All CMH Medical Plans offer meaningful choices and options that you and your family deserve. You may choose one of two plans: Medical Plan #1 OR Medical Plan #2. Both plans offer the same coverage for medical services and prescriptions drugs. The difference between the plans is the level of deductible you must reach before the benefit kicks in, as well as the amount of your maximum out-of-pocket costs for the year.
It's important to carefully review all the choices available to you. Remember, when you enroll in one of the CMH Medical Plan options, you are also automatically enrolled in our Prescription Drug Program.
No matter which medical option you select, you are responsible for co-pays at the time of service. For 2011, we're waiving co-pays and dollar limits for preventive care (wellness) visits if you enroll in either Medical Plan #1 or #2. Please refer to the chart below to see how participating can improve your health AND your financial situation.
| Medical Benefits-Wellness Visits |
| No co-pay; No calendar year maximum (CYM) on all wellness-related visits. Note: to qualify for waived co-pays and unlimited co-pays and well visits , the procedure code must begin with the letter "V", often called "v-codes." A code with a different letter would not qualify for this benefit, and very likely be subject to deductibles and co-insurance. Typical well visits include colonoscopies, annual physicals/associated lab tests and mammograms, well child care (up to 30 months), routine exams, annual gynecological exams, mammograms, pap smears, immunizations, prenatal physician visits (one co-pay for entire pregnancy), and smoking cessation, counseling and nicotine replacement therapy. |
Note: Co-pays and co-insurance for wellness visits inside or outside the CMH network are the same.
| Medical Benefits-Other Visits | ||
| Visit Type | Inside the CMH PHO Network | Outside the CMH PHO Network |
| Physician Office Visit | $20 co-pay | $20 co-pay |
| Specialist Office Visit | $40 co-pay | $40 co-pay |
| Emergency Room Visit (Co-pay waived if admitted) |
$100 co-pay | $100 co-pay |
| Podiatry Office Visit (Surgery requires medically necessary & pre-approval) |
$40 co-pay | $40 co-pay |
| Cardiac Rehab Series | $40 co-pay | $40 co-pay |
Mental Health & Substance Abuse* |
$20 co-pay | $20 co-pay |
* You must call United Behavioral Health @ 1-866-868-7406 to receive maximum benefits.
Note: Co-pays do not count toward your deductible or your annual out-of-pocket maximum.
Medical Plan #1 |
Medical Plan #2 |
|||
| Within CMH PHO | Outside CMH PHO | Within CMH PHO | Outside CMH PHO | |
| Calendar Year Deductible | $450/Individual $900/Family |
$ 900/Individual $1,800/Family |
$1,400/Individual $2,800/Family |
$2,800/Individual $5,600/Family |
| Out-of-Pocket Maximum (Excluding Co-Pays) |
$1,750/Individual $3,500/Family |
$4,000/Individual $8,000/Family |
$2,800/Individual $5,600/Family |
$5,600/Individual $11,200/Family |
Three levels of coverage now apply:
If a procedure is not offered within the CMH PHO, it will be paid at the highest level (typically 90%) ONLY if you pre-authorize that visit PRIOR to service. You need to pre-authorize by calling a Referral specialist at 207-795-5746. This person will certify the service is not offered within the CMH PPO and will ascertain if any related procedures (e.g. diagnostic labs, xrays, tests, etc) can be performed at CMMC, Bridgton, Rumford, etc.
Diagnostic services available within the CMH PHO but performed outside the CMH PHO will be paid at the 70% or the 50% levels regardless.
Please note, beginning 1/1/2012, only services offered within CMH hospitals and providers will be eligible for the 90% coverage level. It is expected that, regardless of availability within the CMH PPO, all other services will be paid at the 70% UHC Options PPO level or at the 50% level.
Once you meet the deductible for your medical plan, the plan will cover most of your medical expenses as described below:
| Medical Benefits-Services | |||
| Hospital | Inside the CMH PHO Network | Inside the UHC Options PPO | Outside of CMH and UHC Networks Other Providers |
| Includes: inpatient surgical facilities & supplies, room & board, newborn care, outpatient surgical facilities & supplies | 90% covered after deductible | 70% covered after deductible | 50%
|
| Physician Charges | |||
| Includes: hospital visits, maternity, surgery, anesthesia, emergency room doctor charge (if billed separately), allergy treatment/testing ($300/yr. max. unless pre-approved) | 90% covered after deductible | 70% covered after deductible | 50% |
| Rehabilitation | |||
| Includes: respiratory therapy, hemodialysis, home health care (after hospital), cardiac therapy, hospice care, extended care, chemotherapy, radiation therapy, physical and/or occupational therapy, speech therapy, chiropractic services | 90% covered after deductible | 70% covered after deductible | 50% |
| Other Services | |||
| Diagnostic lab & X-ray | 90% covered after deductible | 70% covered after deductible | 50% |
| Ambulance service (if deemed medically necessary) |
90% covered after deductible | 90% covered after deductible | 50% |
| Pre-admission testing | 90% covered after deductible | 70% covered after deductible | 50% |
| Durable medical equip. ($3,000/yr. max.) | 90% covered after deductible | 90% covered after deductible | 50% |
| Insulin pumps and supplies | 90% covered after deductible | 70% covered after deductible | 50% |
| Organ & bone transplants | 90% covered after deductible | 70% covered after deductible | 50% |
| Vasectomy & tubal ligation | 90% covered after deductible | 70% covered after deductible | 50% |
| Removal of impacted wisdom teeth | 90% covered after deductible | 70% covered after deductible | 50% |
| Acupuncture ($300/yr. max.) | 50% covered after deductible | 50% covered after deductible | 50% |
Note: Visit or dollar maximums listed in the preceding tables are calendar year maximums.
For more information, refer to the Medical Summary Plan Description (.pdf)
In most cases you cannot make changes to your benefit elections during the year unless you have a change in family or employment status — what the IRS calls a "qualifying event."