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JHU SHP Plan — 2022 – 2023

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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
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