4.1. SR 11-27-2000 - Laserfiche WebLink

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FROM MINNESOTA INSURANCE PHONE NO. : 7637807927 Partial Listing 'of Covered Services Lifetime Maximum Benefit Out-of-Pocket Maximum Member Family Member Family In-Network Benefits These benefits apply when services are provided by networl<: providers or for services authorized in advance oy Medica Health Plans. Unlimited. $1200 per calendar year. $5000 per calendar year. $200. $400. When you receive covered services after deductible has been satisfied, Medica Health Plans PAYS: 100%. The deductible does not apply. 100%. The deductible does not apply. 100%. The deductib.le does not apply. 100%. The deductible does not apply. 100%. The deductible does not apply. 100%. The deductible does not apply. 100~~o. The deductible does not apply. 80%. 100%. The deductible does not apply. 80%. 80%. 80%. 80%. 80%. 100%. The deductible does not apply. 100%~ The deductible does not apply. Nov. 17 2000 11:23AM Pi Out-ot-Network Beneiitsh These benefits apply when services are lJrovided by llorl-networl< providtlr",. $1,000,000. $3000 per c~Jendar year. --.....-.- Does not apply. $400 per calendar year. --', ..---..'. $800 per calandar year. .....-- When you receive covered services atter deductible has been satisfied. Medica Insurance C?~~ny PAYS: No coveragi;. 70%~ 70%~ 70%~ 70%~ No coverage. 70%~ 70%~ 70%~ 70%~ 70%: limited to 120 days per member. per calendar year for all inpatient services combined. 70%~ 70%~ 70%: 70%: 70%: 80%. See below. 80%. See below. 80%. See below. 80% after In-Network deductible has been satisfied. 100%. The deductible does not apply. 70%: 100%. The de~uctible does not apply. 70%~ 80%. 70%:' Liniited to 120 days per member, per calendar year for all inpatient services combined. · Postnatal services ~%. ~~~c.tib~e do~~ot ~PPL...!9.o(~.:,.. __.. _. _. ~...,_,_ ___. ''._____ "Coverage is limited to the non-network provider reimbursement amount (as defined in your Certificate of Coverage) after deductible is met. "'It you decide to utilize your Out-at-Network Benefits, you may pay more man you would for In-NetworK Benefits. The amount you pay could include a percentage coinsurance. a fIXed dollar copayment and/or deductible amounts. In addition, if the amount that your non-network provider bills you is more than the non-netwoi"k provider reimbursement amollnt (as defined in your Certificate of Coverage), you are responsible for paVing the difference, and such difference will not be applied toward the Out-ot-Pocket Maximum. Deductible PREVENTIVE CARE RECEIVED IN THE PHYSICIAN'S OFFICE OR HOSPITAL · Routine physical exams · Immunizations · Well child care · Mammograms · Pap smears · Routine eye exams · Allergy shots SERVICES RECEIVED IN THE PHYSICIAN'S OFFICE . Office visits for illness Qr injury · Lab and x-ray · Surgical services SERVICES RECEIVED IN A HOSPITAL OR SURGICENTER · Inpatient hospital Facility Physician · Outpatient hospital Facility Physician surgical · Lab & x-ray Facility Physician ......--.-- URGENT OR EMERGENCY CARE · Urgent care center · Hospital emergency room ~ Emergency ambulance EMERGENCY SERVICES FROM NON.NETWORK PROVIDERS MATERNITY CARE RECEIVED IN THE PHYSICIAN'S OFFICE OR HOSPITAL · Prenatal services · Delivery services . Physician Hospital