PURMS

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Full Plan Dental
POLICY #  PURMS01
EFFECTIVE DATE 4/1/2000
Deductible $125.00 per person / $375 per family / Carry over - YES
In Network 90% of negotiated fees
Out of Network 80% of covered expenses
Out of Pocket $500  in network fees - $1,000 combined in network and out of network 
Hospital - Inpatient  
Hospital - Inpatient - Maternity 48 hr stay vaginal delivery / 96 hr stay cesarean section  (Mom and baby both)
Hospital - Maternity - Early Discharge allow 2 post discharge visits / 1 must be a home visit
Hospital Psych/Substance Abuse IN  inpatient 30 days per year covered / 2 partial days = 1 inpatient day
Hospital Psych/Substance Abuse OUT 50% of $80 / 52 visits per yr / per person
Psych & Substance Other 50% for testing and prescriptions
Psych & Substance Lifetime Maximum $25,000 in and out-patient combined limits apply whether PPO providers or not
Maximum Benefit $2,000,000 for any 1 injury /  sickness or pregnancy / during a lifetime can fully restore benefit if no treatment for 24 months or proof of good health
Common Accident Feature If 2 or more family members are injured in the same accident - no deductible will apply for that year or the next year except if the charges are not related to the accident
Private Duty Nursing $125 per day limit - must be licensed nurse providing the service
Reconstructive Surgery covered following a mastectomy
Emergency Transportation rail - ambulance - plane maximum  $2,500 per confinement
Rental or Purchase Medical Equip. $10,000 person's lifetime (wheelchair - bed - iron lung …)
Mammogram Screening One per calendar year by recommendation of a Dr, Nurse or PA aides up to 20 hours per week
Home Health Care must have a written plan by a doctor / confinement in a hospital would  be required  if if home health care were not provided / under continuous care by that doctor
Convalescent Care Facility 50% of the most common semi-private room from the hospital they just left. 90 days for any 1 injury or sickness. Must be inpatient for 3 days in a row prior to confinement, prior confinement must be covered. Must enter within 7 days of leaving the hospital. Stay must result from the same injury or sickness. Doctor who saw them in the hospital must recommend - approve and supervise care
A new 3 day stay must precede a later period of care if totally unrelated or more than 7 days after discharge or after normal duties resume
Hospice Care Must be terminal with 6 months or less to live, benefits can be extended if Dr. recertifies that person has 6 months or less to live & recommends admission into the hospice program
Bereavement benefits - lifetime maximum  3 months following the death of a family member
Treatment of feet $2,000 per cal yr for: an open cutting operation / the removal of nail roots / treatment of weak, strained, unstable or unbalanced feet, metatarsalgia or bunions or corns calluses or toenails if you have a metabolic or peripheral vascular disease 
Pre-Existing Conditions Injury / sickness or pregnancy for which the covered person consulted a doctor, took medicine, or received other medical care or advice within 12 months before becoming covered or existence of symptoms which would cause an ordinary prudent person to seek advice, diagnosis or are or treatment within 12 months before becoming covered.  Expenses will be covered after you are covered for 6 months in a row 
Chiropractic adjustments $500 per person - per calendar year payable
Wellness and Alternative Coverage $500 per person - per calendar year payable
Confinement when coverage terminates If confined - covered until the date discharged - 3 months from date the coverage ended or the date the maximum has been paid
Second Surgical Consultation Must be within 90 days of when surgery was recommended - must take place prior to entering the hospital for the surgery - procedure must be done only on a hospital inpatient basis - specialist must examine the covered person in person. 100% of covered expense paid  up to $100  no deductible (rest is major medical) for visit - x-rays and lab work, two consultations can be covered for any one procedure by a different specialist. Doctor must have a surgical specialty for which surgery is recommended / can not do the second opinion and the surgery
VISION CARE  
EYE EXAM Routine eye examinations, including refractions are covered up to $150 annually
HARDWARE Up to $300 every two calendar years
DENTAL  
DEDUCTIBLE  $50 FOR BASIC AND/OR MAJOR
PRE-DETERMINATION REQUIRED NO - BUT RECOMMENDED
MAXIMUM PAYABLE $2,000 PER PERSON / PER CAL YEAR
PREVENTIVE  
INCLUDES EXAMS - PROPHY - FLUORIDE - X-RAYS - SPACE MAINTAINERS - STUDY MODELS/DIAGNOSTIC CASTS
DEDUCTIBLE  NONE
ORAL EXAMS 80% NOT MORE THAN ONCE EVERY 6 MONTHS
FULL MOUTH X-RAY FREQUENCY 80% NOT MORE THAN ONCE EVERY 3 YRS
BITEWINGS FREQUENCY 80% NOT MORE THAN ONCE EVERY 6 MONTHS
PROHPY FREQUENCY 80% NOT MORE THAN ONCE EVERY 6 MONTHS
FLUORIDE FREQUENCY 80% ONCE PER YEAR
FLUORIDE TO AGE 19
SEALANTS COVERED ON PERMANENT MOLARS
SEALANTS TO AGE AGES 6 TO UNDER AGE 19
BASIC/RESTORATIVE  
INCLUDES FILLINGS - ENDODONTICS - PERIODONTICS - DENTURE REPAIRS - ORAL SURGERY - OFFICE VISITS - APPLIANCE TO CORRECT THUMBSUCKING - EMERG. PALLIATIVE TREATMENT - SPEC. CONSULT 
PERIO - HOW IS IT COVERED? 80% SCALING NOT MORE THAN ONCE EVERY 6 MONTHS
BASIC RESTORATIVE PERCENTAGE 80%
BASIC RESTORATIVE DEDUCTIBLE $50.00
BITEGUARD COVERAGE YES - $50 DEDUCTIBLE 80%
MAJOR  
INCLUDES CROWNS - BRIDGES - PONTICS - DENTURES
MAJOR  PERCENTAGE 50%
DEDUCTIBLE  $50
RESTRICTIONS MUST BE 5 YEARS SINCE LAST PLACEMENT
ORTHODONTICS NO DEDUCTIBLE / 50% / TO A LIFETIME MAXIMUM PAYABLE OF $2,000
LIMITATIONS/WAITING PERIODS YES - IF ELIGIBLE FOR COVERAGE AND YOU DON'T ENROLL 
MISSING TOOTH CLAUSE? NO IF ENROLLED ON 4-1-2000 / YES IF EFFECTIVE ON ANY OTHER DATE
© Copyright 2010 PURMS Self Insurance Fund