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Office of Group Benefits Magnolia Open Access Health Plan for State of Louisiana Employees and Retirees

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Office of Group Benefits Magnolia Open Access Health Plan for State of Louisiana Employees and Retirees Office of Group Benefits Magnolia Open Access Health Plan for State of Louisiana Employees and Retirees provided by 5525 Reitz Avenue • Baton Rouge, Louisiana • 70809-3802 www.bcbsla.com 40HR1695 R03/15 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company An independent licensee of the Blue Cross and Blue Shield Association. NON-GRANDFATHERED PPO HEALTH BENEFIT PLAN NOTICE Health care services may be provided to You at a Network health care facility by facility-based physicians who are not in Your health plan’s Network. You may be responsible for payment of all or part of the fees for those Non-Network services, in addition to applicable amounts due for Copayments, Coinsurance, Deductibles and non-Covered Services. Specific information about Network and Non-Network facility-based physicians can be found at www.bcbsla.com/ogb or by calling the customer service telephone number on the back of Your identification (ID) card. The Claims Administrator bases the payment of Benefits for the Plan Participant’s Covered Services on an amount known as the Allowable Charge. The Allowable Charge depends on the specific Provider from whom You receive Covered Services. Mike Reitz President and Chief Executive Officer Louisiana Health Service & Indemnity Company Blue Cross and Blue Shield of Louisiana Incorporated as Louisiana Health Service & Indemnity Company 40HR1695 R03/15 2 MAGNOLIA OPEN ACCESS COMPREHENSIVE MEDICAL BENEFIT PLAN TABLE OF CONTENTS Page ARTICLE I. UNDERSTANDING THE BASICS OF YOUR COVERAGE ..................................................... 6 ARTICLE II. DEFINITIONS ......................................................................................................................... 11 ARTICLE III. SCHEDULE OF ELIGIBILITY ............................................................................................... 26 Persons to be Covered ............................................................................................................................... 26 Continued Coverage ................................................................................................................................... 29 COBRA ........................................................................................................................................................ 32 Change of Classification ............................................................................................................................. 37 Contributions ............................................................................................................................................... 37 Medical Child Support Orders ..................................................................................................................... 37 Termination of Coverage ............................................................................................................................. 38 ARTICLE IV. BENEFITS ............................................................................................................................ 38 Benefit Categories ....................................................................................................................................... 38 Deductible Amounts .................................................................................................................................... 39 Coinsurance ................................................................................................................................................ 39 Out-of-Pocket Maximum ............................................................................................................................. 40 Accumulator Transfers ................................................................................................................................ 40 ARTICLE V. HOSPITAL BENEFITS .......................................................................................................... 40 Inpatient Bed, Board and General Nursing Service .................................................................................... 41 Surgical Services (Inpatient and Outpatient) .............................................................................................. 41 Other Hospital Services (Inpatient and Outpatient) .................................................................................... 42 Emergency Room ....................................................................................................................................... 43 Pre-Admission Testing ................................................................................................................................ 43 ARTICLE VI. MEDICAL AND SURGICAL BENEFITS .............................................................................. 43 Surgical Services ........................................................................................................................................ 43 Inpatient Medical Services .......................................................................................................................... 45 Outpatient Medical Services and Surgical Services ................................................................................... 45 ARTICLE VII. PRESCRIPTION DRUG BENEFITS.................................................................................... 46 ARTICLE VIII. PREVENTIVE OR WELLNESS CARE .............................................................................. 46 Well Woman Examinations ......................................................................................................................... 46 Physical Examinations ................................................................................................................................ 46 Immunizations ............................................................................................................................................. 47 Preventive or Wellness Care Required by the Patient Protection and Affordable Care Act ....................... 47 New Recommended Preventive or Wellness Care Services ...................................................................... 48 ARTICLE IX. MENTAL HEALTH BENEFITS ............................................................................................. 48 ARTICLE X. SUBSTANCE ABUSE BENEFITS ........................................................................................ 48 ARTICLE XI. ORAL SURGERY AND DENTAL SERVICES ..................................................................... 48 Surgical Services ........................................................................................................................................ 48 Dental Services ........................................................................................................................................... 49 40HR1695 R03/15 3 ARTICLE XII. ORGAN, TISSUE, AND BONE MARROW TRANSPLANT BENEFITS ............................. 50 Acquisition Expenses .................................................................................................................................. 50 Organ, Tissue and Bone Marrow Transplant Benefits ................................................................................ 50 Solid Human Organ Transplants ................................................................................................................. 51 Tissue Transplant Procedures (Autologous and Allogeneic) ...................................................................... 51 Bone Marrow Transplants ........................................................................................................................... 51 ARTICLE XIII. PREGNANCY AND NEWBORN CARE BENEFITS .......................................................... 52 Pregnancy Care .......................................................................................................................................... 52 Care for Newborn When Covered at Birth as a Dependent ........................................................................ 52 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act ......................................... 53 ARTICLE XIV. REHABILITATIVE CARE BENEFITS ................................................................................ 53 Occupational Therapy ................................................................................................................................. 53 Physical Therapy ......................................................................................................................................... 54 Speech/Language Pathology Therapy ........................................................................................................ 54 Chiropractic Services .................................................................................................................................. 54 ARTICLE XV. OTHER COVERED SERVICES, SUPPLIES OR EQUIPMENT ......................................... 55 Ambulance Service Benefits ....................................................................................................................... 55 Attention Deficit/Hyperactivity Disorder ....................................................................................................... 56 Autism Spectrum Disorders (ASD) ............................................................................................................
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