JHU SHP Plan — 2022 – 2023
Medical Services and Supplies
Student Health Program is no longer part of EHP, as of June 30, 2023.
For questions about health care services and claims on and after July 1, 2023, contact WellFleet Customer Service. For services and claims before July 1, 2023, contact EHP Customer Service.
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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; in-network 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 | 80% of allowed benefit; deductible applies |
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 | 80% of allowed benefit; deductible applies |
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) |
Blood Pressure Cuff | 80% of allowed amount; deductible applies | 80% of allowed benefit; deductible applies |
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; in-network 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: in-network 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) | 90% of allowed amount; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) | 90% of allowed benefit; 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 (See Surgical procedures for inpatient surgery) |
Skilled nursing/rehabilitation facility | 90% of allowed amount; deductible applies (pre-authorization required) | 90% of allowed benefit; deductible applies (pre-authorization required) |
Short-term acute rehabilitation | 90% of allowed amount; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) | 90% of allowed benefit; 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 90% of allowed amount; deductible applies (pre-authorization required) | 100% of allowed benefit for the first 30 days, then 90% 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 90% of allowed amount; deductible applies (pre-authorization required) | 100% of allowed benefit for the first 30 days, then 90% 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, $100,000 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) | 90% of allowed amount; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) | 90% of allowed benefit; 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) | 90% of allowed amount; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) | 90% of allowed benefit; 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 | 90% of allowed benefit; deductible applies |
Cardiac rehabilitation | 90% of allowed amount; deductible applies | 90% of allowed benefit; deductible applies |
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
June 30, 2023
Group Number
E0001600
Plan Codes
803C0000