610 Auburn Ravine Rd. Suite C Auburn Ca. 95603
Office 530-823-7510 Fax 530-823-7215
SAFETY HOTLINE
800-864-6993
Benefits Pre Agreement
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Situation |
PS1 MMCP IN-NETWORK |
PS1 MMCP OUT-NETWORK |
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Anesthesia |
Refer to Professional Fees for Surgical and Medical Services section for benefit information. |
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Selected services provided by Optometrists will be covered under the following conditions: 1. The services must be within the scope of the Optometrist’s license. 2. The service would otherwise be covered if performed by a medical doctor (MD). That is, services to treat underlying medical conditions for which you would otherwise see a medical doctor are covered. Note that the following exclusion is still applicable under the plans: Eye examinations, glasses or contact lenses for diagnosis or treatment of refractive errors except to the extent needed for repair of damages caused by bodily injury are not covered. Charges for these exclusions are generally covered by your vision plan. |
Routine eye exams are not covered. Services for illness or injury are covered. $35 co-pay per visit then 100% of eligible expenses. See Vision Service Plan Call 1-888-877-4782 |
Routine eye exams are not covered. Services for illness or injury are covered. 75% of eligible expenses after satisfying $300 deductible. See Vision Service Plan Call 1-888-877-4782 |
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Hearing examinations and associated covered services received from a health care provider in the provider’s office.
Please note that Benefits are available for charges connected to the purchase or fitting of Hearing Aids.
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Hearing exam, testing and/ or permanent hearing aid are covered at 100% of eligible expenses up to $600 maximum payment per calendar year. |
Hearing exam, testing and/ or permanent hearing aid are covered at 75% of eligible expenses after satisfying $300 deductible up to $600 maximum payment per calendar year. |
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Injections received in a Physician's Office
Copay does not apply if only service is an allergy injection. |
$20 PCP/$35 specialist co-pay then 100% of eligible expenses. |
75% of eligible expenses after satisfying $300 deductible |
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Counseling covered for Diabetic Education only. Covered only if provided by MD or facility. |
$35 co-pay then 100% of eligible expenses if billed and/or serviced in office; no co-pay if billed and/or serviced as out patient. |
75% of eligible expenses after satisfying $300 deductible. |
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Primary Care Providers (PCPs). OB/GYN Providers will be treated as Primary Care Providers (PCPs) also, A $20 co-pay applies to the following provider types: Family practice GP OB/GYN Internal Medicine Pediatricians Nurse Practitioners Chiropractors Physical Therapists Physician Assistants Covered Health Services received in a Physician's office including: · Treatment of a Sickness or Injury. · Preventive medical care. · Voluntary family planning. · Well-baby and well-child care. · Routine well woman examinations, including pap smears, pelvic examinations and mammograms. · Routine well man examinations, including PSA tests. · Routine physical examinations, including vision and hearing screenings. (Vision screenings do not include refractive examinations to detect vision impairment. See Eye Examinations section.). · Immunizations.
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$20 co-pay then 100% of eligible expenses. All preventative services are covered for in network providers. HPV injections (Gardasil)
vaccine for males and
females are covered.
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75% of eligible expenses after satisfying $300 deductible Routine childhood (generally age 6 and under) immunizations for Diphtheria, Pertussis or Tetanus (DPT), measles, mumps, rubella and polio. Preventive Care Well Child visit, Not Covered out of network. For Out of Network - Phenylkentonurial blood test (PKU) for infants under the age of one year is covered. HPV injections (Gardasil)
vaccine for males and
females are covered.
Preventative Adult visit Not Covered out of network. Except for- each year a digital rectal examination age 40 or over. Each year a stool blood slide test after age 49. Every three years a proctosigmoidoscopy after age 49. Other Preventative Care Services are not covered. PSA, Not Covered out of network. 75% of eligible expenses after satisfying $300 deductible out of network for: Pap Smear – 1 each calendar year. Mammogram: 1 baseline for women age 35 to 39. Every two years for women age 40 to 49. Every year for women age 50 or over. |
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Physician Office Services – Specialist
Covered Health Services given by a Network Provider, other than a Covered Person's primary physician. It applies to all Covered Health Services and Supplies given in connection with each office visit. · This Copayment does not apply to the prenatal and postnatal office visits to the Network obstetrician/gynecologist who is primarily responsible for maternity care.
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$35 co-pay per visit then 100% of eligible expenses.
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75% of eligible expenses after satisfying $300 deductible.
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Professional Fees for Surgical and Medical Services
Professional fees for surgical procedures and other medical care received in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or Alternate Facility. When these services are performed in a Physician's office, Benefits are described under Physician's Office Services.
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100% of eligible expenses. |
75% of eligible expenses after satisfying $300 deductible.
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$35 co-pay per visit then 100% of eligible expenses. This is not a required service to obtain benefits. |
75% of eligible expenses after satisfying $300 deductible. This is not a required service to obtain benefits.
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Situation |
PS1 MMCP IN-NETWORK |
PS1 MMCP OUT-NETWORK |
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Coinsurance Amounts
The percentage of Eligible Expenses payable by the plan for certain Covered Health Services after you meet the annual deductible.
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100% - Reimbursement after patient payment of co-pay. |
75% of eligible expenses after satisfying $300 deductible OR 60% of eligible expenses after satisfying $300 deductible if a required notification to Care Coordination (1-800-842-9905) is not given or approved OR 38% of eligible expenses after satisfying $100 deductible if a required notification is not given for Mental Health or Substance Use Disorder services. |
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If Out-of-Pocket is met. |
Not Applicable |
100% of eligible expenses after satisfying individual or family out-of-pocket. When out of pocket is met and if a required notification to Care Coordination is not given or approved benefits are 80% of eligible expenses after satisfying $300 deductible. Mental Health/Substance Use Disorder only 50% after satisfying individual or family out-of-pocket if certification is not obtained for out of network services. |
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Situation |
PS1 MMCP IN-NETWORK |
PS1 MMCP OUT-NETWORK |
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Individual |
None |
$300 - Deductible is applied to out-of-network service for each individual, per calendar year. $100 –Out of network mental health calendar year deductible applies. The $100 deductible cross applies with the out of network medical calendar year deductible. |
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Family Deductible |
None |
$900 - Cumulative family deductible applies to out-of-network services, per calendar year. $300 – Out of network mental health calendar year deductible applies. The $300 deductible cross applies with the out of network medical calendar year deductible. |
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Situation |
PS1 MMCP IN-NETWORK |
PS1 MMCP OUT-NETWORK |
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Individual |
None |
$2,000
MH/SA - Out of pocket maximum per calendar year $1,500 |
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Family |
None |
$4,000
MH/SA - Out of pocket maximum per calendar year $3,000 |
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Out of Network Benefits
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When Covered Health Services are received from non-Network providers, Eligible Expenses are determined based on either:
Fee(s) that are negotiated with the provider.
Available data resources of competitive fees in that geographic area.
NOTE: If care is received from a non-network physician, facility, or other health care professional you will incur greater financial expense compared to an in-network provider. Your plan only pays a portion of those charges and it is your responsibility to pay the remainder. You are required to pay the amount that exceeds the allowable amount, which could be significant, and that amount does not apply to the Out-of-Pocket Maximum. We recommend you ask the non-network physician or health care professional about their billed charges before you receive care.
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Unlimited |
Unlimited |
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Situation |
PS1 MMCP IN-NETWORK |
PS1 MMCP OUT-NETWORK |
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Pre-certification Requirements |
Prior notification is required before you receive certain Covered Health Services.
The physician and/or the facility is required to obtain pre-certification for the following: 1-800-842-9905: · All Confinements in any facility. · Services from a Home Health Care Agency. · All expenses relating to organ/tissue transplants. · Hospice · Durable Medical Equipment over $1,000 · Reconstructive procedures · Dental Services if rendered as a result of an accident · Maternity services (if exceeds the 48/96 guidelines}.
Please refer to the Mental Health and Substance Use Disorder section for notification requirements pertaining to Mental Health and Substance Use Disorder treatment.
Special Note Regarding Medicare You are not required to notify Care Coordination before receiving Covered Health Services when Medicare is the primary payer. |
Prior notification is required before you receive certain Covered Health Services.
Employee’s are required to obtain approval from Care Coordination: 1-800-842-9905: · All Confinements in any facility. · Services from a Home Health Care Agency. · Private Duty Nursing · All expenses relating to organ/tissue transplants. · Hospice · Durable Medical Equipment over $1,000 · Reconstructive procedures · Dental Services if rendered as a result of an accident · Maternity services (if exceeds the 48/96 guidelines}.
Benefits will be payable at 60% if the member does not call prior to receiving the service.
Please refer to the Mental Health and Substance Use Disorder section for notification requirements pertaining to Mental Health and Substance Use Disorder treatment.
Special Note Regarding Medicare You are not required to notify Care Coordination before receiving Covered Health Services when Medicare is the primary payer. |
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Ambulance Services -Emergency Only
Emergency ambulance transportation by a licensed ambulance service to the nearest Hospital where Emergency Health Services can be performed. |
Ground Transportation: 100% of eligible expenses.
Air Transportation: 100% of eligible expenses. |
Ground Transportation: 100% of eligible expenses. Air Transportation: 100% of eligible expenses. |
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Ambulance Non-Emergency Services Only to a Facility.
Transportation must be necessary to treat an illness or injury and must be to the nearest facility equipped to provide the appropriate care. |
100% of eligible expenses
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75% of eligible expenses after satisfying $300 deductible
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Ambulatory Surgical Center |
Refer to Outpatient Surgery benefit below for a description of Covered Health Services. |
Refer to Outpatient Surgery benefit below for a description of Covered Health Services. |
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Outpatient Surgery, Diagnostic and Therapeutic Services
Covered Health Services received on an outpatient basis at a Hospital, Office or Alternate Facility including: · Surgery and related services. · Mammography testing. · Genetic Testing for breast cancer susceptibility regardless of family or medical history. · Other diagnostic tests and therapeutic treatments (including cancer chemotherapy or intravenous infusion therapy). Benefits under this section include only the facility charge and the charge for required services, supplies and equipment. Benefits for the professional fees related to outpatient surgery, diagnostic and therapeutic services are described under Professional Fees for Surgical and Medical Services.
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100% of eligible expenses.
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75% of eligible expenses after satisfying $300 deductible.
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Emergency Health Services-True Emergency
Services that are required to stabilize or initiate treatment in an Emergency. Emergency Health Services must be received on an outpatient basis at a Hospital or Alternate Facility.
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$25 co-pay then 100% of eligible expenses. If admitted to the hospital, co-pay is waived.
For Mental Health and Substance Use Disorder In-Network, $15 co-pay applies and then 100% coinsurance. |
$25 co-pay then 100% of eligible expenses. If admitted to the hospital, co-pay is waived. Please remember that if you are admitted to a Hospital as a result of an Emergency, you must notify Care Coordination within 24 hours or the same day of admission, or as soon as reasonably possible. For Mental Health and Substance Use Disorder Out of Network, deductible applies and then 75% coinsurance. |
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Emergency Room Services-Not True Emergency
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75% of eligible expenses after satisfying $300 deductible. |
75% of eligible expenses after satisfying $300 deductible. |
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Inpatient Stay in a Hospital. Benefits are available for: · Services and supplies received during the Inpatient Stay. · Room and board in a Semi-private Room (a room with
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100% of eligible expenses.
Notification required 1-800-842-9905 |
75% of eligible expenses after satisfying $300 deductible. Failure to notify Care Coordination at 1-800-842-9905 prior to receiving the service will result in a reduction of the benefit coinsurance payable Benefits will be reduced to 60% of eligible expenses after satisfying $300 deductible if a required notification to Care Coordination (1-800-842-9905) is not given or approved. |
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When services to treat urgent health care needs are provided in a Physician's office, Benefits are available as described under Physician's Office Services.
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$25 co-pay then 100% of eligible expenses. |
75% of eligible expenses after satisfying $300 deductible |
Ron Sprague