|
Catastrophic Plan Benefits
Sound Harbor Essential
$1,500, $2,500 or $5,000 Deductible
|
The
Essential plan offers catastrophic-type coverage. You have a choice of
three deductibles: $1,500, $2,500 or $5,000. Coverage includes
preventive care (including an annual eye exam), chiropractic, massage
therapy and acupuncture. Although there is no prescription drug benefit, prescription
discounts are available at some pharmacies. Maternity is not
covered under this plan.
Click
here to see if your doctor or practitioner belongs to the
provider network. Medical emergencies are covered worldwide.
Click here
for Important Information About This Benefit Summary.
|
| |
|
Benefits |
KPS Health Plans
Sound Harbor Essential |
|
Network Provider |
Annual Deductible
Per
calendar year; your
choice of three amounts |
|
|
Choice 1 |
Choice 2 |
Choice 3 |
|
Per person |
$1,500 |
$2,500 |
$5,000 |
|
Per family |
$4,500 |
$7,500 |
$15,000 |
|
Lifetime Maximum |
$2,000,000 per person |
Annual Out-of-Pocket Maximum
Deductible not included; after the
out-of-pocket maximum is satisfied, network providers are covered at
100% |
|
Per person |
$6,000 |
$10,000 |
$20,000 |
|
Per family |
$18,000 |
$30,000 |
$60,000 |
Hospital
Inpatient/Outpatient
Emergency Room |
80% |
|
Outpatient Professional |
80% |
|
Maternity |
Not covered |
|
Sterilization |
Not covered |
Preventive Care
Routine exam, immunizations, well-baby care (includes
professional services for smoking cessation and routine eye exam) |
80% to $200
maximum per calendar year |
|
Routine Vision Exams |
Annual eye exam
included in
Preventive Care benefit |
|
Vision Hardware |
Not covered |
Ambulance
Air and ground combined |
80% to $2,000
maximum per calendar year |
Home Health
Limited
to 130 visits per calendar year |
80% |
Hospice
Limited
to 6 months per calendar year |
80% |
Skilled Nursing Facility
In lieu of
hospitalization |
80% |
|
Durable Medical Equipment (DME) |
80% to $2,500
maximum per calendar year |
Organ Transplant
12-month waiting period |
80% to $100,000
lifetime maximum |
|
Rehabilitation - Outpatient |
80% to $500 maximum
per calendar year |
|
Rehabilitation - Inpatient |
Not covered |
|
Mental Health
(inpatient/outpatient) |
Not covered |
|
Chemical Dependency
(inpatient/outpatient) |
Not covered |
|
Prescription Drugs |
Not covered, but
discounts
are available at
some pharmacies |
|
Nutritional Guidance |
80% to $400 maximum
per calendar year |
Spinal Manipulations
Limited to
12 manipulations per person, per calendar year |
80% |
Acupuncture
Limited to
12 needle treatments per person, per calendar year |
80% |
|
Naturopathy |
80% |
|
Physical/Massage Therapy |
Covered under
Outpatient Rehabilitation benefit |
|
Dietitians/Nutritionists |
80% |
|
Smoking Cessation |
Covered under
Preventive Care benefit |
|
Important
Information About This Benefit Summary |
|
This is a brief summary of benefits; it is
not a contract or a certificate of coverage. The complete terms of coverage
are determined by the carrier's contract. While we have accurately
represented the information in this Benefit Summary as of the time it was
published, should any discrepancies exist between this Benefit Summary and
the carrier's contract, the carrier's contract shall prevail. Please refer
to the carrier's contract for a complete statement of benefits including
waiting periods, limitations and exclusions. |
|
