| Medical Procedure |
Hometown Health
HMO Plan
Available in Northern Nevada only
|
|
| Annual Deductible |
None
|
| Annual Co-Payment Limit on Allowable Charges |
Plan pays 100% after co-payments reach $3,500 in a year ($7,000 for a family) |
| Overall Lifetime Maximum |
None
|
| Hospital |
|
|
|
You pay $200 per day; $1,000 maximum per admission |
|
|
You pay $200 per visit |
| Extended Care Facility (Skilled Nursing) |
You pay $200 per day, $1,000 maximum per admission; 30 day maximum per calendar year |
| Physician Services - Routine Physical |
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|
|
You pay $20 per visit |
- Children
|
You pay $20 per visit |
Office Visits
|
You pay $20 per visit |
| Diagnostic X-Ray and Lab |
Plan pays 100% |
| CAT Scans & MRI's |
You pay $100 per procedure |
| Durable Medical Equipment |
Plan pays 100% |
| Casts, Splints, Trusses, Braces & Crutches |
You pay $25 per item |
| Home Nursing Care |
You pay $20 per visit, maximum of 45 visits per year |
| Chiropractic Care |
You pay $20 per visit (maximum benefit of $1,000 per calendar year)
|
| Physical Therapy |
You pay $20 per visit (maximum of 20 sessions per calendar year) |
| Speech Therapy |
You pay $20 per visit (maximum of 20 sessions per calendar year) |
| Maternity Care |
Same as any other illness |
| Psychiatric Care - |
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|
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You pay $200 per day; $1,000 maximum per admission; 40 days maximum per calendar year; for severe conditions; prior authorization required |
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You pay $40 per visit; maximum of 12 visits per calendar year (maximum of 40 visits for severe conditions); prior authorization required for more than 12 months |
| Substance Abuse - |
You may choose between coverage under the Beat It! Program or your HMO, or a combination of both, as follows (See Nevada Fee-for-Service Plan A for details on Beat It!):
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|
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You pay $200 per admission; $1,000 maximum per admission; $9,000 benefit maximum per year; prior authorization required |
|
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You pay $40 per visit; maximum of 12 visits per calendar year; prior authorization required for more than 12 visits |
| Prescription Drugs |
Must be obtained at a participating HMO pharmacy |
|
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You pay $10 per generic and $30 per brand name w/ no generic equivalent, and $45 or 40% whichever is greater, for non-formulary prescription, up to a 30-day supply |
Maintenance (30 day supply or more thru the Mail Order)
|
Mail order - you pay 2 co-pays per prescription for a 90-day supply |
| Hearing Aids |
Not covered
|
| Emergency Room Care |
Urgent Care - You pay $40 co-pay
Emergency Room - You pay $100 co-pay
|
