Medica Choice Passport MN BENEFITS & Topics/Medica Certificate of...Medica Choice Passport MN...

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  • Medica Choice Passport MN

    BENEFITS & COVERAGE

    CERTIFICATE

    MEDICA CHOICE PASSPORT MN 1500-25% HSA

    Individual Plan

    BPL #76447

    DOC #28850

  • 2014 Medica. Medica is a registered service mark of Medica Health Plans. Medica refers to the family of health

    plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company,

    Medica Self-Insured, and Medica Health Management, LLC.

    MEDICA CUSTOMER SERVICE

    Minneapolis/St. Paul

    Metro Area:

    (952) 945-8000

    TTY Users: National

    Relay Center:

    1-800-855-2880 then ask

    them to dial Medica at

    1-800-952-3455 Outside the Metro Area:

    1-800-952-3455

    Find more information about your benefits by logging on to

    mymedica.com.

  • MIC PP MN LG (1/15) 1 1500-25% HSA BPL 76447 DOC 28850

    Table of Contents

    Introduction .............................................................................................................................. 4

    Medical Loss Ratio (MLR) standards under the federal Public Health Service Act .................. 4 What you must do to be eligible for benefits ........................................................................... 5 If you need language interpretation ........................................................................................ 5 How you accept coverage ...................................................................................................... 5 Medicas nondiscrimination policy ........................................................................................... 6 Health savings accounts ......................................................................................................... 6

    Member Rights And Responsibilities ..................................................................................... 7

    Member bill of rights ............................................................................................................... 7 Member responsibilities .......................................................................................................... 7

    Before You Access Care ......................................................................................................... 9

    Provider network..................................................................................................................... 9 Referrals ................................................................................................................................. 9 Prior authorization .................................................................................................................. 9 Benefits .................................................................................................................................10 Claims ...................................................................................................................................12 Continuity of care ...................................................................................................................12

    Benefits & Coverage ...............................................................................................................14

    Deductibles, out-of-pocket maximums, and lifetime maximum ...............................................14 Deductibles ............................................................................................................................14 Out-of-pocket maximum ........................................................................................................14 Lifetime maximum amount .....................................................................................................14 Covered benefits and the amounts you pay ...........................................................................16 Ambulance ............................................................................................................................17 Anesthesia.............................................................................................................................18 Behavioral Health Mental Health ........................................................................................19 Behavioral Health Substance Abuse ...................................................................................22 Clinical Trials .........................................................................................................................24 Durable Medical Equipment, Prosthetics, and Medical Supplies ............................................25 Emergency Room Care .........................................................................................................28 Genetic Testing and Counseling ............................................................................................29 Home Health Care .................................................................................................................30 Hospice Services ...................................................................................................................32 Hospital Services ...................................................................................................................33 Infertility Diagnosis ................................................................................................................34 Lab and Pathology .................................................................................................................36 Medical-Related Dental Services ...........................................................................................37 Physical, Speech, and Occupational Therapies .....................................................................41 Physician Services ................................................................................................................44 Pregnancy Maternity Care ..................................................................................................48 Prescription Drugs .................................................................................................................50 Prescription Specialty Drugs ..................................................................................................54 Preventive Health Care..........................................................................................................56

  • MIC PP MN LG (1/15) 2 1500-25% HSA BPL 76447 DOC 28850

    Reconstructive and Restorative Surgery ................................................................................58 Skilled Nursing Facility...........................................................................................................60 Temporomandibular Joint (TMJ) and Craniomandibular Disorder ..........................................62 Transplant Services ...............................................................................................................63 X-Ray and Other Imaging ......................................................................................................66

    Covered Health Services ........................................................................................................67

    Ambulance services ..............................................................................................................67 Behavioral health mental health ..........................................................................................67 Behavioral health substance abuse ....................................................................................68 Durable medical equipment, prosthetics, and medical supplies .............................................70 Emergency room care ...........................................................................................................70 Home health care ..................................................................................................................70 Hospice services ...................................................................................................................71 Infertility diagnosis .................................................................................................................72 Medical-related dental services .............................................................................................72 Newborn coverage ................................................................................................................72 Pregnancy maternity care ...................................................................................................72 Physician services .................................................................................................................74 Post-mastectomy coverage ...................................................................................................74 Prescription drugs ..................................................................................................................74 Prescription specialty drugs ...................................................................................................76 Transplant services organ and bone marrow ......................................................................78

    Exclusions ...............................................................................................................................79

    How Providers Are Paid By Medica .......................................................................................83

    Network providers ..................................................................................................................83 Withhold arrangements...........................