La. Admin. Code tit. 32 § V-305

Current through Register Vol. 50, No. 9, September 20, 2024
Section V-305 - Schedule of Benefits
A. Benefits, Copayments, and Coinsurance

Copayments and Coinsurance

Network Providers

Non-Network Providers

Physician Office

* General Practice

* Family Practice

* Internal Medicine

* OB/GYN

* Pediatrics

$25 Copayment per Visit

No Coverage

Allied Health/Other Professional

Visits:

* Chiropractors

* Federally Funded Qualified Rural

* Health Clinics

* Nurse Practitioners

* Retail Health Clinics

* Physician Assistants

$25

Copayment per Visit

No Coverage

Specialist Office Visits including surgery performed in an office setting:

* Physician

* Podiatrist

* Optometrist

* Midwife

* Audiologist

* Registered Dietician

* Sleep Disorder Clinic

$50

Copayment per Visit

No Coverage

Ambulance Services - Ground (for Emergency Medical Transportation only)

$50 Copayment

$50 Copayment

Ambulance Services - Air (for Emergency Medical Transportation only) Non-emergency requires prior authorization2

$250 Copayment

No Coverage

Ambulatory Surgical Center and Outpatient Surgical Facility

$100 Copayment

No Coverage

Bariatric Surgery Services Facility Services4

$2,500.00 Copayment2,3

No Coverage

Bariatric Surgery Services Professional Services4

90% - 10%2,3

No Coverage

Bariatric Surgery Services Preoperative and Postoperative Medical Services4

80% - 20%2,3

No Coverage

Birth Control Devices - Insertion and Removal

(as listed in the Preventive and

Wellness Article in the Benefit Plan.)

100% - 0%

No Coverage

Cardiac Rehabilitation (limit of 36visits per Plan Year)

$25/$50

Copayment per day depending on Provider Type2

$50

Copayment-Outpatient Facility2

No Coverage

Chemotherapy/Radiation Therapy (Authorization not required when performed in Physician's office)

Office $25

Copayment per Visit Outpatient Facility 100% - 0%1,2

No Coverage

Diabetes Treatment

80% - 20%1

No Coverage

Diabetic/Nutritional Counseling -Clinics and Outpatient Facilities

$25 Copayment

No Coverage

Dialysis

100% - 0%1

No Coverage

Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices

80% - 20%1,2 of first $5,000

Allowable per Plan Year;

100% - 0% of Allowable in Excess of $5,000 per Plan Year

No Coverage

Emergency Room (Facility Charge)

$200 Copayment; Waived if admitted to the same facility

Emergency Medical Services (Non-Facility Charges)

100% - 0%1

100% - 0%1

Eyeglass Frames and One Pair of Eyeglass Lenses or One Pair of Contact Lenses (purchased within six months following cataract surgery)

Eyeglass

Frames Limited to a Maximum Benefit of $501

No Coverage

Emergency Ground Ambulance Services; In-State

$50 Copayment

$50 Copayment

Emergency Ground Ambulance Services; Out-of-State

$50 Copayment

$50 Copayment

Flu shots and H1N1 vaccines (administered at Network Providers, Non-Network Providers, Pharmacy, Job Site or Health Fair)

100% - 0%

100% - 0%

Hearing Aids (Hearing Aids are not covered for individuals age eighteen (18) and older.)

80% - 20%1,3

No Coverage

Hearing Impaired Interpreter Expense

100% - 0%

No Coverage

High-Tech Imaging - Outpatient

* CT Scans

* MRA/MRI

* Nuclear Cardiology

* PET Scans

$50

Copayment2

No Coverage

Home Health Care

(limit of 60 Visits per Plan Year)

100% - 0%1,2

No Coverage

Hospice Care

(limit of 180 Days per Plan Year)

100% - 0%1,2

No Coverage

Injections Received in a Physician's Office (when no other health service is received)

100% - 0%1

No Coverage

Inpatient Hospital Admission, All Inpatient Hospital Services Included

$100

Copayment per day2, maximum of $300 per Admission

No Coverage

Inpatient and Outpatient Professional Services for which a Copayment is Not Applicable

100% - 0%1

No Coverage

Mastectomy Bras (limited to three (3) per Plan Year)

80% - 20%1 of first $5,000 Allowable per Plan Year;

100% - 0% of Allowable in Excess of $5,000 per Plan Year

No Coverage

Mental Health/Substance Abuse -Inpatient Treatment and Intensive Outpatient Programs

$100

Copayment per day2, maximum of $300 per Admission

No Coverage

Mental Health/Substance Abuse Office Visit and Outpatient Treatment (Other than Intensive Outpatient Programs)

$25 Copayment per Visit

No Coverage

Newborn - Sick, Services excluding Facility

100% - 0%1

No Coverage

Newborn - Sick, Facility

$100

Copayment per day2, maximum of $300 per Admission

No Coverage

Oral Surgery

100% - 0%1,2

No Coverage

Pregnancy Care - Physician Services

$90 Copayment per pregnancy

No Coverage

Preventive Care - Services include screening to detect illness or health risks during a Physician office visit. The Covered Services are based on prevailing medical standards and may vary according to age and family history. (For a complete list of benefits, refer to the Preventive and Wellness Article in the Benefit Plan.)

100% - 0%3

No Coverage

Rehabilitation Services - Outpatient: * Speech * Physical/Occupational (Limited to 50 Visits combined PT/OT per Plan Year. Authorization required for visits over the combined limit of 50.) (Visit limits do not apply when services are provided for Autism Spectrum Disorders.)

$25 Copayment per Visit

No Coverage

Skilled Nursing Facility (limit of 90 days per Plan Year)

$100 Copayment per day2, maximum of $300 per Admission

No Coverage

Sonograms and Ultrasounds (Outpatient)

$50 Copayment

No Coverage

Urgent Care Center

$50 Copayment

No Coverage

Vision Care (Non-Routine) Exam

$25/$50

Copayment depending on Provider Type

No Coverage

X-ray and Laboratory Services (low-tech imaging)

Hospital Facility

100% - 0%1

Office or Independent Lab 100% - 0%

No Coverage

1Subject to Plan Year Deductible, if applicable

2Pre-Authorization Required, if applicable. Not applicable for Medicare primary.

3Age and/or Time Restrictions Apply

4No Benefits will be payable unless Prior Authorization is obtained, including Plan Participants with Medicare as the Primary Plan.

La. Admin. Code tit. 32, § V-305

Promulgated by the Office of the Governor, Division of Administration, Office of Group Benefits, LR 41:359 (February 2015), effective March 1, 2015, Amended LR 43:2157 (11/1/2017), (effective 1/1/2018), Amended LR 48:2770 (November 2022), LR 491379 (8/1/2023), Amended LR 50781 (6/1/2024).
AUTHORITY NOTE: Promulgated in accordance with R.S. 42:801(C) and 802(B)(1).