JHU SHP Plan — 2021-2022
Medical Services and Supplies
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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