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Frequently Asked Questions
Below are some of the questions that are frequently asked by our members, as well as information on more general topics.
If you have any questions not addressed in this space please do not hesitate to contact HRH of Coloado. |
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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.
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Topics
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Must see contracted provider. |
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PPO - at a contracted provider, there is one office visit co-payment if plan has co-pay. Then charges are paid at the end of the pregnancy, billed on a global basis, subject to the plan deductible and coinsurance.
EPO - office visit co-pay for 1st prenatal visit, then hospital co-pay at the time of delivery. |
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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. |
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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. |
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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. |
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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. |
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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. |
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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:)
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Age 0-12 months
Age 13-35 months
Age 3-6 years
Age 7-12 years
Age 0-12 years
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5 well-child visits
2 well-child visits
3 well-child visits
3 well-child visits
Required Immunizations as recommended by the
American
Academy of Pediatrics |
1 PKU (phenylketonuria) |
"Well-Child Visit" means a visit to a provider that includes the
following elements: age appropriate physical exam (but not a complete
physical exam unless this is age appropriate), history, anticipatory
guidance and education (e.g., examine family functioning and dynamics,
injury prevention counseling, discuss dietary issues, review age appropriate
behaviors, etc.), growth and development assessment. For older children,
this also includes safety and health education counseling. A child is
covered through age 18 years and will be covered from age 19 - 25 if they
are an eligible dependent.
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- Child wellness/0 through 12 years of age: in-network benefits
- 100%, subject to member's copay with no maximum; out-of network
benefits 100% up to $300, thereafter deductible is waived, paid at
60%.
- Adult wellness: in-network benefits - 100% up to $300, subject to
member's copay; out-of-network benefits - 100% up to $300. If any of
the covered items are submitted because of a diagnosis or ailment,
they will not be covered by the wellness benefit. They could,
however, be covered by other provisions of the plan. The plan
language would determine this in all cases. For PPO members, an
office visit copay will be required for covered items. |
| COVERED UNDER WELLNESS (co-pay required) |
NOT COVERED UNDER WELLNESS |
Routine Vision Exams
Routine Physicals (including sports)
Routine Mammograms
Routine Pap/Pelvic
Routine Cholesterol Screening
Routine CBC and other Blood work
Routine Urinalysis
Routine Blood-Stool Testing
Routine Chest X-rays
Immunizations
Flu Shots
Hepatitis B Shots
Routine Sigmoidoscopy
Routine Prostate Exam
Routine Heart Imaging
Routine Bone Density Screening
Office Charges for Above Routine Services |
Hearing Exams
Family Planning
Health Club Dues
Athletic Equipment
Employment Physicals including DOT Physicals |
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*Updated 12/10/2009
If you have questions or problems that this site could not answer please contact us via email or phone.
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