Page 94 - Aegion Value Plan SPDs
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HEALTH BENEFITS COVERAGE UNDER FEDERAL LAW
Choice of Primary Care Physician
The Plan generally allows the designation of a Primary Care Physician (PCP). You have the right to
designate any PCP who participates in the Claims Administrator’s Network and who is available to accept
You or Your family members. For information on how to select a PCP, and for a list of PCPs, contact the
telephone number on the back of Your Identification Card or refer to the Claims Administrator’s website,
www.anthem.com. For children, You may designate a pediatrician as the PCP.
Access to Obstetrical and Gynecological (ObGyn) Care
You do not need prior authorization from the Plan or from any other person (including a PCP) in order to
obtain access to obstetrical or gynecological care from a health care professional in the Claims
Administrator’s network who specializes in obstetrics or gynecology. The health care professional,
however, may be required to comply with certain procedures, including obtaining prior authorization for
certain services or following a pre-approved treatment plan. For a list of participating health care
professionals who specialize in obstetrics or gynecology, contact the telephone number on the back of Your
Identification Card or refer to the Claims Administrator’s website, www.anthem.com.
Statement of Rights Under the Newborns’ and Mother’s Health Protection Act
Group Health Plans and health insurance issuers generally may not, under Federal law, restrict benefits for
any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law
generally does not prohibit the mother’s or newborn’s attending provider (e.g., Your physician, nurse
midwife, or physician assistant), after consulting with the mother, from discharging the mother or her
newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under
Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing
a length of stay not in excess of 48 hours (or 96 hours). However, to use certain providers or facilities, or
to reduce Your out-of-pocket costs, You may be required to obtain pre-certification. For information on pre-
certification, contact Your Plan Administrator.
Also, under federal law, plans may not set the level of benefits or out-of-pocket costs so that any later
portion of the 48 hour (or 96 hour) stay is treated in a manner less favorable to the mother or newborn than
any earlier portion of the stay.
Statement of Rights Under the Women’s Cancer Rights Act of 1998
If You have had or are going to have a mastectomy, You may be entitled to certain benefits under the
Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related
benefits, coverage will be provided in a manner determined in consultation with the attending physician and
the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same Deductibles and Coinsurance applicable to other
medical and surgical benefits provided under this plan. See the Schedule of Benefits.
If You would like more information on WHCRA benefits, call Your Plan Administrator.
Coverage for a Child Due to a Qualified Medical Support Order (“QMCSO”)
If You or Your spouse are required, due to a QMCSO, to provide coverage for Your child(ren), You may
ask Your Employer or Plan Administrator to provide You, without charge, a written statement outlining the
procedures for getting coverage for such child(ren).
94
Choice of Primary Care Physician
The Plan generally allows the designation of a Primary Care Physician (PCP). You have the right to
designate any PCP who participates in the Claims Administrator’s Network and who is available to accept
You or Your family members. For information on how to select a PCP, and for a list of PCPs, contact the
telephone number on the back of Your Identification Card or refer to the Claims Administrator’s website,
www.anthem.com. For children, You may designate a pediatrician as the PCP.
Access to Obstetrical and Gynecological (ObGyn) Care
You do not need prior authorization from the Plan or from any other person (including a PCP) in order to
obtain access to obstetrical or gynecological care from a health care professional in the Claims
Administrator’s network who specializes in obstetrics or gynecology. The health care professional,
however, may be required to comply with certain procedures, including obtaining prior authorization for
certain services or following a pre-approved treatment plan. For a list of participating health care
professionals who specialize in obstetrics or gynecology, contact the telephone number on the back of Your
Identification Card or refer to the Claims Administrator’s website, www.anthem.com.
Statement of Rights Under the Newborns’ and Mother’s Health Protection Act
Group Health Plans and health insurance issuers generally may not, under Federal law, restrict benefits for
any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law
generally does not prohibit the mother’s or newborn’s attending provider (e.g., Your physician, nurse
midwife, or physician assistant), after consulting with the mother, from discharging the mother or her
newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under
Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing
a length of stay not in excess of 48 hours (or 96 hours). However, to use certain providers or facilities, or
to reduce Your out-of-pocket costs, You may be required to obtain pre-certification. For information on pre-
certification, contact Your Plan Administrator.
Also, under federal law, plans may not set the level of benefits or out-of-pocket costs so that any later
portion of the 48 hour (or 96 hour) stay is treated in a manner less favorable to the mother or newborn than
any earlier portion of the stay.
Statement of Rights Under the Women’s Cancer Rights Act of 1998
If You have had or are going to have a mastectomy, You may be entitled to certain benefits under the
Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related
benefits, coverage will be provided in a manner determined in consultation with the attending physician and
the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same Deductibles and Coinsurance applicable to other
medical and surgical benefits provided under this plan. See the Schedule of Benefits.
If You would like more information on WHCRA benefits, call Your Plan Administrator.
Coverage for a Child Due to a Qualified Medical Support Order (“QMCSO”)
If You or Your spouse are required, due to a QMCSO, to provide coverage for Your child(ren), You may
ask Your Employer or Plan Administrator to provide You, without charge, a written statement outlining the
procedures for getting coverage for such child(ren).
94
