2016 GROUP HMO ACA Medical Certificate of Coverage

85 Pages·2015·0.38 MB·English

2016 GROUP HMO ACA
Medical Certificate of Coverage

Welcome to Physicians Plus Insurance Corporation

We are pleased to provide you with this Certificate. Your Medical Certificate is like an owner’s manual to
your health insurance. This Certificate and the other Policy documents describe your Benefits, as well as
your rights and responsibilities, under the Policy. This is the Medical Certificate used by Physicians Plus to
administer benefits and process claims. For accurate information regarding your coverage, obligations, and
responsibilities under the Policy, this Medical Certificate of Coverage must be read together with your
Summary Plan Documents and other Policy documents. Throughout this Certificate you will find
statements that encourage you to contact us for further information.
Whenever you have a question or concern regarding your plan or benefits, please call us at:

Member Services [phone] or [phone].
It will be our pleasure to assist you.

IMPORTANT NOTICES
 Your Application is part of your Policy: Please read and review the application you completed to
obtain this Policy. Please call us if you need to obtain a copy at any time. Omissions or misstatements
in the application could cause an otherwise valid claim for benefits to be denied. Carefully check the
application and write to Physicians Plus within 10 days if any information shown on the application is
not correct and complete. The application is part of the insurance contract (this Policy). The insurance
contract was issued on the basis that the answers to all questions and any other material information
shown on the application are correct and complete.

 Guaranteed Renewability: This Policy is guaranteed renewable; see Section 12: Disenrollment and
When Coverage Ends for additional information on renewability.

 Claims Payment: When Prior Authorized by Physicians Plus, Covered Services received from a Non-
Participating Provider are covered up to the Maximum Allowed Amount (subject to applicable
Deductibles, Coinsurance, Copayments). You are responsible for any amounts in excess of the
Maximum Allowed Amount. The Maximum Allowed Amount may be less than the Amount Billed by
the provider of services. Please refer to Section 16: Definitions for the definition of Maximum Allowed
Amount.

How to Use this Certificate
We encourage you to read your Policy documents carefully. We especially encourage you to review the
benefit limitations of this Certificate by reading the Summary Plan Documents along with Section 6: Benefits
and Services and Section 8: Exclusions and Limitations. You should call us if you have questions about the
limits of the coverage available to you. Many of the sections of this Certificate are related to other sections
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of the document. You may not have all of the information you need by reading just one section. We also
encourage you to keep your Certificate and Summary Plan Documents in a safe place for your future
reference.

Benefits listed in this Medical Certificate of Coverage are available only as long as the Group Policy and
your coverage are in effect. This Certificate replaces and supersedes any other Certificate, which may have
been previously issued.

Please be aware that your Physician is not responsible for knowing or communicating your Benefits. As a
Physicians Plus member, you are responsible for understanding the benefits to which you are entitled under
the Policy and the rules you must follow to receive those benefits. If you are not sure of your coverage or
your level of benefits, we are happy to assist. Please contact the Member Services department at (608) 282-
8900 or [phone].

Information about Defined Terms
Because this Certificate is part of a legal document, we want to give you information about the document
that will help you understand it. Certain words have special meanings. We have defined these words in
Section 16: Definitions. You can refer to the Definitions section as you read this document to have a
clearer understanding of your Certificate. When we use the words "we," "us," and "our" in this document,
we are referring to Physicians Plus Insurance Corporation. When we use the words "you" and "your," we
are referring to people covered under this Policy.

This Certificate is Part of a Group Policy
The Member Certificate is a description of the health insurance benefits provided to Physicians Plus
Subscribers and their Qualified Dependents through the Group Policyholder (typically, your employer).
This Certificate summarizes the benefits provided under the Group Master Policy. Any benefit described is
subject to the terms and conditions of the Group Master Policy. Together, this Certificate, the Group
Master Policy, the Summary Plan Documents, the Employer Group Application, the Employee Applications,
and any applicable riders, addendums, attachments and/or amendments make up the Policy.
The Group Policy is issued by Physicians Plus and delivered to the Group Policyholder in the State of
Wisconsin. The laws of the state of Wisconsin govern all terms, conditions and provisions of the Policy. All
benefits are provided in accordance with the terms, conditions and provisions of the Policy and applicable
Wisconsin and federal laws.
Your Responsibilities

The following points outline important member responsibilities under this Policy. Fulfilling these
responsibilities will help you gain the most from your health insurance Policy.

 Use our Network of Providers
For coverage under this HMO Policy, you must receive health care services from a
Participating Provider. Participating Providers are sometimes called Preferred Providers or Network
Providers. You can find a Participating Provider in our provider directory at http://directory.pplusic.com/
or by calling Member Services at [phone]. Always consult with your Primary Care Physician (PCP)
for all of your primary and specialty care needs.

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 Obtain Required Prior Authorizations
Please talk with your Primary Care Physician (PCP) to obtain Prior Authorization from Physicians Plus
before services are provided. Please contact our Member Services department if you have questions
regarding our Prior Authorization requirements. See Section 3.2 of this Certificate for additional
information.

All inpatient care including hospitalizations, hospital rehabilitation, hospice care and skilled nursing facilities
require Prior Authorization before services are provided. If you do not obtain Prior Authorization when
required, services may not be covered[A1].

 Be Enrolled and Pay Required Premium
Benefits are available to you only if you are enrolled for coverage under the Policy. Your enrollment
options, and the corresponding dates that coverage begins, are listed in Section 9: Effective Dates and
Eligibility. To be enrolled with us and receive benefits, both of the following apply:
‐ You must meet your Policy’s eligibility requirements.
‐ You must pay your required premium.
This Policy is guaranteed renewable so long as you pay premiums and continue to meet eligibility criteria.
Please see Section 12: Disenrollment and When Coverage Ends for additional information.

 Pay Your Share for Covered Healthcare
You must pay a Copayment, Coinsurance, or Deductible for most Covered Health Services. These
payments are due at the time of service or when billed by the Physician, provider or facility. Copayment,
Coinsurance, and Deductible amounts are listed in your Summary Plan Documents.

 Show Your ID Card
You should show your identification (ID) card every time you request health services. If you do not show
your ID card, the provider may fail to bill the correct entity for the services delivered, and any resulting
delay may mean that you will be unable to collect benefits otherwise owed to you. Receipt of an ID card
does not guarantee coverage. Coverage is based on eligibility and benefits at the time services are
rendered.

 Choose a Primary Care Physician (PCP)
Physicians Plus requires all members to choose a primary care physician (PCP) who will coordinate your
care. It is your responsibility to select the health care professionals who will deliver care to you. We
arrange for Physicians and other health care professionals and facilities to participate in our Network. Our
credentialing process confirms public information about the professionals’ and facilities’ licenses and other
credentials, but does not assure the quality of their services. These professionals and facilities are
independent practitioners and entities that are solely responsible for the care they deliver. You may change
your Primary Care Physician (PCP) at any time by calling our Member Services department at (608) 282-
8900 or [phone], or by visiting our web site at www.pplusic.com or by submitting the request
through our online member portal. The change will be effective on the first of the month following your
notification to Physicians Plus of the change.

 Decide What Services You Should Receive
Care decisions are between you and your Providers. We do not make decisions about the kind of care you
should or should not receive. We are happy to provide coverage information regarding your health
insurance, cost-sharing, and Prior Authorization requirements.

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 Be Aware Your Health Insurance Plan Does Not Pay for All Health Services
Your right to this Policy’s benefits is limited to Covered Health Services. You must pay the full cost of all
excluded services and items. Review Section 8: Exclusions and Limitations to become familiar with this
Certificate’s exclusions. This Policy was not priced or designed to cover every Illness or Injury that you or
your dependents may encounter while insured by this Policy. This Policy provides coverage for only
treatment, services and supplies that are identified as “Physicians Plus will cover” and that you receive while
you are eligible and covered under the Policy. As a member of Physicians Plus, you are responsible for
understanding the benefits you are entitled to under this Policy and the rules you must follow to receive
those benefits.

Our Responsibilities
 Decision-Making
We do not make decisions about the kind of care you should or should not receive. You and your
providers must make those treatment decisions. We make administrative decisions regarding whether this
Policy will pay for any portion of the cost of a health care service you intend to receive or have received.
Our decisions are for payment purposes only.

We have the discretion to do the following:
‐ Interpret benefits and the other terms, limitations and exclusions set out in this Certificate, the
Summary Plan Documents, and any Riders and/or Amendments.
‐ Make factual determinations relating to benefits. We may delegate this discretionary authority to
other persons or entities that may provide administrative services for this Policy. The identity of the
service providers and the nature of their services may be changed from time to time in our
discretion.

 Pay for Our Portion of the Cost of Covered Health Services
We pay benefits for Covered Health Services as defined in this Policy. This means we only pay our portion
of the cost of Covered Health Services. It also means that not all of the health care services you receive
may be paid for (in full or in part) by this Policy.

 Pay Providers When the Services they Provide are Covered by this Policy.
When you obtain Covered Health Services from a Physicians Plus Participating Provider, Charges will be
paid based on the terms, conditions, limitations and benefits of your Policy and the contract between
Physicians Plus and the Participating Provider. If there is a difference in the amount paid by Physicians Plus
and the Amount Billed by the Participating Provider for Covered Health Services, you are not responsible
for that difference (other than for applicable Deductibles, Coinsurance, and Copayments).

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Table of Contents

Welcome to Physicians Plus Insurance Corporation ................................................................ 1
Table of Contents .......................................................................................................................... 5
1. Contact Information ................................................................................................................. 6
2. Member Rights and Responsibilities ....................................................................................... 7
3. General Requirements of this Policy ...................................................................................... 8
4. Emergency Medical Care ...................................................................................................... 13
5. Immediate and Urgent Medical Care .................................................................................. 14
6. Benefits and Services ............................................................................................................. 15
Acupuncture ........................................................................................................................................ 15
Ancillary Services ................................................................................................................................ 15
Anesthesia Services ............................................................................................................................. 15
Ambulance Services ............................................................................................................................ 15
Autism .................................................................................................................................................. 16
Behavioral Health and Alcohol and Other Drug Abuse (AODA) Services ................................... 16
Childhood Immunizations .................................................................................................................. 19
Chiropractic Services .......................................................................................................................... 19
Clinical Trials ....................................................................................................................................... 19
Dental, Oral Surgery, and Temporomandibular Disorders (TMD) ............................................... 21
Detoxification Services ....................................................................................................................... 22
Diagnostic Services ............................................................................................................................. 23
Hospital, Facility and Skilled Nursing Services ................................................................................ 24
Infertility Services ............................................................................................................................... 24
Inpatient Care ..................................................................................................................................... 24
Outpatient Care .................................................................................................................................. 25
Skilled Nursing Facility/Swing Bed .................................................................................................... 26
Hospice Care ....................................................................................................................................... 27
Hearing Aids ........................................................................................................................................ 27
Insulin and Disposable Diabetic Supplies .......................................................................................... 27
Kidney (Renal) Disease Treatments and Transplants ..................................................................... 28
Lead Poisoning ..................................................................................................................................... 28
Maternity Services .............................................................................................................................. 28
Medical Services .................................................................................................................................. 29
Medical Supplies and Durable Medical Equipment (DME) Including Prostheses ......................... 29
Phase II - Outpatient Cardiac Rehabilitation ................................................................................... 31
Podiatry ................................................................................................................................................ 32
Preventive Care and Services ............................................................................................................ 32
Radiation Therapy ............................................................................................................................... 32
Surgical Services .................................................................................................................................. 33
Termination of Pregnancy.................................................................................................................. 34
Therapies - Physical, Speech, Occupational, Habilitative and Rehabilitative ............................... 34
Transplants - Tissue/Organ ................................................................................................................ 35
Vision Services ..................................................................................................................................... 36
7. Prescription Drugs and Pharmacy ....................................................................................... 37
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8. Exclusions and Limitations .................................................................................................... 45
9. Effective Dates and Eligibility ............................................................................................... 49
10. Other Policy Provisions ....................................................................................................... 52
11. Coordination of Benefits ..................................................................................................... 59
12. Disenrollment and When Coverage Ends ......................................................................... 62
13. Extension of Benefits ........................................................................................................... 63
14. Appeal Process ..................................................................................................................... 64
15. Privacy and Confidentiality ................................................................................................. 68
16. Definitions ............................................................................................................................. 71

1. Contact Information

Physicians Plus Web site: www.pplusic.com

Physicians Plus Member Portal: Access your eligibility, claims, and authorization information through
Physicians Plus Member Portal, our 24/7, free, secure, and easy-to-
use online resources. Visit www.pplusic.com for more information.

Physicians Plus Nurse Line: Health Care Advice Anytime! Available 24/7.
Call one of the nurses toll-free at:
[phone] or (866)-PPLUSRN

Member Services: For Questions Regarding Benefits, Claims, Prior Authorizations, and
General Inquiries during normal business hours.
Phone: [phone] or [phone]
Fax: [phone]
E-Mail: [email protected]

Wisconsin Relay: Please note: hearing and speech-disabled members can receive
assistance from Wisconsin Relay as part of the Telecommunications
Relay System by dialing:
711 anywhere in the United States or 1-800-947-3529 for TDD/TTY.

Behavioral Health Management: For prior authorization or assistance finding a Behavioral Health
provider (including an Alcohol and Other Drug Abuse provider),
please contact Behavioral Health Management at:
Phone: [phone] or (800) 683[A2]-2300[A3]

Pharmacy Services: Phone: [phone] or [phone]
Fax: [phone]

Report Fraud, Waste, or Abuse to Physicians Plus: [phone] or [phone]
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Medical Claims Mailing Address
Physicians Plus Insurance Corporation
Attn: Claims
PO Box 2078
Madison, WI 53701-2078

Chiropractic Claims Mailing Address
ChiroTech America, Inc.
N14 W23833 Stone Ridge Drive, Suite 330
Waukesha, WI 53188

Pharmacy Claims Mailing Address
Physicians Plus Insurance Corporation
Attention: Pharmacy Services
PO Box 2078
Madison, WI 53701-2078

2. Member Rights and Responsibilities

We believe that you have certain basic rights regarding your health care and health insurance. In addition,
we believe that you also have some basic responsibilities. Your rights and responsibilities are described
below. You have the right to:
1. Receive quality health care services that are right for you.
2. Receive information about Physicians Plus, its services, its practitioners and providers, and
members’ rights and responsibilities.
3. Be treated with respect and recognition of your dignity and right to privacy. You also have a right
to the privacy of your medical and financial records, unless you allow their release.
4. Participate with practitioners and providers in decision-making regarding your health care.
5. A candid discussion of appropriate and medically necessary treatment options for your conditions,
regardless of cost or benefit coverage.
6. Information about preventive health services including self-care and how to stay healthy.
7. Voice complaints or appeals about Physicians Plus or the care provided to you.
8. Make recommendations regarding the Physicians Plus member rights and responsibilities Policy.

You have the responsibility to:
1. Read available member materials about your health plan, benefits and coverage.
2. Build a relationship with your Primary Care Physician and keep your appointments or give proper
notice if you must cancel.
3. Provide, to the extent possible, information that Physicians Plus and its practitioners and providers
need in order to care for you.
4. Provide correct health insurance information and arrange to pay for services if you are billed.
5. Ask questions about your illness, your treatment plan, and how to manage your health.
6. Follow the plans and instructions for care that you agreed on with your practitioners.
7. Treat health care providers, employees and other patients with respect and display behavior proper
for a health care setting.
8. Understand your health problems and participate to the extent possible in developing mutually
agreed-upon treatment goals.
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3. General Requirements of this Policy

The requirements in this section are general and apply to all services, treatments, and supplies covered
under the Policy.

3.1 All Benefits Provided Under this Policy Must Be Medically Necessary.
For coverage under this Policy, all treatments, services, and supplies must be Medically Necessary.
Physicians Plus determines Medical Necessity for coverage purposes.

3.2 Prior Authorization Must Be Obtained for Services that Require Prior Authorization.
Certain services require written approval from Physicians Plus before the services are provided. This
written approval is also known as “Prior Authorization.” Prior authorization requirements may change from
time to time as part of our on-going programs to provide high quality, medically necessary health care
services in the most appropriate and cost-effective setting. For more information concerning services that
require Prior Authorization, please visit www.pplusic.com and click on “Member” then “Member Materials”
or contact our Member Services department at [phone] or [phone]. The requirements and
explanations in this section regarding Prior Authorization apply to all treatments, services, and supplies that
require Prior Authorization. They are:
 It is your responsibility to make sure Prior Authorizations are approved when necessary. Typically,
your provider will fill out the information needed on the Physicians Plus Prior Authorization Form
and then send it to Physicians Plus along with any relevant medical documentation for review.
Physicians Plus will send a letter to you and your provider when a decision is made whether to
approve or deny the Prior Authorization request.
 If a Prior Authorization is required but not obtained, Physicians Plus will not pay for the
treatment(s), services or supplies provided. (See Section 8: Exclusions and Limitations).
 Coverage for services and benefits is determined at the time the claim for payment is submitted by
the provider or member to Physicians Plus.
 To obtain a Prior Authorization, medical documentation supporting the Prior Authorization request
must be provided to Physicians Plus.
 A Prior Authorization is only valid if the information provided to obtain the Prior Authorization is
accurate and consistent with the services actually provided.
 Prior Authorization is conditioned on meeting Physicians Plus’s clinical guidelines.
 A Prior Authorization request must be approved by Physicians Plus to take effect.
 Prior Authorization approvals may come with certain visit limits, time limits, or conditions on the
approval. For example, Physicians Plus may approve up to 6 visits to treat a covered condition.
Before the 7th visit, a new Prior Authorization would need to be obtained.
 Obtaining a Prior Authorization is not a guarantee of benefits. If the information provided to obtain
the Prior Authorization is not accurate or is not consistent with the services actually provided,
Prior Authorization does not guarantee coverage. Similarly, if eligibility requirements are not met
when the service is rendered, the Prior Authorization would not guarantee coverage.
 Physicians Plus will determine your benefits based on your available coverage at the time services
were provided. Claims will be processed and apply to any applicable limits and cost-sharing in the
order they are received by Physicians Plus.
 Prior Authorization must be obtained regardless of whether Physicians Plus is the primary or
secondary health insurance carrier.

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If Prior Authorization is not obtained for a benefit that requires Prior Authorization, Physicians Plus will not
cover the benefit.

The following are examples of services that require Prior Authorization in writing by Physicians Plus before
obtaining services. This is not an all-inclusive list. In this Prior Authorization section, when we say, “this
includes” we mean, “this includes but is not limited to.” We give examples to describe care within each
category; we are not describing an exhaustive list of services in that category. Additional prior authorization
requirements can be found in Section 6: Benefits and Services.

Prior Authorization is required for:
 All treatment, services and supplies requested or performed by any Non-Participating Provider,
including but not limited to, physicians, clinics, hospitals, facilities, DME suppliers and pharmacies
(this Prior Authorization requirement does not apply to Emergency Medical Care – see our
definition of Emergency Medical Care in Section 16: Definitions).
 Hospital, Facility, or Inpatient Admissions. This includes all inpatient care: medical, behavioral,
hospice, rehabilitation, skilled nursing facilities or other inpatient care.
 All services from a Non-Participating Provider (other than Emergency Medical Care[A4]).
 Intensive therapy services for the treatment of autism. To obtain Prior Authorization or find a
Participating Provider, contact Behavioral Health Management at [phone] or [phone].
 All genetic testing.
 [A5]Home care services, supplies and therapies, including, but not limited to, skilled nursing care;
 Reduction mammoplasties, gynecomastia, blepharoplasties, Botox injections, septorhinoplasties, and
any service that may be considered cosmetic.
 Benign skin lesion procedures (for example, lipoma removal).
 All prosthetics.
 Durable Medical Equipment (DME) and Supplies when the expense exceeds $750.
 All Transplant evaluations and services.
 All new services and technologies described by Category III CPT codes and Unlisted Category I
Surgical and Radiology Codes in ICD-10 (International Classification of Diseases, 10th Edition).

Other services requiring Prior Authorization are stated in Section 6: Benefits and Services.

When a Participating Provider provides the following medically necessary covered services, no Prior
Authorization is required:
 Non-intensive therapy services for Autism.
 Chiropractic care.
 Immediate and urgent medical care with a Participating Provider.
 Obstetric and gynecological services performed by a participating OB/GYN or a participating
licensed nurse practitioner within the scope of the nurse’s license.
 Office visits provided by your Primary Care Physician (PCP).
 Routine eye exams and refractions.
 Routine hearing exams.
 Outpatient Behavioral Health (BH) (nervous or mental illness) and Alcohol or Drug Abuse (AODA)
(chemical dependency) services. To find a Participating Provider, contact Behavioral Health
Management at [phone] or [phone].

3.3 Requirements Regarding Health Care Providers
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The requirements in this section apply to all treatments, services, and supplies a member seeks or receives.
 Participating Providers. For services and supplies to be covered under this Policy, you must
receive them from a Participating Provider. Participating Providers may also be referred to as
Preferred Providers or Network Providers. This requirement does not apply when a member is
experiencing an Emergency Medical Condition. See Section 4: Emergency Medical Care for
additional information.
 Provider Directory. You can find a Participating Provider in our provider directory at
http://directory.pplusic.com/ or by calling Member Services. The Physicians Plus provider directory
provides the names, locations and phone numbers of all Participating Providers associated with
Physicians Plus. This directory is updated on an ongoing basis and is subject to change. You can find
the most current updated provider directory at www.pplusic.com. To obtain additional information
or to request a printed copy of the provider directory please contact our Member Services
department.
 Provider Location. Some providers may practice at more than one clinic. Please refer to the
index of the provider directory to see all participating locations. Providers are considered
Participating Providers only at the locations listed in the provider directory.
 Primary Care Physician (PCP). Always consult with your Primary Care Physician (PCP)
regarding your primary and specialty care needs.
 Provider Specialty. Certain services require the use of particular provider specialties. See Section
6: Benefits and Services for whether the service you are seeking requires a particular type of
provider.
 Scope of Practice. Providers must act within the scope of their professional license when seeking
services. Do not obtain services from a provider acting outside the scope of their professional
license.
 Non-Participating Providers. Physicians Plus does not have contracts with Non-Participating
Providers and therefore has no control over denied services due to the lack of documentation,
billing errors, costs, billing, inaccurate coding practices (as determined by national standard coding
guidelines), or the quality of treatments, services and supplies provided by a Non-Participating
Provider.

Physicians Plus will not interfere with the professional relationship a member has with a physician, hospital
or other health care provider. However, in order to be covered, treatment, services and supplies must be
provided by:
 A member’s Primary Care Physician (PCP); or
 A participating facility, provider or physician;
 A provider or physician other than an Participating Provider when a member is referred by the PCP
and Physicians Plus approves and/or Prior Authorized the services;
 When a member requires Emergency Medical Care, a provider or physician other than a
Participating Provider;
 If a member is a dependent student while away at school and services are Prior Authorized by
Physicians Plus, a provider or physician other than a Participating Provider;
 A hospital when referred by a physician as described in (a), (b), (c), or (d) above and Prior
Authorized by Physicians Plus; or
 A participating hospital.
Physicians Plus is not responsible for any injury, damage, or expense (including attorney’s fees) a member
suffers as a result of any improper advice, action or omission on the part of any physician, hospital or other
health care provider. Physicians Plus is obligated to provide only the benefits specifically stated in the Policy.
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