This benefits package includes individuals with chronic care disease states who are the most medically vulnerable of our population and who require intensive care. Consequently, members falling within this benefits package will receive complex case management for the following conditions:
• Coronary Artery Disease (CAD)
• Congestive Heart Failure (CHF)
• Chronic Obstructive Pulmonary Disease (COPD)
Please refer to the Plan Benefits Design in the Forms and References section of this manual for a
complete list of covered services, non-covered services, cost sharing, and service limits, which
are subject to change
Co-payments are an essential part of the new benefits design. Each member of the Plan must take
some financial responsibility for their health care. Thus, co-pays are built into each benefits package
according to the services needed and the acuity of the member involved. For Essential Care Choices,
the members may pay a higher co-pay. Members who have a chronic illness that the Plan is targeting
may pay a lower co-pay for their care.
Many services have visit, financial, or coverage limits that are outlined in the new Plan design.
Providers will be paid only for services within these coverage limits, and no services outside of these
limits will be prior authorized by the Plan.