Wayne County/Oakland County

Benefits at a Glance for HealthChoice Small Business Program

Co-pay Package

This is intended as an easy-to-read summary. It is not a contract.  An official description of benefits is contained in applicable HealthChoice Subscriber certificates and riders.  Payment amounts are based on the HealthChoice approved amount, less any applicable co-pay amounts required by the program.  This coverage is provided pursuant to a current, signed group-operating agreement between the group and the HealthChoice Executive Director.  Services must be provided by member’s primary care physician (PCP) or receive prior approval from health plan.

HEALTHCHOICE BENEFITS AT A GLANCE

Preventive Services

Preventive Physical Exam Covered – No co-pay for Preventive Health Exam (1 preventive health exam is provided per calendar year for adults, as required by federal preventive care guidelines for children), Non-preventive office visits are subject to $20.00 co-pay
Annual Gynecological Exam Covered
Annual Pap Smear Screening Covered
Annual Mammography Screening Covered
Well Baby and Child Care Covered
ACIP Required/Recommended Immunizations – pediatric and adult Covered
Prostate Specific Antigen (PSA) screening Covered
Hearing Screening Covered

 

Physician Office Visits

Office Visits Covered – $20.00 co-pay
Specialist Visits Covered – $30.00 co-pay

 

Prescription Drugs

Generic Drugs Covered – $10.00 co-pay per prescription
Brand Name Drugs Covered – $20.00co-pay per prescription
Psychotherapeutics Covered – 50% of each prescription drug

 

Emergency Care

Hospital Emergency Visit Covered –$100.00 co-pay if not admitted; No co-pay if admitted. Provider is only responsible for 110% of Michigan Medicaid DRG rate for Emergency Services. Members are liable for any and all charges that exceed 110% of Michigan Medicaid rates.
Urgent Care Center (24 hour access) Covered – $25.00 co-pay per visit
Ambulance Services – medically necessary Covered if admitted – $50.00 co-pay if not admitted

 

Mental Health and Substance Abuse Services

Inpatient Mental Health and/or Substance Abuse Services* Covered – $200.00 co-pay per admission. Subject to limitations indicated in the Subscriber’s Certificate

 

Outpatient Mental Health and Substance Abuse /Professional Services Covered – $20.00 co-pay

*- Requires Prior Authorization

Diagnostic and Therapeutic Services

Radiology Covered – No co-pay
Diagnostic Laboratory Covered – No co-pay
Physical Therapy Covered – $20.00 co-pay (30 visits/year limit)
Durable Medical Equipment Covered – 50% per prescribed equipment

 

Maternity Services Provided by a Physician

Pre-Natal and Post-Natal Care Covered – $20.00 co-pay
Delivery and Nursery Care Covered –$200.00 co-pay per admission

 

Hospital Care

Inpatient physician care, general nursing care,

Hospital Services and Supplies

Covered – $200.00 co-pay per admission.

Subject to limitations indicated in the Subscriber’s Certificate

 

Outpatient Hospital Services Covered – $50.00 co-pay

Alternatives to Hospital Care

Home Health Care Covered – $20.00 per visit

Surgical Services

Surgery – includes all related services and anesthesia. See member certificate for specifics Covered – (see hospital care co-pay above)

 

Other Rider Services

Vision Exam & Glasses Covered subject to Co-payments set forth on Appendix I and exclusions set forth on Appendix J.
Dental Covered subject to co-payments set forth on Appendix D and exclusions set forth on Appendix E.