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JHU SHP Plan — 2021-2022

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EHP Network Provider Out of Network Provider
Acupuncture
Medically necessary services for anesthesia, pain control, and therapeutic purposes 80% of allowed amount; deductible applies ($300 annual maximum for all networks combined) 70% of allowed benefit; deductible applies ($300 annual maximum for all networks combined)
Allergy Tests & Procedures
Allergy tests 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Desensitization materials and serum 80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Ambulance Transportation
Medically necessary ground transport 100% of allowed amount; deductible applies 100% of allowed benefit; deductible applies
Medically necessary air transport 100% of allowed amount; deductible applies 100% of allowed benefit; deductible applies
Biofeedback
Biofeedback Not Covered Not Covered
Chemo & Radiation Therapy
Physician visit 100% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Materials and treatment 80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Chiropractic Care
Chiropractor with PT privileges (physical therapy services) Refer to Therapy section Refer to Therapy section
Chiropractic services 80% of allowed amount; deductible applies (20 visit per condition per plan year maximum for all networks combined) 80% of allowed benefit; deductible applies (20 visit per condition per plan year maximum for all networks combined)
Dialysis
Medically necessary services 80% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Durable Medical Equipment
Breast pumps (standard) and related supplies 100% of allowed amount; deductible waived 70% of allowed benefit; deductible applies (pre-authorization required)
Contraceptive devices 100% of allowed amount; deductible waived 80% of allowed benefit; deductible applies
Custom DME, including custom wheelchairs 80% of allowed amount; deductible applies (pre-authorization required) 80% of allowed benefit; deductible applies (pre-authorization required)
Custom-molded orthotics 80% of allowed amount; deductible applies (pre-authorization required) 80% of allowed benefit; deductible applies (pre-authorization required)
Insulin pumps, Continuous Glucose Monitor and related supplies 80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Hearing aids 80% of allowed amount; deductible applies (pre-authorization required) replacement aids once every 36 months all networks combined 80% of allowed benefit; deductible applies (pre-authorization required) replacement aids once every 36 months all networks combined
Non-custom medical equipment and supplies 80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Prosthetic devices 80% of allowed amount; deductible applies (pre-authorization required) 80% of allowed benefit; deductible applies (pre-authorization required)
Emergency Services
Emergency care (facility fees) $50 co-pay, then 100% of allowed amount; deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $50 co-pay, then 100% of allowed benefit; deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage
Emergency care (professional fees) 100% of allowed amount: deductible applies 100% of allowed benefit: deductible applies
Home Health Services
Medically necessary services 100% of allowed amount for first 90 visits per plan year, then 80% of allowed amount; deductible applies (pre-authorization required) 90% of allowed benefit for first 90 visits per plan year, then 80% of allowed benefit; deductible applies (pre-authorization required)
Home infusion therapy 90% of allowed amount; deductible applies (pre-authorization required) 90% of allowed benefit; deductible applies (pre-authorization required)
Hospice Care
Inpatient and home hospice 100% of allowed amount (pre-authorization required) 100% of allowed benefit (pre-authorization required)
Hospital Care
Inpatient care including newborn nursery care; NICU (facility fees) 100% of allowed amount for first 30 days, then 80% of allowed amount, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) 100% of allowed amount for first 30 days, then 80% of allowed amount, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient care (professional fees) 80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Skilled nursing/rehabilitation facility 100% of allowed amount for first 30 days, then 80% of allowed amount, deductible applies; pre-authorization required) 100% of allowed amount for first 30 days, then 80% of allowed amount, deductible applies; pre-authorization required)
Short-term acute rehabilitation 100% of allowed amount for first 30 days, then 80% of allowed amount, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) 100% of allowed amount for first 30 days, then 80% of allowed amount, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Observation care (facility fees) $50 co-pay, then 100% of allowed amount; deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $50 co-pay, then 100% of allowed benefit; deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage
Observation care (professional fees) 100% of allowed amount; deductible applies 100% of allowed benefit; deductible applies
Outpatient surgery & ambulatory surgical center (facility fees) 90% of allowed amount; deductible applies (includes freestanding surgical centers) 90% of allowed benefit; deductible applies (includes freestanding surgical centers)
Outpatient surgery & ambulatory surgical center (professional fees) 80% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Hyperbaric Oxygen Therapy
Medically necessary services 90% of allowed amount; deductible applies (pre-authorization required) 90% of allowed benefit; deductible applies (pre-authorization required)
Immunizations
Preventive immunizations for communicable diseases 100% of allowed amount; deductible waived 70% of allowed benefit; deductible applies
Travel immunizations Not Covered Not Covered
Infusion Therapy
Home infusion therapy 90% of allowed amount; deductible applies (pre-authorization required) 90% of allowed benefit; deductible applies (pre-authorization required)
Outpatient infusion therapy 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Injections
Injections 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Materials and serum 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Laboratory
Laboratory tests including pathology 90% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Mental Health & Substance Use Disorder Services
Outpatient mental health care (facility fees) 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Outpatient mental health care (professional fees) 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Inpatient mental health care (facility fees) 100% of allowed amount for the first 30 days, then 80% of allowed amount; deductible applies (pre-authorization required) 100% of allowed benefit for the first 30 days, then 80% of allowed benefit; deductible applies (pre-authorization required)
Inpatient mental health care (professional fees) 80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Outpatient substance use disorder care (facility fees) 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Outpatient substance use disorder care (professional fees) 100% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Inpatient substance use disorder care (facility fees) 100% of allowed amount for the first 30 days, then 80% of allowed amount; deductible applies (pre-authorization required) 100% of allowed benefit for the first 30 days, then 80% of allowed benefit; deductible applies (pre-authorization required)
Inpatient substance use disorder care (professional fees) 80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Intensive outpatient program 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Partial hospital facility services 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Medication management 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Mental health testing and procedures 90% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Methadone Treatment
Medically necessary outpatient care 90% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Nutritional Counseling
Medically necessary services 90% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Office Visits for Treatment of Illness or Injury
Primary care office visit only (Adult) 80% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Primary care office visit (Pediatric: age 19 and under) 100% of allowed amount; deductible applies 90% of allowed benefit; deductible applies
Primary care office visit only (GYN) 80% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Specialty care office visit only (Adult & Pediatric) 90% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Treatment and diagnostic services in the office 90% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Preventive Services
Preventive exam (PCP, GYN and Well Child care) 100% of allowed amount; deductible waived (well child care limited to office visit, immunizations and PKU, flu vaccine, urinalysis and lead testing) 70% of allowed benefit; deductible applies (well child care 90% of allowed benefit, deductible applies limited to office visit, immunizations and PKU, flu vaccine, urinalysis and lead testing)
Diagnostic services for preventive exam 100% of allowed amount; deductible waived (well child care limited to office visit, immunizations and PKU, flu vaccine, urinalysis and lead testing) 70% of allowed benefit; deductible applies (well child care 90% of allowed benefit, deductible applies, limited to office visit, immunizations and PKU, flu vaccine, urinalysis and lead testing)
Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. 100% of allowed amount; deductible waived (one PAP per 12-month period) 70% of allowed benefit; deductible applies (one PAP per 12-month period) 90% of allowed benefit mammograms only
Routine hearing exams 100% of allowed amount; deductible waived (Pediatric: age 19 and under) 70% of allowed benefit; deductible applies (Pediatric: age 19 and under)
Private Duty Nursing
Private Duty Nursing Not Covered Not Covered
Radiology Procedures
All imaging studies including X-Ray, ultrasound, MRI, CT and PET scans 90% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Reproductive Health
Physician office visits (prenatal care only) Routine prenatal visits covered at 100%; all other pre-natal visits at 90% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Infertility treatment Covered at EHP network providers only: 50% of allowed amount, deductible applies, plus a separate $1,500 lifetime ART treatment deductible, $20,000 lifetime ART treatment maximum combined including prescription drugs. No lifetime maximum benefit applied to AI/IUI (pre-authorization required for all services and prescriptions) Covered at EHP network providers only
Birthing centers (facility fees) 90% of allowed amount; deductible applies (pre-authorization required) 90% of allowed benefit; deductible applies (pre-authorization required)
Birthing centers (professional fees) 80% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Inpatient maternity care and delivery; newborn nursery care; NICU (facility fees) 100% of allowed amount for first 30 days, then 80% of allowed amount, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) 100% of allowed amount for first 30 days, then 80% of allowed amount, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient maternity care and delivery; newborn nursery care; NICU (professional fees) 80% of allowed amount; deductible applies (maternity care – delivery and anesthesia 90% of allowed amount; deductible applies) (newborn care – initial and discharge visits 90% of allowed amount; deductible applies) (newborn care – all other inpatient visits – 80% of allowed amount, deductible applies) 70% of allowed benefit; deductible applies (maternity care – delivery and anesthesia 70% of allowed benefit; deductible applies) (newborn care – initial and discharge visits 90% of allowed benefit; deductible applies) (newborn care – all other inpatient visits – 80% of allowed benefit, deductible applies)
Interruption of pregnancy 80% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Female sterilization (professional services for surgery, anesthesia and related pathology) 100% of allowed amount; deductible waived 80% of allowed benefit; deductible applies
Male sterilization (professional services for surgery, anesthesia and related pathology) 100% of allowed amount; deductible waived 80% of allowed benefit; deductible applies
Surgical Procedures
Surgical treatment for morbid obesity 80% of allowed amount; deductible applies (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Primary care office surgical procedures 80% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Specialist care office surgical procedures 80% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (facility fees) 90% of allowed amount; deductible applies (includes freestanding surgical centers) 90% of allowed benefit; deductible applies (includes freestanding surgical centers)
Outpatient surgery (including freestanding surgical centers) (professional fees) 80% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
Inpatient surgery (facility fees) 100% of allowed amount for first 30 days, then 80% of allowed amount, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) 100% of allowed amount for first 30 days, then 80% of allowed amount, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient surgery (professional fees) 80% of allowed amount; deductible applies (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Therapy
Physical therapy/occupational therapy medically necessary services 80% of allowed amount; deductible applies (excludes maintenance therapy) 80% of allowed benefit; deductible applies (excludes maintenance therapy)
Speech therapy (non-developmental medically necessary services) 80% of allowed amount; deductible applies (pre-authorization required) 80% of allowed benefit; deductible applies (pre-authorization required)
Pulmonary rehabilitation 90% of allowed amount; deductible applies (pre-authorization required) 90% of allowed benefit; deductible applies (pre-authorization required)
Cardiac rehabilitation 90% of allowed amount; deductible applies (pre-authorization required) 90% of allowed benefit; deductible applies (pre-authorization required)
Vision therapy Not Covered Not Covered
Habilatative Services 80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Urgent Care Center
Physician visit 100% of allowed amount; deductible applies 100% of allowed benefit; deductible applies
Diagnostic services and treatment 100% of allowed amount; deductible applies 100% of allowed benefit; deductible applies
Revised
September 9, 2022
Group Number
E00016
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