PURMS

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Plan Detail Dental
POLICY # PURMS02
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 None
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
Chiropractic adjustments $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
DENTAL  
DEDUCTIBLE $50 FOR BASIC AND/OR MAJOR  
PRE-DETERMINATION REQUIRED N0 - BUT RECOMMENDED  
MAXIMUM PAYABLE $1,000 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 $500
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