| 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 |
$100 co-pay |
$100 co-pay |
Podiatry Office Visit |
$40 co-pay |
$40 co-pay |
Cardiac Rehab Series |
$40 co-pay |
$40 co-pay |
Mental Health |
$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 |
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|
Within CMH PHO |
Outside CMH PHO |
Within CMH PHO |
Outside CMH PHO |
Calendar Year Deductible |
$500/Individual |
$1000/Individual |
$1,500/Individual |
$3,000/Individual |
Out-of-Pocket Maximum |
$2,000/Individual |
$4,000/Individual |
$3,000/Individual |
$6,000/Individual |
Three levels of coverage now apply:
Effective January 1, 2012, there will be no allowance for services performed OUTSIDE the CMH network to be paid at the In-Network level. The In-Network facilities are identified as Central Maine Medical Center, Bridgton Hospital, Rumford Hospital, Parkview Hospital in Brunswick and Franklin Memorial Hospital in Farmington.
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 (after deductible) |
Inside the UHC Options PPO (after deductible) |
Outside of CMH and UHC Networks |
Includes: inpatient surgical facilities & supplies, room & board, newborn care, outpatient surgical facilities & supplies |
90% |
70% |
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% |
70% |
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% |
70% |
50% |
Other Services |
|
|
|
Diagnostic lab & X-ray |
90% |
70% |
50% |
Ambulance service |
90% |
70% |
50% |
Pre-admission testing |
90% |
70% |
50% |
Durable medical equip. ($3,000/yr. max.) |
90% |
70% |
50% |
Insulin pumps and supplies |
90% |
70% |
50% |
Organ & bone transplants |
90% |
70% |
50% |
Vasectomy & tubal ligation |
90% |
70% |
50% |
Removal of impacted wisdom teeth |
90% |
70% |
50% |
Acupuncture ($300/yr. max.) |
50% |
50% |
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."