The Orthodox Health Plan 

Indemnity Medical Insurance Plan

• The Traditional Choice plan is offered to employees located in areas other than in the service areas of the Open Choice (PPO) plan. Traditional Choice is an indemnity plan permitting freedom of choice of providers. Claim reimbursement is based upon reasonable and customary limits, rather than negotiated discounts.

  The plan design reflected on the following pages contains the basic provisions of our Traditional Choice product. It is subject to modification in response to state or federal legislation.

    

 

Plan Features
Plan Deductible (per calendar year; applies to all covered services)	$300 Individual $600 Family
Coinsurance Limit	$1,500 Individual $3,000 Family
Lifetime Maximum	Unlimited
Physician Services (except Mental Health/Alc/Drug)	80% after deductible
Routine Physicals/Immunizations- well-baby care to age 7; children age 7+ and adults: 1 routine exam per 24 months (1 routine exam annually for members age 65 and older), including immunizations. Routine ob/gyn exam: 1 routine exam per calendar year, including 1 pap smear and related fees	80% after deductible
Routine Mammography One baseline mammogram for covered females age 35 but less than 40 One mammogram every two years for covered females age 40 - 49 One mammogram per calendar year for covered females age 50 and older	80% after deductible
Hospital Services
Inpatient coverage	80% after deductible
Outpatient coverage	80% after deductible

 

 

Skilled Nursing Facility	80% after deductible up to 90 days per calendar year
Home Health Care	80% after deductible up to 120 visits per calendar year
Private Duty Nursing	80% after deductible up to 70 eight-hour shifts per calendar year
Hospice Care	80% after deductible
Inpatient coverage	30 days inpatient maximum
Outpatient coverage	$5,000 outpatient maximum
Ambulance	80% after deductible
Durable Medical Equipment	80% after deductible

  

 

 

Prescription Drug	Preferred Benefits		Non-Preferred Benefits
Pharmacy Drugs	100% after $10 copay for generic formulary drugs, $15 copay for brand name formulary drugs and $30 copay for non-formulary brand drugs up to a 34 day supply at participating pharmacies.		80% after deductible
Mail Order Drugs	100% after $20 copay for generic formulary drugs, $30 copay for brand name formulary drugs and $60 copay for non-formulary brand drugs up to a 90 day supply at participating participating Mail Order vendor		80% after deductible for mail order drugs
Maternity
(coverage includes voluntary sterilization and voluntary abortion)		80% after deductible
Mental Health Services and Alcohol/Drug Abuse Inpatient coverage		80% after deductible
Maximum		30 days per calendar year*
Outpatient coverage		50% after deductible up to 30 visits per calendar year

 

Institutes of Excellence®
Expenses incurred in connection with transplant procedures	Payable as any other covered expense
Lodging Expenses Maximum	$50 per person per night
Travel and Lodging Maximum	$10,000 per one type of procedure
Other Expenses	80% after deductible

Members are responsible for obtaining precertification for inpatient hospital confinements; a $200 penalty will apply per occurrence, for failure to obtain precertification.

 

 

Eligibility	All employees
Dependents Eligibility	Spouse, children from birth to 19 or 23 if in school
Private Room Limit	Semi-Private
Actively-At-Work/Dependent Non-Confinement Rules	Apply (unless waiver required by law)
Pre-Existing Conditions Rule	Apply (unless waiver required by law)
Conversion	Standard conversion privilege applies
Continuation	Standard continuation applies - COBRA or state mandated
Extension of Benefits	12 months extension if totally disabled when coverage ceases - extension applies to all covered expenses
Medicare	Government Exclusion - Medicare eligible benefits are subtracted from Covered Medical Expenses before secondary Aetna benefits are calculated.
Coordination with Other Benefits	Up to 100% of Allowable Expenses per year
Subrogation	<Include unless prohibited by state law> Third party liability claims with recovery potential will be forwarded to the designated subrogation vendor for pursuit - $500 threshold applies.

 

Aetna contractual definitions will apply to all treatment.

 

Deductible

• Deductible - an out-of-pocket expense applicable to all benefits. Calendar year deductibles are

  individual and family, with family limits equal to none, 2x or 3x the individual deductible.

Covered expenses are reduced by the amount of the deductible at the time of claim adjudication by the claim processor.

All out-of-pocket expenses (except those resulting from application of a coinsurance percentage, e.g., 80%) are referred to as deductibles.

Deductibles apply independently (i.e., no cross application between calendar year and per confinement deductibles). There is no deductible carryover provision.

Coinsurance Limits

Coinsurance limits are the maximum amount of out-of-pocket expenses (other than copays and deductibles) that an employee/family will have to pay in a calendar year. Expenses are reimbursed at 100% once these limits are met. Coinsurance limits apply on a calendar year basis only. Coinsurance limits are individual and family, with family limits equal to none, 2x or 3x the individual limit.

Expenses applicable to coinsurance limit - Only those out-of-pocket expenses resulting from the application of a coinsurance percentage (except outpatient mental disorders and alcoholism and drug expenses and any penalty amounts) may be used to satisfy the coinsurance limit.

Claims Submission

Members are responsible for submission of claims under Traditional Choice.

 

 

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