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Comprehensive Plan The Comprehensive Plan is a traditional, fee-for-service health benefits plan. We first apply your deductible to most or all of your covered services. Then we pay benefits according to your coinsurance rate. Your Outline of Coverage and any Riders listed on your Outline of Coverage will tell you if your coverage includes benefits we pay without a deductible. You get the most from your benefits when you use Participating providers. Participating providers bill us directly for their services, eliminating up-front payments and relieving you of complicated paperwork. They also accept our allowed price as payment in full, billing you only for deductible and coinsurance when appropriate. For a complete description of your health plan's benefits, read your contract carefully. Office Visits Benefits for office visits include chiropractic visits and mental health and substance abuse treatment visits. You first pay your deductible, which applies to most or all of your benefits. When you've met your deductible, coinsurance applies until you've met your out-of-pocket limit for the year. We pay 100% of our allowed price for covered services after you meet your out-of-pocket limit. Mental Health and Substance Abuse Treatment Visits Most plans require that you use a provider in our behavioral health care network and also that you call for prior approval to initiate care. If your coverage includes Open Network Mental Health, these terms do not apply to your coverage. Your Outline of Coverage indicates if you have Open Network Mental Health benefits. Chiropractic visits We cover chiropractic visits to treat neuromusculoskeletal conditions if you use a Participating provider. Any visits after 12 in a calendar year require Prior Approval from us. Your chiropractor must send us a treatment plan to get approval for additional visits in that year. We do not cover chiropractic services rendered by Nonparticipating providers. Surgery Your plan's deductible and coinsurance apply to benefits for surgery performed in a doctor's office and to procedures performed in an outpatient hospital setting. Maternity We cover maternity services including prenatal care, delivery and the baby's nursery charges. Your maternity benefits include our popular Better Beginnings Program for expectant parents. Emergency Care We cover hospital services when you show symptoms severe enough that a "prudent layperson" would believe that your health would be threatened without treatment. Your symptoms must meet our criteria for an emergency medical condition. If you go to the emergency room when you could have safely received care somewhere else, your care may not be covered. |
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