Page 5 - 2016 Enrollment
P. 5
Capsa Solutions
Continued Plan Offering BCBS of IL
$3,000 Ded Qualiied $1,500 Ded Traditional $750 Ded Traditional
HDHP $1,500 Ded Qualiied HDHP PPO Plan PPO Plan
In-Network In-Network In-Network
Physicians ofice 100% after ded 90% after ded Covered at 100% Covered at 100%**
Outpatient facility 100% after ded 90% after ded Covered at 100% Covered at 100%**
Outpatient hospital 100% after ded 90% after ded Covered at 100% Covered at 100%**
* Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc) which are ded/coinsurance
Hospital Services
Inpatient 100% after ded 90% after ded 80% after ded 80% after ded
Outpatient 100% after ded 90% after ded 80% after ded 80% after ded
Emergency room 100% after ded 90% after ded $250 copay $150 copay
Ambulance 100% after ded 90% after ded 80% after ded 80% after ded
Mental Health
Inpatient 100% after ded 90% after ded 80% after ded 80% after ded
Limitations None None None None
Outpatient—ofice 100% after ded 90% after ded $25 copay $20 copay
visits
Limitations None None None None
Substance Abuse
Inpatient 100% after ded 90% after ded 80% after ded 80% after ded
Limitations None None None None
Outpatient 100% After ded 90% After ded $25 copay $20 copay
Limitations None None None None
Skilled nursing care 100% after ded 90% after ded 80% after ded 80% after ded
(no limits)
Home healthcare 100% after ded 90% after ded 80% after ded 80% after ded
(no limits)
Hospice care 100% after ded 90% after ded 80% after ded 80% after ded
Durable medical 100% after ded 90% after ded 80% after ded 80% after ded
equipment
Prosthetic devices 100% after ded 90% after ded 80% after ded 80% after ded
Chiropractic Care—30 visits
100% after ded 90% after ded $25 copay $20 copay
Outpatient Therapies
Physical therapy 100% after ded 90% after ded $25 copay $20 copay
Limitations No limits No limits No limits No limits
Speech therapy 100% after ded 90% after ded $25 copay $20 copay
Limitations No limits No limits No limits No limits
Occupational 100% after ded 90% after ded $25 copay $20 copay
therapy
Limitations No limits No limits No limits No limits
Transplants (Some transplants must be performed in hospitals with approved BCBS human organ transplant programs)
100% after ded 90% after ded 80% after ded 80% after ded
5
Continued Plan Offering BCBS of IL
$3,000 Ded Qualiied $1,500 Ded Traditional $750 Ded Traditional
HDHP $1,500 Ded Qualiied HDHP PPO Plan PPO Plan
In-Network In-Network In-Network
Physicians ofice 100% after ded 90% after ded Covered at 100% Covered at 100%**
Outpatient facility 100% after ded 90% after ded Covered at 100% Covered at 100%**
Outpatient hospital 100% after ded 90% after ded Covered at 100% Covered at 100%**
* Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc) which are ded/coinsurance
Hospital Services
Inpatient 100% after ded 90% after ded 80% after ded 80% after ded
Outpatient 100% after ded 90% after ded 80% after ded 80% after ded
Emergency room 100% after ded 90% after ded $250 copay $150 copay
Ambulance 100% after ded 90% after ded 80% after ded 80% after ded
Mental Health
Inpatient 100% after ded 90% after ded 80% after ded 80% after ded
Limitations None None None None
Outpatient—ofice 100% after ded 90% after ded $25 copay $20 copay
visits
Limitations None None None None
Substance Abuse
Inpatient 100% after ded 90% after ded 80% after ded 80% after ded
Limitations None None None None
Outpatient 100% After ded 90% After ded $25 copay $20 copay
Limitations None None None None
Skilled nursing care 100% after ded 90% after ded 80% after ded 80% after ded
(no limits)
Home healthcare 100% after ded 90% after ded 80% after ded 80% after ded
(no limits)
Hospice care 100% after ded 90% after ded 80% after ded 80% after ded
Durable medical 100% after ded 90% after ded 80% after ded 80% after ded
equipment
Prosthetic devices 100% after ded 90% after ded 80% after ded 80% after ded
Chiropractic Care—30 visits
100% after ded 90% after ded $25 copay $20 copay
Outpatient Therapies
Physical therapy 100% after ded 90% after ded $25 copay $20 copay
Limitations No limits No limits No limits No limits
Speech therapy 100% after ded 90% after ded $25 copay $20 copay
Limitations No limits No limits No limits No limits
Occupational 100% after ded 90% after ded $25 copay $20 copay
therapy
Limitations No limits No limits No limits No limits
Transplants (Some transplants must be performed in hospitals with approved BCBS human organ transplant programs)
100% after ded 90% after ded 80% after ded 80% after ded
5
