Health Summary Plan Description

Hospital Benefits (including Mental Health and Substance Abuse Treatment)

As of January 1, 2016, ValueOptions is now Beacon Health Options. For more information, please see the Winter 2015 Take 2.

The Plan uses the BlueCard PPO network and The Industry Health Network (TIHN) for all hospital benefits except mental health and substance abuse. The Plan uses the ValueOptions network for mental health and substance abuse benefits. Non-network services are only covered in the event of an emergency. See page 34 for a description of emergency treatment.

Eligibility

Plan I

Plan I Earned, Self-Pay and Senior Performer participants and their enrolled dependents are eligible for the hospital benefits, including treatment for mental health and substance abuse conditions. In accordance with the Mental Health Parity and Addiction Equity Act of 2008, Plan I hospital coverage includes coverage for mental health and substance abuse benefits. This means that deductibles, copays, coinsurance and out-of-pocket maximums for Plan I hospital benefits now include mental health and substance abuse benefits.

Plan II

Plan II Earned and Self-Pay participants and their enrolled dependents are eligible for the hospital benefits. Coverage for the treatment of mental health and substance abuse conditions is not included.

Deductible

Hospital charges are subject to a calendar year deductible. The hospital deductible is separate from the deductibles for the other benefits provided by the Plan, including the medical, prescription drug and dental deductibles. The sole exception is the Plan I mental health and substance abuse hospital deductible, which is combined with the Plan I hospital deductible. The amount of the hospital deductible varies depending on which network you use and the Plan for which you are eligible.

The family deductible is satisfied when at least two or more family members have paid the amount of the family deductible in covered expenses. However, the Plan will not apply more than the individual deductible amount to any one family member. For example, if a participant in Plan I who has a spouse and two children uses BlueCard PPO hospitals, the $500 family
deductible will be satisfied once he and his family have paid a total of $500 in covered expenses. However, the Plan will not apply more than $250 toward the deductible for any one family member.

The Plan applies expenses toward your deductible as it processes claims, rather than according to the date of service. Providers submit their claims in accordance with their own billing schedules and claims are frequently not received in the order of their date of service, particularly when multiple providers are used.

If you go to a hospital for emergency treatment your deductible is based on the BlueCard PPO deductibles outlined to the left. These deductibles apply even if you called or visited TIHN first and they told you to go to the emergency room. TIHN hospital deductibles apply only to non-emergency hospital care received through TIHN.

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that applied toward your deductible under Plan I will apply toward your Plan II deductible. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is also true.

Hospital Deductibles
  Network Non-Network
Plan I

TIHN (non-emergency care only) – $150 per person / $300 per family

BlueCard PPO/ValueOptions – $250 per person / $500 per family

No coverage*
Plan II

TIHN (non-emergency care only) – $150 per person / $300 per family

BlueCard PPO – $500 per person / $1,000 per family

No coverage*

* Coverage will be provided in the event of an emergency. See page 34 for a description of emergency treatment.


Coinsurance and Out-of-Pocket Maximums

Once the deductible has been satisfied, the Plan will provide reimbursement of covered hospital expenses at 90% of the Contract Allowance.

The out-of-pocket maximum is the maximum amount you and your family must pay for covered expenses during the calendar year after your deductible is satisfied. For example, a participant who is single and who has satisfied his deductible is responsible for 10% of the first $17,500 of covered network hospital expenses, or $1,750. This is called the coinsurance. When you have paid your deductible and the maximum out-of-pocket amount, the Plan will reimburse 100% of covered hospital expenses, with the exception of emergency room copays.

Plan I mental health and substance abuse out-of-pocket hospital expenses are combined with Plan I out-of-pocket hospital expenses.

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that applied toward your out-of-pocket maximum under Plan I will apply toward your Plan II out-of-pocket maximum. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is also true.

Hospital Coinsurance and Out-of-Pocket Maximums
Plan I and Plan II Network Non-Network
Plan Pays 90% of Contract Allowance No coverage*
Coinsurance 10% of Contract Allowance No coverage*
Out-of-Pocket Maximum $1,750 per person/$3,500 per family No coverage*

* Coverage will be provided in the event of an emergency. See page 34 for a description of emergency treatment.


Emergencies

Emergency treatment at network and non-network hospitals is covered within 72 hours after an accident or within 24 hours of a sudden and serious illness. There is a copay for the emergency room. This copay is waived if there is immediate confinement for the same accident or illness.

Emergency Room Copay
Plan I $100 per visit
Plan II $200 per visit

If you are admitted to a non-network hospital, you or the hospital should call one of the following within 48 hours to report the emergency admission:

  • For participants and dependents covered under Plan I with a mental health or substance abuse emergency – ValueOptions (866) 277-5383.

    Mental health and substance abuse treatment are not covered under Plan II.
  • For all other emergency admissions – Anthem Blue Cross (800) 274-7767.

Your care will be reviewed and the coverage will be authorized if it is medically necessary.

Hospital Benefits (other than Mental Health and Substance Abuse )

Hospital benefits include the following:

  • Emergency treatment including services billed by the hospital on their statement of charges. Any services that are not included on the hospital bill and are billed separately, such as physicians' or surgeons' charges, may be covered under the medical benefits. Urgent care centers are also covered under the medical benefits.
  • Inpatient hospice care provided by a Medicare-certified program, when an individual is terminally ill with a life expectancy of less than 12 months. Hospice benefits are not subject to the deductible. Outpatient hospice care may be covered under the medical benefits.
  • Network birthing centers. Charges for non-network birthing centers may be covered under the medical benefits.
  • Outpatient hospital treatment for diagnostic services and therapy such as x-rays, machine tests, physical therapy and chemotherapy.
  • Outpatient surgery in a hospital, surgical suite or ambulatory surgical center, including charges for services connected with surgery that are billed by the facility. Services not billed by the facility and charges at a non-network surgical suite or surgical center may be covered under the medical benefits.
  • Semi-private room, board, hospital services and supplies for acute care for a covered diagnosis. For stays in a private room, the Plan pays the hospital's most common semi-private room rate. You are responsible for the difference between the semi-private and private room rates.

Hospital services and supplies include:

  • Administration of blood or blood plasma. (The actual charge for blood is covered under the medical benefits.)
  • Anesthesia.
  • Basal metabolism studies.
  • Cardiac testing.
  • Drugs and medicines.
  • Intensive care.
  • Operating, delivery and treatment rooms.
  • Oxygen.
  • Physiotherapy and hydrotherapy.
  • Special diets.
  • Splints, casts and dressings.
  • Staff nursing care.
  • X-ray and laboratory exams.

Hospital Stays for Maternity

A stay related to childbirth, miscarriage, ectopic pregnancy, or premature termination of pregnancy is only covered if the patient is a participant or the spouse or same-sex domestic partner of a participant. A newborn's ordinary nursing care in the hospital is also covered. For dependent children, only complications of pregnancy are covered. Complications of pregnancy do not include elective termination of pregnancy.

Under federal law, the Plan generally may not restrict benefits for any hospital stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother'sor newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, the Plan may not, under federal law, require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Hospital Benefits for Mental Health and Substance Abuse
(Plan I only )

Mental health and substance abuse benefits cover a vast number of conditions. Among them are anxiety, stress, eating disorders, depression, bi-polar disorders such as manic depression, psychosis, schizophrenia and substance abuse (alcohol and drugs). If you have a question about a particular mental health or substance abuse condition and whether it is covered please contact ValueOptions at (866) 277-5383 or visit www.valueoptions.com/sagph.

All mental health and substance abuse hospital claims are administered by ValueOptions. See page 85 for how to file a claim. Benefits include the following:

  • Inpatient care – Treatment that is provided in a 24-hour medical facility.
  • Alternative levels of care–
    • Residential Treatment Center – Treatment that is provided in a 24-hour non-medical facility.
    • Partial Hospital Program – Treatment that is provided for 6 – 8 hours per day.
    • Intensive Outpatient Program – Treatment that is provided for 2 – 3 hours per day.
  • Emergency treatment, including services billed by the hospital on their statement of charges. Services that are not included on the hospital bill and are billed separately, such as non-psychiatric professional charges, may be covered under the medical benefits.

Non-Covered Hospital Expenses

  • All expenses at a non-network hospital, except for emergency treatment as described on page 34.
  • A stay in a facility or hospital that is not registered as a general hospital by the American Hospital Association and does not meet accreditation standards of the Joint Commission on
    Accreditation of Hospitals, except facilities that provide alternative levels of care for the treatment of mental health and substance abuse to Plan I participants and dependents.
  • A stay primarily for diagnostic tests, pulmonary tuberculosis, convalescent care, rest cure or custodial care.
  • A stay primarily for physical or rehabilitative therapy. If a patient is transferred to a hospital's rehabilitation wing (either from the same acute care hospital or from another acute care hospital), and the care is still considered acute care, the Plan may consider benefits.
  • Care that is covered under other portions of the Plan, such as ambulance, blood and blood plasma, x-ray or radiation therapy, special braces, appliances or equipment, or outpatient care.
  • Convalescent facilities.
  • Charges in connection with cosmetic surgery, except under the limited circumstances described on pages 40 and 44.
  • Non-network birthing centers. (Limited coverage for these services is provided under the medical benefits.)
  • Outpatient hospice care. (This is covered under the medical benefits.)
  • Personal comfort items such as TV or telephone.
  • Physician's surgical suite or a non-network surgery center. (Limited coverage for these services is provided under the medical benefits.)
  • Services of doctors, surgeons and anesthesiologists not employed by the hospital. (These are covered under the medical benefits.)
  • Services of technicians and other vendors not employed by the hospital.
  • Skilled nursing facilities. If a patient is transferred to a skilled nursing facility from an acute care hospital and the care is still considered acute, the Plan may consider benefits.
  • Urgent care centers. (These are covered under the medical benefits.)

See also General Exclusions on page 72.