|
Benefits and Services
|
Coverage
|
Doctor
Visits
|
Office
visits to your primary care physician
|
$15
Copayment
|
|
Home
visits by your primary care physician
|
$25
Copayment
|
|
Non-routine
after hours visits to your primary care physician
|
$25
Copayment
|
|
Office
visits to referred specialists
|
$25
Copayment
|
|
|
$15
Copayment
|
|
Immunizations
(except for travel or employment)
|
$15
Copayment
|
|
Routine
gynecological care (no referral required)
|
$25
Copayment
|
|
Mammography
(no referral required)
|
Covered
100%
|
|
Well-baby/Well-Child
care
|
$15
Copayment
|
Maternity
|
Obstetrical
care (including pre- and postnatal care)
|
Covered
with a $25 copayment for first visit. Subsequent visits to your
OB/GYN covered 100%. Inpatient
admission covered with a $125 copayment per day up to $625 maximum
per admission (waived if readmitted within 90 days of discharge
for same diagnosis)
|
|
Newborn
care (both doctor and hospital)
|
Covered
100%
|
Hospital
Services*
|
Unlimited
inpatient stay
|
$125 copayment per day up to $625 maximum
per admission (waived if readmitted within 90 days of discharge
for same diagnosis)
|
|
Surgery
|
Covered
100%
|
|
Anesthesia
|
Covered
100%
|
|
Drugs
and medication
|
Covered
100%
|
|
Inpatient
doctor care
|
Covered
100%
|
|
General
nursing care
|
Covered
100%
|
|
Administration
of blood
|
Covered
100%
|
|
Organ
transplantation, non-experimental
|
Covered
100%
|
|
|
Covered
with a $50
copayment (which is waived if you are admitted to the hospital)
|
|
Ambulance
service
|
Covered
100% when medically necessary
|
Specialized
Services
|
Allergy
testing and treatment
|
|
|
Diagnostic,
Laboratory and X-ray services
|
Covered
100%
|
|
Short-term
rehabilitation therapy* (including Occupational, Physical
and Speech Therapy)
|
Covered
100%. Up to 60 consecutive days per condition covered, subject to
significant improvement
|
|
Respiratory
Therapy*
|
Covered
100%
|
|
Chemotherapy*
|
Covered
100%
|
|
Radiation
Therapy*
|
Covered
100%
|
|
Vision
Care, including screening, eye exams and refractions
|
Covered
100% once every two calendar years**
|
|
Hearing
Screening
|
Covered
100%**
|
Specialized
Services
|
Skilled
nursing facility services, as specified*1
|
Covered
100% up to 180 days per calendar year
|
|
Outpatient
Surgery*
|
$100 copayment
(facility)
|
|
Durable
Medical Equipment*
|
Rental
or purchase covered 100% when authorized by Primary Care Physician
and pre-approved by KHPE
|
|
Home
Health Care*
|
Covered
100%
|
|
Dialysis*
|
Covered
100%
|
|
General
nursing care
|
Covered
100%
|
|
Mental
Health Care, as specified
|
20
outpatient visits per calendar year covered with a $35 copayment per visit. 35 inpatient days
per calendar year covered with a $125 copayment per day up to $625 maximum per admission*
|
|
Serious
Mental Illness
|
60
outpatient days/visits per calendar year covered with a $35
copayment per visit. 30 inpatient days per calendar year covered
with a $125
copayment per day up to $625 maximum per admission*
|
|
Treatment
for Substance Abuse
|
60
outpatient visits per calendar year covered with a $25 copayment
per visit. 30 inpatient days per calendar year covered with a $125 copayment per day up to $625 maximum per admission*
(lifetime
limits of 120 outpatient visits and 90 inpatient days)
|
|
Annual
copayment maximum
|
$1,500 per person or
$3,000 per family annually
|
As
with all health insurance plans, KHPE’s coverage excludes certain
services. Those not covered by KHPE include, but are not limited
to, the following:
ü
Services not medically necessary
ü
Services not provided or referred
by your primary care physician, except in emergencies
ü
Experimental and investigational
services or items
ü
Routine physical exams for non-preventive
purposes such as insurance or employment applications, college,
or premarital examinations
ü
Service or supplies payable under
Workers’ Compensation, Motor Vehicle Insurance, or other legislation
of similar purpose
ü
The cost of services for which another
party has primary responsibility
ü
Care for military service connected
disabilities when appropriate government facilities are reasonably
accessible
ü
Long-term rehabilitative therapy
ü
Non-medical, rehabilitative services for the treatment of substance
abuse in an acute care hospital
ü
Hearing Aids
ü
Radial Keratotomy
ü
Custodial or domiciliary care
ü
Weight loss programs except when
provided through Healthy LifestylesSM1 programs
ü
Personal or comfort items not medically
necessary, such as air conditioners, humidifiers, telephone or similar
items
ü
Normal deliveries outside the KHPE service area within 30 days of
the estimated delivery date
ü
Contraceptive devices and birth
control pills, except by additional benefit rider
ü
In-vitro fertilization, embryo transplant,
and ovum retrieval
ü
Reversal of voluntary sterilization
ü
Transsexual surgery
ü
Cosmetic surgery except for those
services which occurred while a member of KHPE and are performed
to restore bodily function or correct deformity resulting from disease,
recent trauma or previous therapeutic process
ü
Immunization for travel or employment
ü
Prescription drugs and medications,
except as required by law or by additional rider
ü
Whole blood or blood plasma
ü
Treatment for temporomandibular
joint syndrome (TMJ)
ü
Care of the feet, unless medically
necessary
ü
Services required by a member who is an organ donor
ü
Dental care including, but not limited
to, orthognathic surgery, unless as a result of an accident
ü
Treatment for injuries sustained
while committing a felony
|