Q. When does my PPO deductible start and end?

A. The deductible is on a calendar year basis, from January 1 to December 31.

Q. Do I have a separate co-payment for lab charges?

A. Yes, the same amount as the office visit co-payment when the lab work is being done by a different provider.

Q. Do emergency room charges apply toward the PPO deductible?

A. Yes, even if your doctor directs you to the emergency room.

EPO

Maternity

Newborn

Pre-existing Conditions

COBRA

Deductible

Deductible Carry Over

PPO Wellness Benefits

A newborn baby is covered for the first 30 days, in the absence of other coverage. If the child is added to the CEBT plan, premiums will be due from the date of birth. The deductible is waived if the mom and newborn are discharged from the hospital at the same time. If the baby is not discharged with mom, then the plan deductible would be applied.

An employee has 30 days from the date of birth to add the newborn to the CEBT plan. If the child is added to another plan we will need an Other Insurance form completed and proof from the other carrier.

Any NEWLY covered employee and/or dependent whose medical coverage becomes effective and who has undergone treatment, incurred expenses, or received a diagnosis for any condition within three (3) months prior to the effective date of medical coverage will be limited to an amount not to exceed $1,000.00 during the first twelve (12) months of coverage.

If this plan is replacing another plan covering your group the pre-existing limitation may not apply. If you are a new employee enrolling in the CEBT Plan and have current qualified coverage the pre-existing limitation may not apply. Please check with the plan administrator for details. The plan follows all HIPAA guidelines.

An employee who loses their coverage, unless due to gross misconduct, can continue on COBRA for up to 18 months at their own cost. Dependents that lose their coverage due to death of the employee, divorce or reaching the maximum age limitations can continue on COBRA for up to 36 months at their own cost.

The following are some, but not all examples of charges that would apply toward the plan deductible.

1. X-rays, MRI's, CT Scans, PET Scans, etc.

2. Hospital charges (in or out patient)

3. Emergency room charges and related providers

4. Charges from any non-contracted provider. These charges would be subject to Reasonable and Customary guidelines based on the geographic location of the provider.

5. Durable medical equipment.

6. Prosthetic devices and orthopedic appliances.

Any office visit, lab or prescription drug co-payments to not apply toward your plan deductible or maximum out of pocket.

Covered charges incurred each calendar year on or after October 1st for which benefits are not payable because the deductible has not been met, will apply toward the next calendar year deductible.

Routine services - The only routine services that are covered are pap/pelvic (once per calendar year unless it comes back abnormal and then two per calendar year are covered). There is no age restrictions for a Pap/Pelvic exam. Age decides frequency payable. Effective July 1, 2008, a $300 routine services benefit will be added to the policy. We will pay 100% of first $300, then any charges exceeding this amount will be the responsibility of the insured. For non PPO providers, charges are subject to R & C.

Deductible is waived for these types of services:

(The following are paid out of wellness:)