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Summary Plan Description Summary Plan Description Racine County Choice Plus 8 Active, Retiree <65 Plan Effective: January 1, 2021 Group Number: 712930 RACINE COUNTY MEDICAL CHOICE PLUS 8 ACTIVE, RETIREE <65 PLAN TABLE OF CONTENTS SECTION 1 - WELCOME ................................................................................................................. 1 SECTION 2 - INTRODUCTION ......................................................................................................... 3 Eligibility ....................................................................................................................................... 3 Special Enrollment Period for Active Eligible Person and/or Dependent only ................ 4 Who Can Enroll ........................................................................................................................... 4 Cost of Coverage ......................................................................................................................... 6 How to Enroll .............................................................................................................................. 6 When Coverage Begins ............................................................................................................... 6 Changing Your Coverage ............................................................................................................ 7 SECTION 3 - HOW THE PLAN WORKS .......................................................................................... 9 Accessing Network and Non-Network Benefits .................................................................... 9 Eligible Expenses ....................................................................................................................... 11 Annual Deductible ..................................................................................................................... 11 Coinsurance ................................................................................................................................ 12 Out-of-Pocket Maximum ......................................................................................................... 12 SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION ........................ 14 Care Management ...................................................................................................................... 14 Prior Authorization .................................................................................................................... 15 Special Note Regarding Medicare ............................................................................................ 16 SECTION 5 - PLAN HIGHLIGHTS ................................................................................................. 17 SECTION 6 - ADDITIONAL COVERAGE DETAILS ...................................................................... 27 Acupuncture Services ................................................................................................................ 27 Ambulance Services - Emergency only .................................................................................. 27 Autism Spectrum Disorder Services ....................................................................................... 27 Cellular and Gene Therapy ....................................................................................................... 30 Clinical Trials .............................................................................................................................. 30 Congenital Heart Disease (CHD) Surgeries ........................................................................... 32 Dental Services - Accident Only .............................................................................................. 33 Dental Services - Oral Surgery (relative to medical condition only) .................................. 34 i TABLE OF CONTENTS RACINE COUNTY MEDICAL CHOICE PLUS 8 ACTIVE, RETIREE <65 PLAN Diabetes Services ....................................................................................................................... 35 Durable Medical Equipment (DME) ...................................................................................... 35 Emergency Health Services - Outpatient ............................................................................... 36 Eye Examinations ...................................................................................................................... 37 Hearing Aids for children under the age of 18 ...................................................................... 37 Home Health Care ..................................................................................................................... 38 Hospice Care .............................................................................................................................. 39 Hospital - Inpatient Stay ........................................................................................................... 39 Injections received in a Physician's Office ............................................................................. 40 Maternity Services ...................................................................................................................... 41 Mental Health Services .............................................................................................................. 42 Morbid Obesity .......................................................................................................................... 43 Neurobiological Disorders - Autism Spectrum Disorder Services ..................................... 44 Ostomy Supplies ........................................................................................................................ 45 Outpatient Surgery, Diagnostic and Therapeutic Services .................................................. 46 Physician Fees for Surgical and Medical Services ................................................................. 47 Physician's Office Services - Sickness and Injury .................................................................. 48 Preventive Care Services ........................................................................................................... 48 Prosthetic Devices ..................................................................................................................... 49 Reconstructive Procedures ....................................................................................................... 49 Rehabilitation Services - Outpatient Therapy ........................................................................ 50 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 51 Spinal Treatment ........................................................................................................................ 51 Substance Use Disorder Services ............................................................................................ 52 Temporomandibular Joint (TMJ) Services ............................................................................. 53 Transplantation Services ........................................................................................................... 54 Urgent Care Center Services .................................................................................................... 55 Virtual Visits ............................................................................................................................... 55 SECTION 7 - Clinical Programs and RESOURCES ..................................................................... 56 Consumer Solutions and Self-Service Tools .......................................................................... 56 Disease and Condition Management Services ....................................................................... 58 Travel and Lodging .................................................................................................................... 61 Women's Health/Reproductive ............................................................................................... 63 ii TABLE OF CONTENTS RACINE COUNTY MEDICAL CHOICE PLUS 8 ACTIVE, RETIREE <65 PLAN SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER .......................... 64 Alternative Treatments .............................................................................................................. 64 Comfort or Convenience .......................................................................................................... 64 Dental .......................................................................................................................................... 65 Drugs ........................................................................................................................................... 66 Experimental or Investigational Services or Unproven Services ........................................ 66 Foot Care .................................................................................................................................... 66 Medical Supplies and Appliances ............................................................................................. 67 Mental Health, Neurobiological Disorders - Autism Spectrum Disorder and Substance Use Disorder Services ..............................................................................................................
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