The Basic Health Benefit Plan may be provided through a commercial insurance carrier, a hospital and medical service corporation or a health care services organization that has been approved as an Accountable Health Plan.
The benefits and services of the Plan may be provided through an indemnity plan with or without a preferred provider network or through the restricted provider network of a health care services organization (health maintenance organization).
The Basic Health Benefit Plan may be offered to any employer at any time.
Immediate coverage for children newly born, adopted or placed for adoption pursuant to A.R.S. §§ 20-826, 20-1057 or 20-1402.
Continuing coverage beyond the limiting age for a child handicapped or disabled pursuant to A.R.S. §§ 20-826 or 20-1407.
Benefits for surgical service which is covered by the policy regardless of the place the surgery is performed pursuant to A.R.S. §§ 20-826, 20-1051 or 20-1402.
Benefits for home health services prescribed in lieu of inpatient hospital care pursuant to A.R.S. §§ 20-826, 20-1051 or 20-1402.
Benefits for diagnostic services performed outside a hospital in lieu of inpatient service pursuant to A.R.S. §§ 20-826, 20-1051 or 20-1402.
Benefits for services performed in a hospital's outpatient department or in a freestanding surgical facility pursuant to A.R.S. §§ 20-826, 20-1051 or 20-1402.
Benefits for breast reconstructive surgery and external postoperative prosthesis following a covered mastectomy pursuant to A.R.S. §§ 20-826, 20-1057 or 20-1402.
Benefits for mammography screening pursuant to A.R.S. §§ 20-826, 20-1057 or 20-1402.
Reimbursement for services within the lawful scope of practice of a registered nurse practitioner or a certified registered nurse qualified under the rules adopted by the State Board of Nursing pursuant to A.R.S. §§ 20-841.03 or 20-1406.03.
Effective July 13, 1995, pursuant to A.R.S. § 20-2321 the Basic Health Benefit Plan also provides that the maternity benefits apply to the cost of the birth of a child who is legally adopted by the enrollee.
With respect to those benefits, the Basic Health Benefit Plan issued by an Accountable Health Plan must contain benefit definitions, language, certificates of coverage, provider definitions, exclusions and limitations and commission structures that are comparable to its most commonly used, or what is presumed to be its most commonly used, group health plan closest in size to the small employer group health plans currently being offered by that Accountable Health Plan in this state.
Attached is the schedule of benefits for the Basic Health Benefit Plan.
| ARIZONA BASIC HEALTH BENEFIT PLAN SCHEDULE OF BENEFITS |
| Calendar Year Deductible |
Individual |
$1000 |
$1500 |
Not Applicable |
|
Family Aggregate |
$2000 |
$3000
$500 additional per hospital admission if pre-Certification not received |
Not Applicable |
| Physician Services |
Office Visit |
80% After Calendar Year Deductible |
60% After Calendar Year Deductible |
$20 Co-Payment |
|
Routine Physical Exams |
Not Covered |
Not Covered |
$20 Co-Payment |
|
Immunizations (Only) |
Patient Pays
$5 Co-Payment |
Not Covered |
$5 Co-Payment |
|
Well Child Care |
80% After Calendar Year Deductible |
Not Covered |
$20 Co-Payment |
|
Well Woman Care |
80% After Calendar Year Deductible |
Not Covered |
$20 Co-Payment |
|
Maternity Services including Pre/Post Natal Care, Labor & Delivery |
80% After Calendar Year Deductible |
60% After Calendar Year Deductible |
$20 Co-Payment |
|
Allergy Testing & Treatment |
80% After Calendar Year Deductible |
60% After Calendar Year Deductible |
$20 Co-Payment |
|
Diagnostic lab & X-ray services |
80% After Calendar Year Deductible |
60% After Calendar Year Deductible |
$20 Co-Payment |
|
Vision Screening |
Not Covered |
Not Covered |
$20 Co-Payment |
| Hospital Services |
Inpatient room & board
Lab & X-ray
Medical supplies & miscellaneous hospital services |
80% After Calendar Year Deductible (Pre-certification required) |
60% After Calendar Year Deductible (Pre-certification required) |
$500 Co-Payment each admission |
|
Outpatient Hospital |
80% After Calendar Year Deductible |
60% After Calendar Year Deductible |
$100 Co-Payment per visit |
| Emergency Care |
Physicians Office |
80% After Calendar Year Deductible |
80% After Calendar Year Deductible |
$20 Co-Payment |
|
Urgent Care Center |
80% After Calendar Year Deductible |
80% After Calendar Year Deductible |
$35 Co-Payment |
|
Hospital |
80% After Calendar Year Deductible |
80% After Calendar Year Deductible |
$50 Co-Payment (Waived if admitted) |
|
Ambulance |
80% After Calendar Year Deductible |
80% After Calendar Year Deductible |
Covered at 100% |
| Prescriptions |
|
80% After Calendar Year Deductible (Generic drugs when available) |
60% After Calendar Year Deductible (Generic drugs when available) |
$20 Co-Payment at a participating pharmacy |
| Durable Medical Equipment |
|
80% After Calendar Year Deductible |
60% After Calendar Year Deductible |
Covered at 100% (Limit of $2000 per calendar year) |
| Mental Health & Substance Abuse Services |
Inpatient Care |
80% After Calendar Year Deductible (Benefit maximum the lessor of 30 days/calendar year and $10,000/lifetime) |
60% After Calendar Year Deductible (Benefit maximum the lessor of 30 days/calendar year and $10,000/lifetime) |
30 days in participating hospital ($500 copayment each admission) |
|
Outpatient Care |
80% After Calendar Year Deductible
Benefit maximum $1000/calendar year |
60% After Calendar Year Deductible
Benefit maximum $1000/calendar year |
$20 Co-Payment
Maximum of 20 visits per calendar year |
| Other Medical Services |
Skilled Nursing Facility |
80% After Calendar Year Deductible (30 days maximum per calendar year) |
60% After Calendar Year Deductible (30 days maximum per calendar year) |
100% Coverage (30 days maximum covered) |
|
Home Health Care |
80% After Calendar Year Deductible |
60% After Calendar Year Deductible |
100% Coverage(60 days maximum covered) |
|
Hospice |
80% After Calendar Year Deductible (6 month maximum) |
60% After Calendar Year Deductible (6 month maximum) |
100% Coverage (6 month maximum) |
|
Family Planning - Vasectomy |
Not Covered |
Not Covered |
$100 Co-Payment |
|
Family Planning - Tubal Ligation |
Not Covered |
Not Covered |
$250 Co-Payment |
|
Short Term Therapy |
80% After Calendar Year Deductible |
60% After Calendar Year Deductible |
$20 Co-Payment |
| Out of Pocket Limit |
|
$1000 per individual, $2000 per family in addition to calendar year deductible and co-payments |
$1500 per individual, $3000 per family in addition to calendar year deductible and co-payments |
Individual - 200% Annual Premium
Family - 200% Annual Premium |
|
Lifetime Maximum Benefit |
$1,000,000 per individual |
$1,000,000 per individual |
|
