Medical
Plan Maximums
This plan provides each
individual with up to $325,000 (effective 1/1/2008) of coverage for covered medical expenses each
calendar year. Included within the $325,000 maximum (effective 1/1/2008) are the following benefit
maximums. If expenses exceed these maximums, this plan will not pay the
additional costs.
- Allergy
testing – Annual maximum of $600.
- Chemical
dependency – Maximum of $5,000 paid in any 24-month period with a lifetime
maximum of $10,000.
- Chiropractic
care – Annual maximum of $750.
- Hearing
aids – Maximum of $1,000 per ear paid in any three consecutive year
period.
- Home
health care – Annual maximum of $5,000.
- Hospice
care – Maximum of 14 inpatient days for hospice care. Skilled care in the
home is limited to 60 visits. Respite care is limited to 120 hours per
three-month period.
- Mental
health (inpatient) – Annual maximum of 15 days.
- Mental
health (outpatient) – Annual maximum of 30 visits.
- Neurodevelopmental
therapy (children age six and under) – Annual maximum of
$1,500.
- Neuropsychological
assessments or tests – Annual maximum of $600 with a lifetime maximum of
$1,200.
- Orthognathic
surgery – Lifetime maximum of $5,000.
- Orthotics
(foot) – Maximum of $200 paid in any three consecutive year
period.
- Preventive
care (participant) – Annual maximum of $400.
- Preventive
care (participant’s spouse) – Annual maximum of $300.
- Preventive
care (children) – $400 maximum during first year of life (0 months through
11 months), $300 maximum during second year of life (12 months through 23
months) and $200 maximum during third through eighteenth year of life (24 months
through 18 years).
- Rehabilitation
(inpatient) – Annual maximum of $24,000.
- Rehabilitation
(outpatient) – Annual maximum of $2,000.
- Skilled
nursing facility – Annual maximum of $10,000.
- TMJ
and MPDS – Lifetime maximum of $2,500.
- Transplants
(donor organ procurement costs) – Maximum of $25,000 per
transplant.
|
|
|
