La. Admin. Code tit. 32 § V-205

Current through Register Vol. 50, No. 9, September 20, 2024
Section V-205 - Schedule of Benefits
A. Benefits and Coinsurance

Coinsurance

Active Employees/ Non-Medicare Retirees (regardless of retire date)

Retirees with Medicare (regardless of retire date)

Network Providers

Non-Network

Network Providers

Physician Office Visits including surgery performed in an office setting:

* General Practice

* Family Practice

* Internal Medicine

* OB/GYN * Pediatrics

90% - 10%1

70% - 30%1

80% - 20%1

Allied Health/Other Professional Visits:

* Chiropractors

* Federally Funded Qualified Rural Health Clinics

* Nurse Practitioners

* Retail Health Clinics

* Physician Assistants

90% - 10%1

70% - 30%1

80% - 20%1

Specialist (Physician) Office Visits including surgery performed in an office setting:

* Physician

* Podiatrist

* Optometrist

* Midwife

* Audiologist

* Registered Dietician

* Sleep Disorder Clinic

90% - 10%1

70% - 30%1

80% - 20%1

Ambulance Services - Ground (for Emergency Medical Transportation only)

90% - 10%1

70% - 30%1

80% - 20%1

Ambulance Services - Air (for Emergency Medical Transportation only) Non-emergency requires prior authorization2

90% - 10%1

70% - 30%1

80% - 20%1

Ambulatory Surgical Center and Outpatient Surgical Facility

90% - 10%1

70% - 30%1

80% - 20%1

Bariatric Surgery Services - Facility Services4

$2,500.00 Copayment2,3

Not Covered

Network Providers $2,500.00 Copayment2,3

Non-Network Providers Not Covered

Bariatric Surgery Services - Professional Services4

90% - 10%2,3

Not Covered

Network Providers 90% - 10%2,3

Non-Network Providers Not Covered

Bariatric Surgery Services - Preoperative and Postoperative Medical Services4

80% - 20%2,3

Not Covered

Network Providers 80% - 20%2,3

Non-Network Providers Not Covered

Birth Control Devices -Insertion and Removal (as listed in the Preventive and Wellness Care Article in the Benefit Plan)

100% - 0%

70% - 30%1

Network Providers 100% - 0%

Non-Network Providers 80% - 20%1

Cardiac Rehabilitation (limit of 36 visits per Plan Year)

90% - 10%1,2

70% - 30%1,2

80% - 20%12

Chemotherapy/Radiation Therapy (Authorization not required when performed in Physician's office)

90% - 10%1,2

70% - 30%1,2

80% - 20%1,2

Diabetes Treatment

90% - 10%1

70% - 30%1

80% - 20%1

Diabetic/Nutritional Counseling - Clinics and Outpatient Facilities

90% - 10%1

Not Covered

80% - 20%1

Dialysis

90% - 10%1

70% - 30%1

80% - 20%1

Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices

90% - 10%1,2

70% - 30%1,2

80% - 20%1,2

Emergency Ground Ambulance Services; In-State

90% - 10%1

90% - 10%1

80% - 20%1

Emergency Ground Ambulance Services; Out-of-State

90% - 10%1

70% - 30%1

80% - 20%1

Emergency Room (Facility Charge)

$200 Copayment1; Waived if admitted to the same facility

Emergency Medical Services (Non-Facility Charges)

90% - 10%1

90% - 10%1

80% - 20%1

Eyeglass Frames and One Pair of Eyeglass Lenses or One Pair of Contact Lenses (purchased within six months following cataract surgery)

Eyeglass Frames - Limited to a Maximum Benefit of $501

Flu shots and H1N1 vaccines (administered at Network Providers, Non-Network Providers, Pharmacy, Job Site or Health Fair)

100% - 0%

100% - 0%

100% - 0%

Hearing Aids (Hearing Aids are not covered for individuals age eighteen (18) and older)

90% - 10%1,3

70% - 30%1,3

80% - 20%1,3

Hearing Impaired Interpreter Expense

100% - 0%

100% - 0%

100% - 0%

High-Tech Imaging -Outpatient

* CT Scans

* MRA/MRI

* Nuclear Cardiology

* PET Scans

90% - 10%1,2

70% - 30%1,2

80% - 20%1,2

Home Health Care (limit of 60 Visits per Plan Year)

90% - 10%1,2

70% - 30%1,2

Not Covered

Hospice Care (limit of 180 Days per Plan Year)

80% - 20%1,2

70% - 30%1,2

Not Covered

Injections Received in a Physician's Office (when no other health service is received)

90% -10%1

70% - 30%1

80% - 20%1

Inpatient Hospital Admission, All Inpatient Hospital Services Included Per Day Copayment Day Maximum Coinsurance

$0

Not Applicable

90% - 10%1,2

$50

5 Days

70% - 30%1,2

$0

Not Applicable

80% - 20%1,2

Inpatient and Outpatient Professional Services

90% - 10%1

70% - 30%1

80% - 20%1

Mastectomy Bras - Ortho-Mammary Surgical (limit of three (3) per Plan Year)

90% - 10%1

70% - 30%1

80% - 20%1

Mental Health/Substance

Abuse - Inpatient Treatment and Intensive Outpatient Programs Per Day Copayment Day Maximum Coinsurance

$0

Not Applicable

90% - 10%1,2

$50

5 Days

70% - 30%1,2

$0

Not Applicable

80% - 20%1,2

Mental Health/Substance Abuse - Office Visit and Outpatient Treatment (Other than Intensive Outpatient Programs)

90% - 10%1

70% - 30%1

80% - 20%1

Newborn - Sick, Services Excluding Facility

90% - 10%1

70% - 30%1

80% - 20%1

Newborn - Sick, Facility Per Day Copayment Day Maximum Coinsurance

$0

Not Applicable

90% - 10%1,2

$50

5 Days

70% - 30%1,2

$0

Not Applicable

80% - 20%1,2

Non-Emergency Ground Ambulance Services

90% - 10%1

70% - 30%1

80% - 20%1

Oral Surgery for Impacted Teeth

90% - 10%1,2

70% - 30%1,2

80% - 20%1,2

Pregnancy Care - Physician Services

90% - 10%1

70% - 30%1

80% - 20%1

Preventive Care - Services include screening to detect illness or health risks during a Physician office visit. The Covered Services are based on prevailing medical standards and may vary according to age and family history. (For a complete list of benefits, refer to the Preventive and Wellness Care Article in the Benefit Plan.)

100% - 0%3

70% - 30%1,3

Network 100% - 03

Non-Network

80% - 20%1,3

Rehabilitation Services - Outpatient:

* Speech

* Physical/ Occupational (Limited to 50 Visits combined PT/OT per Plan Year. Authorization required for visits over the combined limit of 50.)

(Visit limits do not apply when services are provided for Autism Spectrum Disorders)

90% - 10%1

70% - 30%1

80% - 20%1

Skilled Nursing Facility (limit 90 days per Plan Year)

90% - 10%1,2

70% - 30%1,2

80% - 20%1,2

Sonograms and Ultrasounds (Outpatient)

90% - 10%1

70% - 30%1

80% - 20%1

Urgent Care Center

90% - 10%1

70% - 30%1

80% - 20%1

Vision Care (Non-Routine) Exam

90% - 10%1

70% - 30%1

80% - 20%1

X-ray and Laboratory Services (low-tech imaging)

90% - 10%1

70% - 30%1

80% - 20%1

1Subject to Plan Year Deductible, if applicable

2Pre-Authorization Required, if applicable. Not applicable for Medicare primary.

3Age and/or Time Restrictions Apply

4No Benefits will be payable unless Prior Authorization is obtained, including Plan Participants with Medicare as the Primary Plan.

La. Admin. Code tit. 32, § V-205

Promulgated by the Office of the Governor, Division of Administration, Office of Group Benefits, LR 41:356 (February 2015), effective March 1, 2015, Amended LR 43:2155 (11/1/2017), (effective 1/1/2018), Amended LR 48:2769 (November 2022), LR 491378 (8/1/2023), Amended LR 50781 (6/1/2024).
AUTHORITY NOTE: Promulgated in accordance with R.S. 42:801(C) and 802(B)(1).