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Benefits and Services

Some benefits described here are based on state laws. We have attempted to describe them accurately, but if there are differences, the laws will govern.

NOTE: Be sure to read about exclusions and waiting periods, including the waiting period for pre-existing conditions, for information about what is NOT covered by Basic Health.

Benefits and Services NOT Subject to the Deductible and Coinsurance

The $250 annual deductible and $1,500 out-of-pocket maximum per person, per calendar year DO NOT apply to the following benefits and services.

Benefits/Services	Member's Payment Responsibility	Description
Preventive care	No copay	Includes routine physicals, immunizations, PAP tests, mammograms, and other screening and testing when provided as part of the preventive care visit.
Office visits	$15 copay	Copay is for office visit only and includes consultations, mental health and chemical dependency outpatient visits, office-based surgeries, and follow-up visits. Copays do not apply to preventive care, laboratory, radiology services, radiation, and chemotherapy. Some services will be subject to coinsurance.
Pharmacy		30-day supply
	Tier 1 $10 copay	Tier 1 includes generic drugs in health plan's preferred drug list (formulary).
	Tier 2 50% of the drug cost	Tier 2 includes brand-name drugs in health plan's preferred drug list (formulary).
Emergency room visit	$100 copay	No copay if admitted; hospital coinsurance and deductible would apply.
Out-of-area emergency services	$100 copay	No copay if admitted; hospital coinsurance and deductible would apply.
Urgent care	$15 copay	Copay is for office visit only, when provided in an urgent care setting. Deductible and coinsurance apply to all other services.
Skilled nursing, hospice, and home health care	No copay	Covered as an alternative to hospital care at the health plan's discretion.
Maternity care	No copay	If the member is eligible for the Maternity Benefits Program, maternity services can only be covered under Basic Health for 30 days following diagnosis of pregnancy. All other maternity services are covered through the Department of Social and Health Services.
Oxygen	No copay	Includes equipment and supplies. Not subject to copays, coinsurance, or deductible. Requires health plan authorization.

Benefits and Services Subject to the Deductible and Coinsurance

Before your health plan pays the 80% coinsurance for the following benefits, you must pay your annual deductible. Once you meet your $250 deductible, all of your coinsurance payments will be applied toward your $1,500 annual out-of-pocket maximum. Deductibles and out-of-pocket maximums are per person, per year.

Once the $1,500 per person out-of-pocket maximum has been reached, the health plan pays for all covered benefits and services with a coinsurance. Members are only responsible for copays for benefits and services listed above. If you change health plans any time during the year, the amount you've paid toward your deductible and out-of-pocket maximum for covered family members will start over with your new health plan.

Benefits/Services	Member's Payment Responsibility	Description
Hospital, inpatient	20% coinsurance; deductible applies. $300 maximum facility charge per admittance.	Facility charges may include, but are not limited to, room and board, prescription drugs provided while an inpatient, and other services received as an inpatient. No charges for maternity care or when readmitted for the same condition within 90 days. If the member is eligible for the Maternity Benefits Program, maternity services can only be covered under Basic Health for 30 days following diagnosis of pregnancy. All other maternity services are covered through the Department of Social and Health Services. See other professional services.
Hospital, outpatient	20% coinsurance; deductible applies.
Other professional services	20% coinsurance; deductible applies.	Includes services received as an inpatient, including, but not limited to, surgeries, anesthesia, chemotherapy, radiation, and other types of inpatient and outpatient services.
Mental health, facility	20% coinsurance; deductible applies to inpatient. $300 maximum facility charge per admittance.	Facility charges may include but are not limited to, room and board, prescription drugs provided while an inpatient, and other services received as an inpatient. Outpatient visits are subject to $15 copay (see "Office visits").
Laboratory	No copay or coinsurance for outpatient services. 20% coinsurance for inpatient hospital-based laboratory services.	Deductible applies to services with coinsurance.
Radiology	20% coinsurance, except for outpatient x-ray and ultrasound.	Deductible applies to services with coinsurance.
Ambulance services	20% coinsurance; deductible applies.	Includes approved transfers from one facility to another. No coinsurance if transfer is required by the health plan.
Chiropractic/physical therapy	20% coinsurance; deductible applies.	Up to a combined maximum of 12 visits per year. (Of those, no more than six can be for chiropractic care.) Visits qualify only when used as post-operative treatment following reconstructive joint surgery. Visits must be within one year of surgery.
Chemical dependency	20% coinsurance and deductible apply to inpatient. $300 maximum facility charge per admittance.	Limited to $5,000 every 24-month period; $10,000 lifetime maximum. Outpatient visits are subject to $15 copay (see office visits).
Organ transplants	Deductible, coinsurance, and copays apply by specific service.	12-month waiting period, except for children up to age 19.