Summary of Health Care Benefits

Allergy Injections. Allergy injections are covered when received in a network provider’s office with no office visit copay.

Allergy Testing. These tests expose the patient to an extract of a suspected allergen, either through injections or skin testing, to identify offending allergens.

Ambulance Service. The plans cover charges for an ambulance for transportation from the site of an accident, or where you are stricken by illness or disease, to the nearest hospital, and between hospitals when certified by a physician as medically necessary.

The plans cover transportation, other than by ground ambulance, only when special treatment is required. The transportation must be to the nearest hospital qualified to provide special treatment. Call PReview for more information at (800) 822-1152.

Anesthesia. Anesthesia services are covered when they are administered in connection with covered operative or cutting procedures. The anesthesia must be ordered by the operating surgeon and administered in a hospital by a physician anesthesiologist. The anesthesiologist must be a different physician than the operating surgeon, his or her surgical assistant, or a physician performing an obstetrical delivery.

If anesthesia is administered by a qualified registered nurse, it must be in a hospital, but the nurse cannot be an employee of any hospital. The nurse must administer the anesthesia under the direction and in the immediate presence of a physician or surgeon.

Chemical Dependency. See Mental Health and Substance Abuse.

Chiropractic. The services of a chiropractor acting within the scope of his/her license are covered.

Clinical Trials. Participation in National Cancer Institute (NCI)-sponsored clinical trials for cancer is covered on a limited basis. This is an exception from the coverage exclusions for experimental procedures. Ohio Med coverage includes Phase II and Phase III clinical trials and does not extend beyond the specific parameters and restrictions of existing trials.

It is important to understand that while clinical trial participants are among the first to receive new treatments before they are widely available, no cancer patient goes without treatment or receives a placebo (inactive substance). Cancer treatment studies lead to advances in cancer treatment, which become the future standard of care.

All care and testing required to determine eligibility for an NCI-sponsored clinical trial and all medical care that is required as a result of participation in a clinical trial will be eligible for coverage by Ohio Med. Preauthorization is required. Call Medical Mutual at (800) 822-1152.

Clinical trials other than for cancer may be added as a benefit as trials become available and their safety is assured.

Colonoscopy. Covered for persons of any age; routine and diagnostic.

Diabetes. Supplies and durable medical equipment (including insulin pumps where medically necessary). (NOTE: these items are provided at 100 percent if obtained through the disease management benefit. Call Matria Healthcare for more information at (888) 250-8854).

Dietitian. Registered dietitian services for obesity and medically necessary conditions up to two visits per patient per condition per benefit period.

Diagnostic Services. Inpatient and outpatient diagnostic services include:

Dialysis Treatments. The treatment of an acute or chronic kidney ailment may include the supportive use of an artificial kidney machine. If the treatment of an acute or chronic kidney ailment is an eligible Medicare benefit, this program will coordinate benefits with the Medicare benefits. If you are eligible for Medicare coverage and will undergo dialysis treatment, notify Medical Mutual at (800) 822-1152.

Durable Medical Equipment (DME). The Ohio Med plans provide benefits at 80 percent for medical supplies and equipment. The equipment must be prescribed by a physician acting within the scope of his or her license. The equipment may be rented or purchased, but the plan will pay no more for the equipment than the customary purchase price. Examples include an iron lung, wheelchair, crutches or braces.

Hearing aids are covered when necessitated as a result of an injury, illness or disease which occurred while you were continuously covered under Ohio Med. If hearing loss has occurred naturally over time, 50 percent of the hearing aid expense is covered up to $1,000 lifetime maximum.

Emergency Care. See In the Event of an Emergency.

* What is an emergency? A medical condition of such severity and pain that a prudent layperson with average knowledge of health and medicine could reasonably expect that by not seeking immediate medical attention that any of the following might result:

1. The health of the individual or the health of a pregnant woman and her unborn child would be placed in serious jeopardy;
2. Serious impairment to bodily functions;
3. Serious dysfunction of any bodily organ or part.

Health Management. These programs, not subject to deductible or copays, offer education and support for patients to assist in the self management of asthma, diabetes, coronary artery disease and cancer, and beginning July 1, 2006 severe low back pain, congestive heart failure and obesity will also be included. The Ohio Med Health Partners program offers employees and family members 24/7 personal health consultants including nurses, health educators and dieticians who are available to answer questions about your condition, chart your progress and explain medications and identify any complications. Call Matria Healthcare to learn more or to get started at (888) 250-8854 or visit Matria on the Web to learn more. For maternity care call Medical Mutual at (800) 822-1152 to enroll or learn more.

Home Health Care. In some cases a physician may prescribe home health care instead of keeping you or your dependent hospitalized. Limited to 100 visits or 180 days, whichever is greater.

Hospice Care. The plans cover both inpatient and outpatient hospice care. Inpatient hospice includes room, board and general nursing services for a terminally ill patient in a Medical Mutual contracting hospice facility. Outpatient means general nursing service provided in a non-facility setting for the terminally ill patient only.

The first 90 days of hospice service must be certified by a physician. After 90 days, hospice service must be recertified by a physician. Recertification must be done every succeeding 30 days.

Hospital Care (Inpatient). Common hospital inpatient services are covered under the Ohio Med Plans, including:

Immunizations. Available vaccines for children include DTaP (Diptheria, Tetanus, Acellular Pertussis), IPV (Inactivated Polio Vaccine), MMR (Measles, Mumps, Rubella), Varicella (Chicket Pox), HBV (Hepatitis B), Hepatitis A, Influenza, HiB (Hemophilus), Pneumococcal Vaccine (PCV), and Meningococcal (MCV) ages 11 - 16 years. Tetanus immunizations every 10 years for persons 18 and over and annual influenza vaccines and Pneumococcal Vaccine for high risk individuals and Hepatitis B immunizations for all members. Also see Well-Child Care.

Inpatient Medical Consultation Services. Ohio Med provides benefits for inpatient medical consultation services when the member or a dependent is confined as a bed patient in a hospital.

Benefits are limited to two medical consultations per hospital confinement. The consulting physician must examine the patient, the patient’s hospital record or medical history as necessary under the circumstances. The consulting physician must provide a signed opinion concerning the examination and medical findings.

Mammography. The benefits available depend on your age as follows:

Mastectomy. Mastectomies are covered, as are the following:

Maternity and Obstetrical Services. The Ohio Med plans cover a variety of obstetrical services including:

If you have family coverage at the time of the child’s birth, or you change to family coverage within 31 days of the birth, your benefits also include:

You must complete an enrollment form to add a new child to your plan. Return the form to your agency within 31 days of the birth. If you do not add your newborn to your plan within 31 days of birth, your next opportunity to do so will be at open enrollment. Coverage begins on the date of birth.

Mental Health. A comprehensive range of mental health benefits are provided by United Behavioral Health (UBH). See the Mental Health section for details.

Nurse Midwife. The Ohio Med plans provide coverage for services administered by a Certified Nurse Midwife. A Certified Nurse Midwife is licensed to practice services while working under the supervision and direction of a physician or surgeon.

Obesity. Benefits are available for the surgical treatment of morbid obesity, which is defined as involving having a Body Mass Index (BMI) of 40 or greater; or 35 or greater if severe comorbidities exist. Certain weight loss medications are covered under this diagnosis. Contact the plan for more information.

Office Visits. For medically necessary office visits, house calls and outpatient consultations, you pay your copay. All covered services performed in a network physician’s office and billed by that office are covered.

Orthoptic/Pleoptic Training. Eye excercises designed to correct the visual axes of eyes not properly coordinated for binocular vision, and to stimulate and train an amblyopic eye, respectively, are covered for certain diagnoses only. Orthoptics limited to 12 lifetime visits. Covered as an office visit.

Outpatient Accident Care Services. The Ohio Med plans cover charges for a physician and registered professional nurse for services relating to the treatment of an accidental injury or poisoning.

Outpatient Care. The following services are covered if performed on an outpatient basis:

Physical Examinations, Annual. One physical examination, including but not limited to cholesterol screening, is covered after the office visit copay. When utilizing the services of a non-network provider, benefits are covered up to $150 after the office visit copay; one exam every two years for ages 40-59; one exam each year for per person age 60 and older.

Preventive Care. You pay no copay or deductible for the following services that are covered at 100%:

Private Duty Nursing. The Ohio Med plans cover the services of a registered professional nurse (RN) or licensed practical nurse (LPN).

Services not covered include those that are primarily non-medical or custodial in nature such as bathing, exercising and feeding.

For patients confined in a facility, Medical Mutual must decide that the services are of such nature or degree of complexity that the facility’s regular nursing staff cannot provide them.

The RN or LPN cannot be an immediate relative or a member of your household.

Prosthetics, Internal and External. Artificial limbs and artificial eyes, including replacements, are covered only if the replacement is medically required because of a change in the physical condition of the patient.

Protein Specific Antigen (PSA) Screening for prostate cancer. A routine PSA screening test every 12 months for men age 40 and older.

Skilled Nursing Facility. The Ohio Med plans pay for admission to a skilled nursing facility without an initial hospital stay if that admission would avoid hospitalization. The patient must require 24-hour observational care, and the level of care must be deemed medically necessary. Coverage up to 180 days per admission at a network facility and is not subject to deductible. Additional days are covered at a lesser percentage. Services covered include, but are not limited to:

Surgery, Physician Charges. The Ohio Med plans cover physician charges associated with surgery, including:

The operating physician must request and use the assistance at the same time of the covered surgery. The operating physician must identify the assistance as medically and surgically necessary.

Surgery, Cosmetic. The Ohio Med plans will cover physician charges for cosmetic surgery if the surgery is required to correct a deformity caused by disease, trauma, birth defects, growth defects or prior therapeutic processes.

Surgery, Incidental Procedures. If your physician performs a second surgical procedure during a scheduled surgery, the plans will pay 50% of the eligible charges for that procedure. This is because all preparations already will have been made and billed to the primary surgery.

Surgery, Oral. In order to be covered in your plan, the surgery must be medically necessary and not covered by any dental plan. The plans cover the following inpatient and outpatient physical services for oral surgery:

Ohio Med will pay for this service in the same manner as any other surgical procedure only if you are not covered by any dental plan. If you are covered by any dental plan, Ohio Med will not pay as secondary insurer.

Temporomandibular Joint (TMJ). The Ohio Med plans cover physician charges associated with surgery for all TMJ disorders, except for orthodontics.

Therapy Services. Medically necessary services or supplies used to promote recovery from an illness or injury are covered at 80% in network and 60% for non-network, after deductible, and include:

Vasectomies. The Ohio Med plans cover this procedure on an outpatient basis. Reversal of this procedure is not covered.

Well-Child Care and Child Immunizations. Benefits are covered at 100% after you pay the office visit copay and not subject to the deductible. This includes the initial inpatient examination of a newborn infant. These services must be provided by a physician who was not the delivering physician or the physician who administered the anesthesia.

The plans cover annual physical exams including hearing examinations, developmental assessments, anticipatory guidance, appropriate immunizations and laboratory tests through age 12. The plans cover immunizations through age 16.