| Medical Procedure |
Health Plan of Nevada
HMO Plan
|
|
| Annual Deductible |
None
|
| Annual Co-Payment Limit on Allowable Charges |
Refer to Certificate of Coverage |
| Overall Lifetime Maximum |
None
|
| Hospital |
|
|
|
You pay $400 per admission |
|
|
You pay $50 per admission |
| Extended Care Facility (Skilled Nursing) |
You pay $400 per admission, 100 days maximum |
| Physician Services - Routine Physical |
|
|
|
You pay $20 per visit |
|
|
You pay $20 per visit |
Office Visits
|
You pay $20 per visit |
| Diagnostic X-Ray and Lab |
You pay $20 per visit for routine procedure |
| CAT Scans & MRI's |
You pay $20 per test or procedure |
| Durable Medical Equipment |
Covered only as authorized alternative to hospitalization (Pre-authorization required) |
| Casts, Splints, Trusses, Braces & Crutches |
Refer to Certificate of Coverage |
| Home Nursing Care |
Play pays 100% |
| Chiropractic Care |
You pay $20 per visit (referral required)
|
| Physical Therapy |
You pay $20 per visit (maximum of 60 consecutive calendar days per condition) |
| Speech Therapy |
You pay $20 per visit, limitations based on diagnosis (maximum of 60 consecutive calendar days per condition) |
| Maternity Care |
You pay same co-pay as any other medical condition |
| Psychiatric Care - |
|
|
|
You pay $400 per admission; 30 days maximum per calendar year |
|
|
You pay $20 per visit for individual, family & partial care therapy |
| Substance Abuse - |
You may choose between coverage under the Beat It! Program or your HMO, or a combination of both, as follows (See Nevada Plan B for details on Beat It!):
|
|
|
You pay $400 per admission |
|
|
You pay $20 per visit per individual or group session |
| Prescription Drugs |
Must be obtained at a participating HMO pharmacy |
|
|
You pay $10 per preferred generic and $35 per preferred brand, and $50 per non-preferred prescription |
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 |
You pay $200 or 50% of EME, subject to the maximum benefit of $5,000 per individual per calendar year and further limited to a single purchase. Repairs & replacement limited to once every 3 years.
|
| Emergency Room Care |
Urgent Care - You pay $20 co-pay in or out of service area
Within Service Area - You pay $25 for physician services, no charge for Emergency Room
Outside Service Area - You pay $50 for physician services, no charge for Emergency Room
|
