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Health Plan: Benefits Summary

Health Plan: Benefits Summary

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Allergy Treatment for Adults and Children—Ultimate Plan
  • There is no co-pay for adult or children, respectively, when receiving allergy treatments.
Alternative Care Benefit

20 visits per year of each:

  • Occupational Therapy
  • Chiropractic Care
  • Speech Therapy
  • Massage Therapy
  • Registered Dietitian (first 5 visits $0 co-pay for all plans-not covered at out-of-network providers)
  • Acupuncture (not covered at out-of network providers)
Behavioral Health Benefits
  • Eliminated Deductible and Coinsurance: Inpatient stays related to substance abuse are covered at 100% just as mental health inpatient stays are covered.
  • Intensive Outpatient Program allows a maximum of 30 days per plan year.
  • Reduced Deductible: The deductible for Intensive Outpatient Programs at out of network providers is $300 per day.
Child Dental Preventive Care Benefits
  • A benefit offered to all children under the medical plan up to age 19.
  • The Plan allows 2 oral exams and 2 cleanings per year, covered at 100% at Network Dentists.
  • Sealants for children's preventative dental care (under the medical plan) will be covered at 100% - 1 treatment every 3 rolling years on permanent molars only for children to age 13.
Durable Medical Equipment
  • Reduced Member Coinsurance: Repairs for Durable Medical Equipment (wheelchairs, canes, etc) only require a 10% coinsurance for Ultimate Plan, 20% coinsurance for Best Plan, 25% coinsurance for Better Plan, 50% coinsurance for Basic.
Emergency Room Out-of-Network
  • Reduced Out of Pocket Expense (All Plan Levels): Emergency Room care at an out of network facility is covered the same as in-network emergency room care.
Orthotics
  • Reduced Member Coinsurance: Custom molded foot orthotics and oral sleep apnea appliances only require a 10% coinsurance for Ultimate Plan, 20% coinsurance for Best Plan, 25% coinsurance for Better Plan (deductible applies for the Best, Better and Basic plan levels).
Physical Therapy
  • Members on the Ultimate Plan level receive up to 20 physical therapy visits each year, the first 5 with no copay and no coinsurance.
  • Hospital-owned physical therapy facilities are limited to 5 visits annually.
  • Freestanding (not hospital affiliated), are preferable – you would get up to 20 visits (visit 6-20 require a copay). Ask the facility if they are hospital owned and if they are an Aetna provider, or call the nurse line at 941.741.2963 for help in finding a freestanding physical therapy facility.
Routine Eye Exams under Medical Plan
  • Routine Eye exams for members are covered annually.
  • Refractions are covered as part of the Routine Eye Exam for contact lenses or glasses. However, the co-pay or coinsurance for the exam still applies.
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