CCAH - IHSS

Summary of Covered Services for IHSS

Benefit year July 1 - June 30

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• Services must be obtained from a participating plan provider

• Read the Member Handbook/EOC for Specific Benefits

• Benefits are subject to Alliance Utilization Management

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Category Description	Member Copayment & Limitations
HOSPITAL SERVICES
Inpatient Room and Services Inpatient physical, occupational and speech therapy Emergency Room (services in and out of the plan’s service area and with non-participating providers) Skilled Nursing (limited to 100 days/ benefit year)	No Copayment No Copayment $25 Copayment (waived if admitted directly to the hospital) No Copayment
PROFESSIONAL SERVICES
PHYSICIAN SERVICES Office Visits Physician services in the hospital Outpatient surgery Immunizations Periodic Physical Examinations	$10 per visit No Copayment No Copayment No Copayment No Copayment
PREGNANCY AND MATERNITY CARE Prenatal care (office visits) Normal delivery, cesarean section, complications of pregnancy, and medical services	No Copayment No Copayment
OTHER HEALTH CARE SERVICES
ACUPUNCTURE (20 visits per benefit year)	$10 per visit, limit of 20 visits maximum per benefit year
AMBULANCE SERVICES	No Copayment
BLOOD AND BLOOD PRODUCTS (includes collection and storage of autologous blood)	No Copayment
CHIROPRACTIC (20 visits per benefit year)	$10 per visit, limit of 20 visits maximum per benefit year
DIAGNOSTIC X-RAY/LAB PROCEDURES	No Copayment
DURABLE MEDICAL EQUIPMENT (including original and replacement orthotics and prosthetics)	No Copayment
FAMILY PLANNING SERVICE Medical, professional and counseling services FDA Approved Contraceptive drugs and devices on the plan formulary	No Copayment $5 per prescription for generic, $15 brand name (over the counter items are not covered)
HEARING AIDS Audiology Exam Hearing Aid Instrument	No Copayment No Copayment
HOME HEALTH CARE	No Copayment
HOSPICE (for a terminal illness)	No Copayment
MENTAL HEALTH Inpatient (30 days per benefit year) Outpatient (20 visits per benefit year) Limits do not apply to services for severe mental illness (SMI) or serious emotional disturbance (SED)	No Copayment $10 per visit Through Managed Health Network (MHN) 1-800-327-0449
PHYSICAL/OCCUPATIONAL/SPEECH THERAPY In office or through home health care	$10 per visit
PRESCRIPTION DRUGS 30-day supply 90-day supply for Maintenance Drugs	$5 per prescription for generic, $15 brand name $5 per prescription for generic, $15 brand name
SUBSTANCE ABUSE Inpatient Outpatient (20 visits per benefit year)	No Copayment $10 per visit Through Managed Health Network (MHN) 1-800-327-0449
URGENT CARE	$5 per visit Must be provided or arranged by your PCP

No deductibles or lifetime maximum limits on benefits under this plan. Copayment maximum $3,000 per benefit year.

Members

Summary of Covered Services for IHSS