HOSPITAL & PHYSICIAN COVERAGE
Coverage for physician services is provided by the Medical Mutual of Ohio (MMO) SuperMed PPO, MedFlex EPO and SkyWay networks. Your hospital and physician coverage under these options is summarized in this section of the handbook.
Some of the most common services covered under your health care plan include:
Hospital Services: Inpatient Services; Room and Board; X-Ray, EEG, EKG; Lab; Ancillaries; Emergency Room; Hospice Care; Skilled Nursing Care; Chemotherapy; Radiation Therapy; Speech Therapy; Home Health Care; Mental Health and Substance Abuse Services; Anesthesia / Medicines / Drugs.
Physician Services: Office Visits; Prescriptions; Surgical Procedures; Anesthesia; Physical Examinations; Allergy Injections; Physician Maternity Services; Outpatient Lab and X-Ray; Assistant Surgeon; Inpatient Consultations / Daily Visits; Prenatal and Postnatal Care; Immunizations.
RESOURCES
Hospital Coverage
If you enroll in the MMO PPO or MMO PPO/HSA Plans, you can use any hospital you choose. However, these Plans provide higher benefits when you use hospitals that are part of the Plan’s network. A listing of the SuperMed PPO network Hospitals in the eight-county area of the Diocese of Cleveland is provided in the Health Care Handbook. Also, you can receive a complete list of SuperMed PPO Hospitals by contacting the Diocesan Employee Benefits Office or on Medical Mutual’s website at www.medmutual.com.
If you enroll in the MMO MedFlex EPO, hospital benefits are provided only from hospitals that are part of the MedFlex network. The lone exception to this are services received resulting from an emergency; emergency claims will be processed as if they were incurred at a MedFlex network hospital. Or, you can receive a complete list of SuperMed PPO Hospitals by contacting the Diocesan Employee Benefits Office or on Medical Mutual’s website at www.medmutual.com.
If you enroll in the SkyCare EPO (formerly MetroSelect EPO), hospital benefits are provided only from SkyWay hospitals. The lone exception to this are services received resulting from an emergency; emergency claims will be processed as if they were incurred at a SkyWay network hospital.
If you or a family member are scheduled for a non-emergency hospital admission, the carrier must be contacted, or for mental and nervous or substance abuse reviews, call the following numbers:
Medical Mutual of Ohio:
(800) 338-4114 (Non-Emergency Admission)
(800) 258-3186 (Mental/Nervous/Substance Abuse)
It is the hospital’s responsibility to call when your admission is to a network hospital. Although some non-network hospitals may call on behalf of the member, it is the member’s responsibility to make sure the carrier is notified of non-network hospital admissions. In the case of an emergency or maternity admission, the carrier must be contacted within 24 hours after the admission by the responsible party.
Physician Coverage
If you enroll in the SuperMed PPO or the MMO PPO/HSA Plans for physician coverage, you can choose to use any qualified physician you wish. But the Plans provide higher benefits when you use doctors who are in the Plan’s network of providers. Here’s how the Plans work:
SuperMed PPO
In Network: When you use a primary care physician who is in the PPO network, you pay $25 for each office visit; there is a $50 co-pay for each specialist office visit. Any services related to the office visit for which the provider bills separately for, will be paid at 80% after an annual deductible of $1,000 per person and $2,000 per family. The maximum out-of-pocket expense (includes co-pays, co-insurance and prescription drugs) you will pay in a calendar year under this plan is $3,000 for single and $6,000 for family coverage.
Out-of-Network: Charges for out-of-network physician services are subject to a $2,000 per person and $4,000 per family annual deductible and then are paid at 60% of the allowed amount. The maximum out-of-pocket expense you will pay in a calendar year is $6,000 for single and $12,000 for family coverage.
MMO PPO/HSA
In Network: When you use a physician who is in the PPO network for non-preventive services, you pay the full cost of each office visit and any services related to the office visit until the deductible is met. Visits to physicians in the PPO network for preventive services are not subject to the deductible and covered at 100%. After the annual deductible of $3,200 per person and $6,400 per family has been met, any office visits or other services will be paid at 80%. The maximum out-of-pocket expense (includes co-pays, co-insurance and prescription drugs) you will pay in a calendar year under this Plan is $4,000 for single and $8,000 for family coverage.
Out-of-Network: Charges for out-of-network physician services are subject to a $6,400 per person and $12,800 per family annual deductible and then are paid at 60% of the allowed amount. The maximum out-of-pocket expense you will pay in a calendar year is $8,000 for single and $16,000 for family coverage.
You should check with your physician to make sure he or she has admitting privileges at a network hospital to receive the highest benefit from your Health Care Plan.
The SuperMed PPO and MMO PPO/HSA Plans provide health care coverage through a comprehensive network of hospitals and physicians. These Plans give you the freedom to choose any network hospital, physician or specialist, for each member of your family, without prior approval.
To receive the maximum amount of coverage from the MMO PPO and MMO PPO/HSA Plans, simply use the services of any hospital or physician listed in the provider directory for the Plans. If you choose to receive services from a hospital or physician who is not listed in the directory and is not part of the network, you will still receive partial coverage for medically necessary services. As always, in the case of a life-threatening emergency, seek care at the nearest facility.
SkyCare EPO (Formerly MetroSelect EPO)
The SkyCare EPO provides medical benefits only from SkyWay providers and hospitals. Lake Hospital System is now part of the network. The lone exception to this design are those services received resulting from an emergency; emergency claims will be processed as if they were incurred at a SkyWay facility.
When you use a primary care physician who is in the SkyWay network, you pay $20 for each office visit; there is a $40 co-pay for each specialist office visit. Any services related to the office visit for which the provider bills separately for, will be paid at 90% after an annual deductible of $500 per person and $1,000 per family. The maximum out-of-pocket expense (includes co-pays, co-insurance and prescription drugs) you will pay in a calendar year under this plan is $2,000 for single and $4,000 for family coverage.
MedFlex EPO
The MedFlex EPO provides medical benefits only from University Hospital network providers and hospitals. The lone exception to this design is service received resulting from an emergency; emergency claims will be processed as if they were incurred at a University Hospital facility. When you use a primary care physician who is in the University Hospital network, you pay $20 for each office visit and a $40 co-pay for each specialist office visit. Any services related to the office visit for which the provider bills separately for, will be paid at 80% after an annual deductible of $750 per person and $1,500 per family. The maximum out-of-pocket expense (includes co-pays, co-insurance and prescription drugs) you will pay in a calendar year under this plan is $2,500 for single and $5,000 for family coverage.
With all Plans, network providers will file claims on your behalf. Also, by contract agreement, these network providers have agreed not to balance bill you for services above the allowed amount.
