PCP, your claim(s) may be denied. • Always check with your PCP before seeking care from a specialist. Your PCP can determine if specialty care (i.e., cardiology, gastroenterology, neurology, etc.) is needed and can provide you with the required referral. • If you see a specialist without a referral, your claim(s) may be denied. www.prominencehealthplan.com Page 5 Summary of Benefits Prominence HealthFirst Nevada Health Link Individual & Family HSA 1 Premier Access to pediatricians For children, you may designate a pediatrician as the primary care practitioner. Access to OB/GYN physicians You do not need prior authorization from Prominence HealthFirst or from any other person (including a PCP) in order to obtain access to obstetrical or gynecological care from a healthcare professional in our network who specializes in obstetrics or gynecology. The healthcare professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating healthcare professionals who specialize in obstetrics or gynecology, contact Prominence Health Plan Member Services at 775.770.9310 and 800.433.3077. Rescissions Prominence HealthFirst will not rescind coverage once a member is enrolled unless the individual (or a person seeking coverage on behalf of the individual) performs an intentional act, practice or omission that constitutes fraud, or unless the individual makes an intentional material misrepresentation of fact, as prohibited by the terms of the Evidence of Coverage. Prominence HealthFirst will provide at least 30 days advance written notice to each participant who would be affected before coverage will be rescinded. 1 All “New” or Qualified Health Plans in existence beginning on or after September 23, 2010. Form #: SMHF-129601342 Emergency Services are provided as follows: a. Without prior authorization requirement, even for out-of-network services; b. Without regard to whether the provider of the services is in-network; c. If the services are out-of-network, without any administrative requirements or coverage limitations that are more restrictive than those imposed on in-network services; and d. Without regard to any other tem or condition of the coverage other than: (1) the exclusion of or coordination of benefits; (2) an affiliation or waiting period permitted under ERISA, the PHSA, or the Internal Revenue Code; or (3) applicable cost sharing. Approval date: 10/07/2014 www.prominencehealthplan.com Distribution date: 01/01/2015 Page 6
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