When Do Out-Of-Area Benefits Apply

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What Is the Annual Deductible
What Percentage of Covered Out-of-Area Expenses Does the Plan Pay
What Is the Annual Out-Of-Pocket Maximum
What Is the Maximum Lifetime Benefit

Managed Choice POS not only provides benefits for covered persons who live in the network service area. It also provides out-of-area benefits for covered persons who have their primary residence outside the network service area.

Out-of-area benefits are the same as out-of-network benefits with these exceptions:

The annual deductible is not required for hospital admissions, skilled nursing facilities, hospice care, or home health care. For other covered expenses, however, you must satisfy the annual deductible.
The plan pays 100% of covered expenses for semi-private hospitalization, skilled nursing facilities, and hospice care, as well as home health care. Most other covered expenses are paid at 80%. Physician charges for some retirees are covered at 70% (See page 41). If you reach your annual out-of-pocket maximum, these benefits will increase to 100% for the rest of the plan year.
The plan pays 50% of covered expenses for chiropractic care and private duty nursing care.
The benefits have family annual deductibles and out-of-pocket maximums, but no individual deductibles and maximums.
The $300,000 lifetime maximum benefit does not apply. The lifetime maximum is unlimited for out-of-area benefits.
There is a separate toll-free number to call for claims processing questions.

As with out-of-network benefits, out-of-area benefits require advance approval for hospitalization and certain outpatient surgical and diagnostic procedures. In addition, advance approval is required for skilled nursing facilities, hospice care, and home health care.

If you choose to receive care that is not covered, you will be responsible for paying the full cost of the service or supply.

Benefits for psychiatric and substance abuse are provided only through the separate network managed by Value Options.

Out-of-area benefits also apply in the following situations:

You are permanently assigned to work in a location not covered by a Managed Choice POS network. In that case, you and all covered family members are eligible for out-of-area benefits only.
The primary residence for a covered dependent child is outside the network service area.

What Is the Annual Deductible

The annual deductible is the amount of covered medical expenses you pay before out-of-area benefits become payable for covered medical expenses. The deductible does not apply to expenses for hospitalization, skilled nursing facilities, home health care, hospice care, or second surgical opinions required as part of the advance approval process.

The family annual deductible for out-of-area benefits is 1% of your annualized base pay as of July 1. For retirees, it is the January 1 base pay in effect the year of retirement.
The annual deductible is calculated by first rounding your annualized base pay to the nearest $1,000. For example, if your annualized base pay as of July 1 is $24,400, the pay is rounded to $24,000. Then, 1% of $24,000, or $240, becomes your family's annual deductible for the year.

If you have four covered family members, here's an example of how the family deductible can work based on an annualized base pay of $24,000:

Family Member One has $60 of expenses that apply toward the family deductible.
Family Member Two has $40 of expenses that apply toward the family deductible.
Family Member Three has $40 of expenses that apply toward the family deductible.
Family Member Four has $100 of expenses that apply toward the family deductible.

Since the family has enough covered expenses to meet the family deductible of $240, no further deductibles are required for the year. In this example, the combination of covered expenses for all family members adds up to the $240 maximum. This means all covered family members can begin receiving out-of-area benefits.

Any copayments for in-network benefits or the psychiatric and substance abuse network do not apply toward your out-of-area annual deductible. In addition, any portion of covered out-of-area expenses that exceeds the usual and prevailing rate and any $300 penalty for failure to obtain advance approval will not apply toward your deductible. If you move into or out of the Managed Choice POS network service area during the year, any covered expenses that apply toward your out-of-network deductible also will apply toward your out-of-area deductible and vice versa.

What Percentage of Covered Out-of-Area Expenses Does the Plan Pay

After you pay any required annual deductible, the plan pays a percentage of covered expenses. You pay the cost not covered by the plan.

Subject to advance approval, the plan pays 100% of the following covered expenses with no deductible required:

Charges for hospitalization
Charges for skilled nursing facilities up to a 180-day lifetime maximum
Charges for home health care up to a 240-day lifetime maximum
Charges for hospice care up to a 180-day maximum

Hospital, skilled nursing facility, and hospice room and board charges are limited to the semi-private rate. The alternate care maximums are a combined maximum for in-network, out-of-network, and out-of-area benefits.

The plan also pays for a second surgical opinion required as part of the advance approval process.

After the deductible, benefits are paid at 50% of covered expenses for:

Charges for chiropractic services
Charges for private duty nursing.

For other expenses, the plan pays 80% of covered charges after you satisfy the deductible.

What Is the Annual Out-Of-Pocket Maximum

The annual out-of-pocket maximum for a family is 3% of annualized base pay as of July 1. For retirees, it is the January 1 base pay in effect the year of retirement. Once the out-of-pocket maximum is reached for a family during the year, the plan will pay 100% of remaining covered expenses for that family for the rest of the plan year.

The annual out-of-pocket maximum is calculated by rounding your annualized base pay to the nearest $1,000 just as with the annual deductible. If your annualized base pay as of July 1 is $24,400, for example, the annual family out-of-pocket maximum is 3% of $24,000, or $720. In this example, once your share of covered expenses, including the annual deductible, reaches $720 for a covered family during the year, the plan will pay 100% of any remaining covered expenses for the family for the rest of the plan year.

Any copayments for in-network benefits or the psychiatric and substance abuse network do not apply toward your Out-of-pocket maximum. In addition, any portion of covered out-of-area expenses that exceeds the usual and prevailing rate and any $300 penalty you incur for failing to receive advance approval will not apply toward your out-of-pocket maximum. Your share of covered expenses for chiropractic care and private duty nursing care also will not apply.

If you move into or out of the service area during the year, any covered expenses that apply toward your annual out-of-network maximum also will apply toward your out-of-area maximum and vice versa.

What Is the Maximum Lifetime Benefit

There is no maximum for out-of-area benefits payable for each covered person.