Employee Benefits Handbook - The Ohio Med Plan

Available in all 88 Ohio counties.
Consists of a broad network of physicians and hospitals.
Begins paying for a variety of medical services after you pay an annual deductible.
Pays 80 percent for medical services after you meet your deductible that are received in and billed by a network physician’s office after you pay the $15 office visit copay.
Pays most eligible charges at 80 percent, if you use a network provider.
Pays most eligible charges at 60 percent, if you use a non-network provider.
Does not require you to select a primary care physician for referrals.
Requires no claims forms when you use network providers.
Pays 100 percent of allowed amount after out-of-pocket maximum is reached.

PLAN FEATURES	PPO Network	Non-Network PPO	Traditional
Deductible individual/family	$200/$400	$400/$800	$200/$400
Out-of-pocket maximum (including deductible) individual/family	$1,000/$2,000	$2,000/$4,000	$1,000/$2,000
Note: When you use a non-network provider, your costs can be significantly higher than if you use a network provider. This is due to higher non-network copayments. The non-network provider also may bill you the balance between his/her charge and Ohio Med's allowance. Check with non-netwrok providers to see if they accept Ohio Med's allowance as payment in full.
PLAN BENEFITS
Office Visits and Consultations (for the office visit portion, all other services subject to deductible and coinsurance.)	$15 copay; 100%	$30 copay; 60%	$15 copay; 100%
Emergency Room Visit*	$75 copay; 80%	$75 copay; 60%	$75 copay; 70%
HOSPITAL BENEFITS
Semi-private room	80%	60%	70%
Maternity care	80%	60%	70%
Diagnostic X-ray and laboratory tests	80%	60%	70%
Other medically necessary treatments and procedures	80%	60%	70%
URGENT CARE	$15 copay; 100%	$30 copay; 60%	$15 copay; 100%
PREVENTIVE CARE
Well Child Care through age 12 (includes hearing exam)	$15 copay; 100%	$15 copay; 100%	$15 copay; 100%
Immunizations through age 16	$15 copay; 100%	$15 copay; 100%	$15 copay; 100%
Annual Physical Exam	$15 copay; 100%	$30 copay then 100% up to $150 max.	$15 copay; 100%
Mammography Screening**	Age restrictions apply; see benefit description
Routine PSA Testing	80%	60%	70%
	Age restrictions apply; see benefit description
Routine Endoscopic Services	80%	60%	70%
Annual Influenza Immunizations	100%	60%	100%
OTHER COVERED EXPENSES
Initial Newborn Exam	100%	100%	100%
Allergy Tests	$15 copay; 100%	$30 copay; 60%	$15 copay; 100%
Allergy Injections	80%	60%	70%
Occupational Therapy/Physical Therapy/Speech Therapy	80%	60%	70%
Ambulance Service	80%	60%	70%
Pre-Admission Testing	80%	60%	70%
Home Healthcare	80%	60%	70%
Skilled Nursing Facility	80%	60%	70%
	(No deductible up to 180 days per admission)
Durable Medical Equipment (initial and medically necessary replacements)	80%	60%	70%
Organ Transplants ($1 million lifetime maximum)	80%	60%	70%
Hospice	100%	100%	100%
Dietitian	80%	60%	70%
Prosthetics	80%	60%	70%

^{* Charge applies to emergency room charges, subject to deductible and coinsurance; copay waived if admitted.

** This dollar maximum is mandated for all providers rendering services in the state of Ohio.The mandate dictates that the maximum be equal to 130% of the Medicare-allowed amount. Therefore, it is subject to change.}

The mailing address of Medical Mutual is on the back of your ID card.

Medical Mutual
PO Box 94776
Cleveland, OH 44101-4776.

Internet: www.medmutual.com

Click here for the phone numbers of all health plans.

Expenses that apply to the out-of-pocket maximum:

$200 individual and $400 family deductible in network; $400 single and $800 family deductible for out-of-network
$75 emergency room charge
$15 or $30 office visit copay
20% or 40% Coinsurance

Expenses not applied to the out-of-pocket maximum:

$350 penalty for failure to notify Medical Mutual of any hospital admission.
$350 penalty for using a non-network hospital for non-emergency care.
Amounts charged by non-network providers in excess of the allowable amount.
Expenses for services which are not Ohio Med benefits.

How the Ohio Med Plan Works

Deductible
With the exception of office visits, before the Ohio Med Plans begin to pay any benefits, you must meet an annual deductible. A deductible is the amount you must pay out of your own pocket for most services in each plan year before Ohio Med begins “sharing” costs. As you receive and pay for covered services, the amount you pay is applied to your deductible. You pay this deductible amount once each benefit year, beginning typically on July 1. The plans also cover some services at 100% even if the deductible has not been met, as described later.

For single coverage, your deductible is $200 per benefit year in network, $400 out-of-network. To meet the annual family deductible, all eligible medical expenses of family members must total $400 in network, or $800 out-of-network. When any one family member has paid their deductible for eligible expenses, that person’s deductible is met. The balance of the family deductible must be met by the combined expenses of other family members.

Any penalty you may pay, for reasons such as failure to receive precertification, is in addition to the deductible and out-of-pocket maximum, and not applied toward the deductible and out-of-pocket maximum.

Copay
After paying your annual deductible, Ohio Med begins paying a portion of your medical expenses; the remaining amount, known as copay, is the portion you must pay. Copay is the percentage of the cost of a service that you “share” until your out-of-pocket maximum is reached. The amount varies depending on the plan in which you are enrolled and the type of service you are receiving. Copays do not count toward satisfying your deductible.

Coinsurance
The portion of the costs paid by the health plan.

Out-of-Pocket Maximum
The out-of-pocket maximum is the total amount you must pay out of your own pocket before your plan covers your medical expenses at 100% for the plan year.¹ The out-of-pocket maximum offers financial protection by limiting the total amount you must pay toward health care services in any benefit year. Once your coinsurance reaches the out-of-pocket maximum amount, the plan will pay 100 percent of allowed charges to the end of the benefit year. There is no limit to the amount Ohio Med will pay per year, except in the case of human organ transplants which are limited to $1 million in a lifetime.

Some expenses are not applied to the out-of-pocket maximum. Expenses for products or services not covered by Ohio Med or which are not medically necessary are not included, nor are any penalties you must pay.

¹Even if you have met your out-of-pocket maximum, you still have to pay your prescription drug copays, your emergency room copay nd mental health copayments.

Selecting a Family Doctor
When you join the Ohio Med PPO plan, you are encouraged to select a network family physician from the provider directory. In addition to the directory, you may call (800)822-1152 for assistance in locating a physician, or visit the Medical Mutual website at www.medmutual.com.

By selecting a family physician, you can establish a comfortable and personal relationship with a doctor who is familiar with your medical history. Consider a physician who specializes in one of the following areas:

Network Provider vs. Non-Network Provider
Under the Ohio Med PPO there are different levels of reimbursement depending on the provider’s contractual relationship with the Ohio Med administrator, Medical Mutual. Those levels are as follows:

Network providers accept the administrator’s reimbursement rate as payment in full for their services. The office visit copay is $15.
Non-network providers may not have a contractual relationship with the plan administrator. Although you may use non-network providers under your PPO plan, you should be aware that some administrative requirements become your responsibility and some financial safeguards do not exist when using non-network providers. For eligible services, Medical Mutual will reimburse 60 percent of its allowed amount to a non-network provider (less any deductibles or coinsurance you owe). Payment will be made to you and you must pay the provider. The office visit copay when using a non-network provider is $30.

Non-network providers can bill you for the difference between their charge and Medical Mutual’s payment amount. This is called balance billing. Any preadmission certifications become your responsibility. Non-network providers are not obligated to submit claim forms for you.
There is a $350 penalty for using a non-network hospital, except in emergencies. All penalties are in addition to the deductible and out-of-pocket maximum.

There is a $350 penalty for failure to precertify a non-network hospital admission. If you use a network facility, the facility will precertify for you. If you use a non-network hospital or facility, you are responsible for precertifying the admission.

For non-network emergency and maternity admissions, you or your physician must notify PReview within one working day of the admission. The Ohio Med administrator will review your medical situation to determine an appropriate length of stay. If you stay longer than your certified visit time, you may be liable for the room and board charges beyond the length of your certification. Call PReview at (800) 258-2873.

Appropriateness Review
Before some treatments are performed, PReview Managed Care must be contacted at (800) 258-2873 for an Appropriateness Review. If an Appropriateness Review is not obtained when one is required, a $350 penalty will be applied to the professional charge.

Your network physician will obtain an Appropriateness Review for you. However if you use a non-network physician, you are responsible for obtaining an Appropriateness Review.

To appeal an Appropriateness Review decision, use the claims appeal process as described here.

Pre-Admission Testing (PAT)
Your physician may determine that you need inpatient hospital care. Often the early part of a hospital stay is used for testing before actual treatment or surgery begins. The PAT program allows certain tests to be performed in a less expensive outpatient setting, before admission.

PAT is not the same as outpatient diagnostic care. Your doctor must schedule an inpatient admission in order for your tests to be covered under the PAT program. Any test that would have been covered on an inpatient basis will be paid as part of your hospital bill.

Case Management Program
Case Management is a professional and focused assessment of care and of the development and implementation of specialized treatment plans for those cases requiring an additional level of management.

Remember, you can always choose to receive services from a non-network provider, but will need to pay any difference between what is charged and Ohio Med’s allowable amount.

The Case Management program can assist in reduction of overall costs and in providing individual care in the following manner:

The case management process is initiated when the registered nurse case manager receives a referral during the normal case review process.
A case manager will review each situation and discuss alternatives with the patient, the patient’s family and the attending physician as needed.
Alternative treatment plans that are clinically appropriate and cost effective may be arranged.

Neonatal problems, back injuries, trauma and AIDS are examples of cases eligible for case management intervention.

Enhanced patient care and satisfaction as well as cost effectiveness are the intended result of case management.


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