| Medical Procedure |
Hometown Health
Northern Nevada Only
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Not Eligible for Medicare
Note: If you or your spouse become eligible for Medicare, it will become necessary for you to switch medical HMO plans at that time. If there are no HMO plans available, your coverage will be terminated.
|
| 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 |
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|
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You pay $200 per day; $1,000 maximum per admission |
|
|
You pay $200 per visit |
| Extended Care Facility |
You pay $200 per day, $1,000 maximum per admission; 30 day maximum per calendar year |
| Physician Services |
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Office Visits
|
You pay $20 per visit |
| Diagnostic X-Ray and Lab |
Plan pays 100% |
| 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) |
| 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 - preauthorization required |
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You pay $40 per visit - preauthorization required for more than 12 visits per calendar year (maximum of 40 visits for severe conditions) |
| Substance Abuse - |
|
|
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You pay $200 per day; $1,000 maximum per admission; $9,000 benefit maximum per year - preauthorization required |
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You pay $40 per visit - preauthorization required for more than 12 visits per calendar year |
| 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 equivalendt, and $45 or 40% whichever is greater, per non-formulary prescription; 30-day or less 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
|
| Vision Care |
Not covered
|
| Ambulance |
You pay $100 per occurance |
| Emergency Room Care from Nonparticipating Provider |
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|
Within Service Area
|
Urgent Care - You pay $40 co-pay |
|
Outside Service Area
|
Emergency Room - You pay $100 co-pay |
