Page 57 - Aegion PPO SPDs
P. 57
COVERED SERVICES
This section describes the Covered Services available under Your health care benefits when provided and
billed by Providers. Care must be received from a Network Provider to be covered at the Network
level, except for Emergency Care and Urgent Care. Services which are not received from a Network
Provider will be considered a Non-Network Service, unless otherwise specified in this Benefit
Booklet. The amount payable for Covered Services varies depending on whether You receive Your care
from a Network Provider or a Non-Network Provider.
If You use a Non-Network Provider, You are responsible for the difference between the Non-Network
Provider’s charge and the Maximum Allowed Amount, in addition to any applicable Deductible. The Claims
Administrator or the Employer cannot prohibit Non-Network Providers from billing You for the difference in
the Non-Network Provider’s charge and the Maximum Allowed Amount.
All Covered Services and benefits are subject to the conditions, Exclusions, limitations, terms and
provisions of this Benefit Booklet, including any attachments, riders and endorsements. Covered Services
must be Medically Necessary and not Experimental/Investigative. The fact that a Provider may prescribe,
order, recommend or approve a service, treatment or supply does not make it Medically Necessary or a
Covered Service and does not guarantee payment. To receive maximum benefits for Covered Services,
You must follow the terms of the Benefit Booklet, including use of Network Providers, and obtain any
required Prior Authorization or precertification. Contact Your Network Provider to be sure that Prior
Authorization/precertification has been obtained. The Claims Administrator bases its decisions about Prior
Authorization, precertification, Medical Necessity, Experimental/Investigative services and new technology
on the Claims Administrator's medical policy and Clinical Guidelines. The Claims Administrator may also
consider published peer-review medical literature, opinions of experts and the recommendations of
nationally recognized public and private organizations which review the medical effectiveness of health
care services and technology.
Benefits for Covered Services may be payable subject to an approved treatment plan created under the
terms of this Benefit Booklet. Benefits for Covered Services are based on the Maximum Allowed Amount
for such service. Plan payment for Covered Services will be limited by any applicable Deductible and,
Benefit Period maximum in this Benefit Booklet.
Preventive Care Services
(Details on Preventive Care Services can be found on the Preventive Care Services flyer posted on
the Aegion intranet and are also available through the HR department.)
Preventive care includes screenings and other services for adults and children. All recommended
preventive services will be covered as required by the Affordable Care Act (ACA). This means many
preventive care services are covered with no Deductible, Copayments or Coinsurance when You use a
Network Provider.
Certain benefits for Members who have current symptoms or a diagnosed health problem may be covered
under diagnostic services instead of this benefit, if the coverage does not fall within ACA-recommended
preventive services.
Covered Services fall under the following broad groups:
1. Services with an “A” or “B” rating from the United States Preventive Services Task Force.
Examples of these services are screenings for:
a. Breast cancer;
b. Cervical cancer;
c. Colorectal cancer;
d. High Blood Pressure;
57
This section describes the Covered Services available under Your health care benefits when provided and
billed by Providers. Care must be received from a Network Provider to be covered at the Network
level, except for Emergency Care and Urgent Care. Services which are not received from a Network
Provider will be considered a Non-Network Service, unless otherwise specified in this Benefit
Booklet. The amount payable for Covered Services varies depending on whether You receive Your care
from a Network Provider or a Non-Network Provider.
If You use a Non-Network Provider, You are responsible for the difference between the Non-Network
Provider’s charge and the Maximum Allowed Amount, in addition to any applicable Deductible. The Claims
Administrator or the Employer cannot prohibit Non-Network Providers from billing You for the difference in
the Non-Network Provider’s charge and the Maximum Allowed Amount.
All Covered Services and benefits are subject to the conditions, Exclusions, limitations, terms and
provisions of this Benefit Booklet, including any attachments, riders and endorsements. Covered Services
must be Medically Necessary and not Experimental/Investigative. The fact that a Provider may prescribe,
order, recommend or approve a service, treatment or supply does not make it Medically Necessary or a
Covered Service and does not guarantee payment. To receive maximum benefits for Covered Services,
You must follow the terms of the Benefit Booklet, including use of Network Providers, and obtain any
required Prior Authorization or precertification. Contact Your Network Provider to be sure that Prior
Authorization/precertification has been obtained. The Claims Administrator bases its decisions about Prior
Authorization, precertification, Medical Necessity, Experimental/Investigative services and new technology
on the Claims Administrator's medical policy and Clinical Guidelines. The Claims Administrator may also
consider published peer-review medical literature, opinions of experts and the recommendations of
nationally recognized public and private organizations which review the medical effectiveness of health
care services and technology.
Benefits for Covered Services may be payable subject to an approved treatment plan created under the
terms of this Benefit Booklet. Benefits for Covered Services are based on the Maximum Allowed Amount
for such service. Plan payment for Covered Services will be limited by any applicable Deductible and,
Benefit Period maximum in this Benefit Booklet.
Preventive Care Services
(Details on Preventive Care Services can be found on the Preventive Care Services flyer posted on
the Aegion intranet and are also available through the HR department.)
Preventive care includes screenings and other services for adults and children. All recommended
preventive services will be covered as required by the Affordable Care Act (ACA). This means many
preventive care services are covered with no Deductible, Copayments or Coinsurance when You use a
Network Provider.
Certain benefits for Members who have current symptoms or a diagnosed health problem may be covered
under diagnostic services instead of this benefit, if the coverage does not fall within ACA-recommended
preventive services.
Covered Services fall under the following broad groups:
1. Services with an “A” or “B” rating from the United States Preventive Services Task Force.
Examples of these services are screenings for:
a. Breast cancer;
b. Cervical cancer;
c. Colorectal cancer;
d. High Blood Pressure;
57
