What Expenses Are Covered

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What Medical and Surgical Expenses Are Covered
What Dental Expenses Are Covered

The health care expenses covered by Managed Choice POS depend on whether the benefits are being paid by:

The medical and surgical coverage administered by Blue Cross Blue Shield of Illinois,
The dental coverage, or
The separate psychiatric and substance abuse network administered by Value Options.

Covered expenses for each of these are described in this section.

What Medical and Surgical Expenses Are Covered

The following services and supplies are covered in-network, out-of-network, and out-of-area, subject to plan provisions described in other sections of this booklet:

Allergy serum and biological serum.
Ambulance use for local travel for life-threatening conditions or those conditions which could put a life in danger or cause serious harm to bodily functions. Air ambulance to the nearest facility that can handle the particular illness or injury is covered when medically necessary.
Anesthetics and their administration.
Artificial limbs, larynx, and eyes.
Audiologist treatment for diagnosed loss or impairment of hearing. This includes examinations to determine the need for hearing aids or the need to adjust them.
Blood and blood plasma not replaced by or for the patient.
Durable medical equipment rental or, at the plan administrator's option, purchase of items such as a wheelchair, iron lung, hospital bed, or equipment for use of oxygen, including repair and necessary maintenance of purchased equipment not provided under a manufacturer's warranty or a purchase agreement.
Eye care - Available for active employees only.
Hearing aids - Available for active employees only.
Heart pacemakers.
Home health care services and supplies on an intermittent, part-time, visiting basis, provided:
- The services are not mainly custodial care,
- The services and supplies are furnished to the person while under a doctor's care, and
- The physician certifies the patient would have had to be confined in a hospital or skilled nursing facility if not for such services.

Out-of-network or out-of-area home health care must be approved by Blue Cross Blue Shield of Illinois in advance. For each covered person, home health care is limited to 240 days. This combined maximum includes in-network, out-of-network, and out-of-area benefits.

Hospice care services and supplies for a covered person who is terminally ill and whose life expectancy is six months or less, as certified by the attending physician.

Out-of-network or out-of-area hospice care services and supplies must be approved by Aetna in advance. For each covered person, hospice care is limited to 180 days for the same or related causes. In-network, out-of-network, and out-of-area maximums are combined for a total of 180 days.

Hospital semi-private room and board and other supplies and services, subject to advance approval for out-of-network or out-of-area admissions.
Inhalation therapy
Injectables, including prescribed insulin
Oxygen
Physical or occupational therapy
Physicians' services for eligible surgical procedures and for other medical care

For certain outpatient, non-emergency surgical and diagnostic procedures that are out-of-network or out-of-area, advance approval is required.

Prescription drugs prescribed by a physician and dispensed by a pharmacy, unless excluded elsewhere in the plan.
Reconstructive surgery and any resulting implants.
Skilled nursing facility services and supplies including room and board and other supplies and services for up to 180 days (365 for in-network, combined with out-of-network and out-of-area) provided:
- The services are not mainly custodial care,
- The services are furnished by order of a physician,
- The physician certifies the patient requires 24-hour skilled care, and
- Care is not principally for tuberculosis, mental deficiency, or mental retardation.

Skilled nursing facility care must be approved by Aetna in advance.

Speech therapy by a qualified speech therapist, provided:
- The speech therapy is to restore speech after a loss or impairment of a demonstrated previous ability to speak, except that the loss or impairment must not be caused by a mental, psychoneurotic, or personality disorder.
- The speech therapy is to develop or improve speech after surgery to correct a defect that both existed at birth and impaired or would have impaired the ability to speak.
Surgical dressings; casts, splints, trusses, braces, and crutches. These include replacements that are functionally necessary.
Surgical transplant services and supplies that are required for a live donor as a result of a surgical transplant procedure, whether the covered person is the donor or the recipient of the transplant. If the covered person is the recipient, Managed Choice POS coverage applies to the extent benefits are not provided by the donor's coverage under Managed Choice POS or any other group or individual coverage.
Treatment by X-ray, radium, or any other radioactive substance or by chemotherapy.
X-ray exams and lab exams. Certain diagnostic procedures provided out-of-network or out-of-area require advance approval.

The following services and supplies also are covered in the Managed Choice POS network, subject to plan provisions relating to in-network benefits:

Birth control pills prescribed by a physician
Chiropractic care
Immunizations
Private duty nursing
Routine health assessments
Weight loss programs for morbid obesity
Well-baby care.

Chiropractic care, podiatric care, private duty nursing and pap smears are covered out-of-area. To be considered a covered expense, the service or supply:

Must be ordered by a physician to treat non-occupational illness or injury,
Must be medically necessary, and
Must not be otherwise excluded.

In addition, only charges for services and supplies up to the usual and prevailing rate qualify as a covered expense.

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

What Dental Expenses Are Covered

In addition to the services and supplies identified as covered medical and surgical expenses, dental coverage includes the following, subject to plan provisions described in other sections of this booklet:

Preventive dental care, limited to:
- Routine checkups and cleanings no more frequently than twice every 12-months and
- Fluoride treatments, space maintainers, and sealants for covered dependents under age 19. Sealants are covered no more than once every three years for any given permanent tooth.
Dental services and oral surgery including a physician's or dentist's services or X-ray exams for all procedures involving one or more teeth, the tissue or structure around them, the alveolar process, or the gums.
Medications prescribed by a dentist.

What Psychiatric and Substance Abuse Expenses Are Covered

Expenses covered by the special psychiatric and substance abuse network include the following if medically or psychologically necessary:

Inpatient treatment in an acute care general or psychiatric hospital providing 24-hour structured and supervised care for

Detoxification when body function, loss of life, or permanent impairment is threatened once substance abuse has stopped. Patients needing this level of treatment require comprehensive medical evaluation and intensive treatment.
Psychiatric treatment, when patients requiring this level of treatment have not improved or cannot reasonably be managed in treatment at the outpatient, residential, or partial hospital level. They require the professional resources, structure, and consistency of a psychiatric inpatient program under the daily direction and supervision of a psychiatrist.

Intermediate treatment in residential and partial hospital programs designed to provide substance abuse rehabilitation and psychiatric treatment as an alternative to inpatient care including:

Partial hospital substance abuse rehabilitation structured to create an environment which helps patients remain substance free.
Partial hospital psychiatric treatment designed for patients with serious mental and emotional disorders who require treatment not possible in an outpatient setting but who do not require inpatient 24-hour structured and supervised care.
Residential substance abuse rehabilitation providing 24-hour treatment designed to help patients function while remaining substance free. The program may include detoxification, if needed.
Residential psychiatric treatment providing 24-hour treatment including family therapy involvement.

Outpatient treatment including individual, family, and group therapy. Family therapy means treatment of one family member and consultation with other members to aid in that treatment. Outpatient substance abuse rehabilitation and psychiatric treatment can occur in outpatient departments of acute care hospitals, private offices of health and mental health professionals, or freestanding facilities established for substance abuse rehabilitation and psychiatric treatment.