Page 10 - Harvard Maintenance HPS Field Ops 2022 Benefits Guide
P. 10
Calendar Year 2022
Benefits Enrollment
Minimum Essential Coverage (MEC) Plan Design
Number of Daily
Inpatient Hospital Beneits Beneit Amount Beneits Per
Coverage Year
Hospital Room and Board Beneits
Room and Board Beneit Per Day for Covered Conditions, Except as Noted Below $500 90
Mental and Nervous Beneit Per Day $100 25
Alcohol Abuse Beneit Per Day $100 25
Substance Abuse (other than alcohol) beneit per day $100 25
Hospital Admission Beneit For Speciied Conditions
Cancer (malignant neoplasm) Beneit Per Day $4,000 1
Heart Attack (myocardial infarction) Beneit Per Day $3,000 1
OR Heart Disease Beneit Per Day $1,500
¹
Accidental Injury Beneit Per Day $2,000 1
Stroke (cerebrovascular accident—CVA) beneit per day $1,500 1
Childbirth Beneit Per Day $1,500 1
Surgery
Maximum Daily Surgery Beneit Per Procedure 2 $1,000 N/A
Maximum Daily Anesthesia Beneit³ $200 N/A
Number of Daily
Outpatient Beneits Beneit Amount Beneits Per
Coverage Year
Doctor Visit Beneits
Daily Beneit for New Patient Oice Visit $75 1
Daily Beneit for Established Patient Oice Visit $70 5
Daily Beneit for Consultation Oice Visit $100 1
Daily Beneit for Emergency Room Doctor Visit $75 1
Radiology Beneits
Daily Beneit for Magnetic Resonance Imaging (MRI) $150 1
Daily Beneit for Computerized Tomography (CT) scan $75 1
Daily Beneit for All Other Radiology Services $40 6
Pathology (Lab) Beneits
Daily Beneit for All Pathology Services $40 6
Emergency Room Visit Beneits
Daily Beneit for the Treatment of an Accidental Injury $500 2
Daily Beneit for the Treatment of a Sickness $50 3
Surgery
Maximum Daily Surgery Beneit Per Procedure 4 $1,000
Maximum Daily Anesthesia Beneit 5 $200
Prescription Drugs Beneits
Daily Beneit Per Generic Drug Prescription (illed or reilled) $25 18
Daily Beneit Per Brand Name Drug (illed or reilled) Discount only
¹ The daily hospital admission beneit is payable for either heart attack or heart disease during a coverage year, but not both
² Daily beneits for covered inpatient surgery are scheduled and vary based on the speciic surgical procedure performed
³ Daily beneits for covered inpatient anesthesia vary and are equal to 20% of applicable inpatient surgical beneit
4 Daily beneits for covered outpatient surgery are scheduled and vary based on the speciic surgical procedure performed
5 Daily beneits for covered outpatient anesthesia vary and are equal to 20% of applicable inpatient surgical beneit 10
Benefits Enrollment
Minimum Essential Coverage (MEC) Plan Design
Number of Daily
Inpatient Hospital Beneits Beneit Amount Beneits Per
Coverage Year
Hospital Room and Board Beneits
Room and Board Beneit Per Day for Covered Conditions, Except as Noted Below $500 90
Mental and Nervous Beneit Per Day $100 25
Alcohol Abuse Beneit Per Day $100 25
Substance Abuse (other than alcohol) beneit per day $100 25
Hospital Admission Beneit For Speciied Conditions
Cancer (malignant neoplasm) Beneit Per Day $4,000 1
Heart Attack (myocardial infarction) Beneit Per Day $3,000 1
OR Heart Disease Beneit Per Day $1,500
¹
Accidental Injury Beneit Per Day $2,000 1
Stroke (cerebrovascular accident—CVA) beneit per day $1,500 1
Childbirth Beneit Per Day $1,500 1
Surgery
Maximum Daily Surgery Beneit Per Procedure 2 $1,000 N/A
Maximum Daily Anesthesia Beneit³ $200 N/A
Number of Daily
Outpatient Beneits Beneit Amount Beneits Per
Coverage Year
Doctor Visit Beneits
Daily Beneit for New Patient Oice Visit $75 1
Daily Beneit for Established Patient Oice Visit $70 5
Daily Beneit for Consultation Oice Visit $100 1
Daily Beneit for Emergency Room Doctor Visit $75 1
Radiology Beneits
Daily Beneit for Magnetic Resonance Imaging (MRI) $150 1
Daily Beneit for Computerized Tomography (CT) scan $75 1
Daily Beneit for All Other Radiology Services $40 6
Pathology (Lab) Beneits
Daily Beneit for All Pathology Services $40 6
Emergency Room Visit Beneits
Daily Beneit for the Treatment of an Accidental Injury $500 2
Daily Beneit for the Treatment of a Sickness $50 3
Surgery
Maximum Daily Surgery Beneit Per Procedure 4 $1,000
Maximum Daily Anesthesia Beneit 5 $200
Prescription Drugs Beneits
Daily Beneit Per Generic Drug Prescription (illed or reilled) $25 18
Daily Beneit Per Brand Name Drug (illed or reilled) Discount only
¹ The daily hospital admission beneit is payable for either heart attack or heart disease during a coverage year, but not both
² Daily beneits for covered inpatient surgery are scheduled and vary based on the speciic surgical procedure performed
³ Daily beneits for covered inpatient anesthesia vary and are equal to 20% of applicable inpatient surgical beneit
4 Daily beneits for covered outpatient surgery are scheduled and vary based on the speciic surgical procedure performed
5 Daily beneits for covered outpatient anesthesia vary and are equal to 20% of applicable inpatient surgical beneit 10
