adultBasic Benefits


 

 

adultBasic benefits include:

Hospitalization  
Physician Services (primary care and specialists)
Emergency Services 
Diagnostic Tests (such as X-rays, mammograms and laboratory tests) 
Maternity Care 
Rehabilitation and Skilled Care (in lieu of extended hospitalization)

There are certain out-of-pocket expenses that you are responsible for, including:

$36.00 per month premium payment if enrolled in the program or $629 per month premium payment if purchasing coverage while on the waitlist
$10.
00 copayment each visit to a doctor 
$20.00 copayment for each visit to a specialist 
$50.00 copayment for each visit to an emergency room (waived if admission to a hospital occurs)

Coinsurance for certain services, up to a maximum of $1,000 per year. Services subject to coinsurance do not have copayments.

 

Below is a detailed summary of benefit and cost changes to the adultBasic program, effective March 1, 2010.  Please note that this list includes only changes to the benefits and costs; otherwise, the program remains the same.

 

adultBasic Benefit and Cost Changes

 

Old Benefit

New Benefit, Effective March 1, 2010

Primary care physician (PCP) office visits

$5 copay

$10 copay (except for preventive care)

Specialist doctor office visits

$10 copay

$20 copay

Emergency room copay

$25 copay

$50 copay

Inpatient hospital services

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance

Two stays per year

Physical, occupational and speech therapy

$2,500 maximum per year, combined

10% coinsurance/$1,000 maximum per year for all coinsurance

15 visits per year, combined

Diabetic supplies

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance

Outpatient surgery
(short procedure unit & facility)

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance

Cardiac rehabilitation
(36 sessions for a 12-week period)

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance

Chemotherapy, dialysis or radiation

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance

Pulmonary rehabilitation
(18 sessions per calendar year)

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance

Respiratory therapy
(18 sessions per calendar year)

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance

Home infusion

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance

Home health care

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance

Skilled nursing facility care
(60 days per calendar year)

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance

Inpatient rehabilitation therapy
(45 days per calendar year)

No charge

10% coinsurance/$1,000 maximum per year for all coinsurance