How the Maroon Plan Works

What Is Covered

The table below describes what the Maroon Plan covers. Unless otherwise noted, the Deductible must be met before the plan pays benefits. Once you reach the Out-of-Pocket Limit, the plan pays 100%. See How it Works.

Covered Service	Maroon Plan Pays
Ambulance Transportation Benefits cover ambulance transportation when it is necessary due to the patient’s condition to the nearest Hospital, Skilled Nursing Facility or from a non-network Hospital to the nearest network Hospital. Coverage is limited to the first trip to and from the Hospital for any one injury, illness or pregnancy. Benefits will not be paid for long distance trips or for the use of an ambulance for the patient’s or family’s convenience.	80%
Chiropractic/Muscle Manipulations and Naprapathy Therapy/Services Must be referred by a physician and provided by a state-licensed chiropractor. Maintenance therapy is not covered. For each condition, the utilization review organization will review treatment to determine medical necessity after 20 therapy sessions.	Naprapathy: 80% Chiropractic/Muscle Manipulations: In-network: 80% Out-of-network: 65%
Consultations Covers consultations requested by your attending physician. The consulting physician must have a special skill or knowledge that applies to the diagnosis or treatment for the condition.	In-network: 80% Out-of-network: 65%
Coordinated Home Care Services must be provided by a Home Health Care Agency and begin within 14 days of discharge from a Hospital or Skilled Nursing Facility. The home health care may include skilled nursing services and services of physical therapists, Hospital labs and medical supplies but does not include private duty nursing. Call the claims administrator for approval or the expenses will not be covered by the plan.	100% up to 120 visits a year.
Diagnostic Services Covers inpatient and outpatient diagnostic services ordered by a physician, dentist or podiatrist including x-rays related to covered inpatient surgery, x-rays related to the correction of fractures or complete dislocations, and surgical pathology related to covered surgery.	In-network: 80% Out-of-network: 65%
Durable Medical Equipment Covers rental (not to exceed the purchase price) or, at the option of the claims administrator, purchase of medical equipment required for temporary therapeutic treatment of an illness or injury, or to replace a bodily function lost or impaired due to illness, injury or congenital defect. The equipment must be used to serve a medical purpose.	80%
Elective Abortions Covered if legal where performed.	In-network: 80% Out-of-network: 65%
Emergency Accident Care Benefits cover initial outpatient treatment and related diagnostic services for accidental injuries when treatment occurs within 72 hours of the accident.	80%
Emergency Medical Care Benefits cover sudden and unexpected onsets of severe medical conditions (such as chest pains, convulsions and persistent abdominal pains) that would lead you to believe that in the absence of immediate medical care would likely result in serious and permanent medical consequences.	80%
Medical Care Outside the United States Medical care services are covered the same as in the United States. The original provider bill should be submitted with a claim form. Claims in a foreign language must be translated into English and will be paid in U.S. currency using the exchange rate on the date of the claim.	80%
Hospice Care Includes supportive services and providing physical, psychological, social, and spiritual care for dying persons and their families. Care can be received in your home, inpatient Hospital or Skilled Nursing Facility. See Hospice Care for details.	100%
Hospital Services – Inpatient Includes bed, board and routine nursing care up to the hospitals most common semi-private room rate or special charges for intensive care confinement, and ancillary services such as operating rooms and drugs, and surgical dressings and lab work.	In-network: 80% Out-of-network: 65%
Human Organ Transplants Contact the utilization review organization to find out whether your transplant is covered and where you can have the service performed. Provides benefits for a medically necessary human organ transplant. If both the donor and recipient have their own coverage, each will have his/her claims paid by his/her own plan. If you are the recipient and the donor has no health care coverage, benefits under this plan will be provided for both you and the donor with payments made to the donor charged against your Lifetime Maximum. If you are the donor and the recipient has no health care coverage, you will receive benefits from this plan but the recipient will not. Covered transplants performed at any facility include parathyroid, muscular skeletal, heart valve, cornea, kidney and bone marrow. In addition, for heart, lung, heart/lung, liver, pancreas or pancreas/kidney organ or tissue transplants, benefits begin no earlier than five days before and 365 days after the transplant surgery, and transportation expenses within the U.S. and Canada for the donor organ to the location of the transplant surgery is covered. However, coverage is only provided if the transplant is performed at a Hospital with a Human Organ Transplant Program approved by the claims administrator. The plan does not cover investigational drugs, travel time and related expenses required by a provider; transportation by air ambulance for the donor or recipient; and cardiac rehabilitation services not provided to the transplant recipient within three days after discharge from a Hospital for transplant surgery.	In-network: 80% Out-of-network: 65%
Infertility Treatment Covered expenses include uterine embryo lavage, embryo transfer, artificial insemination, in vitro fertilization, gamete intrafallopian tube transfer (GIFT), zygote intrafallopian tube transfer (ZIFT) and low tubal ovum transfer for covered individuals who can not conceive after one year of trying in the normal manner or who cannot sustain a successful pregnancy. For in vitro, GIFT and ZIFT, expenses are covered only if the patient was unable to attain or sustain a successful pregnancy through the other covered procedures, the patient hasn’t completed four oocyte retrievals (except that if a live birth follows a complete oocyte retrieval, then two more complete oocyte retrievals are covered), and the procedures are performed at a medical facility that conforms to the American College of Obstetric and Gynecology guidelines or the American Fertility Society minimal standards for in vitro fertilization. Expenses above the lifetime limit of $50,000 are not covered by the plan.	In-network: 80% Out-of-network: 65%
Expenses above the lifetime limit of $50,000 are not covered by the plan. Maternity Services Certain services for newborn infants are covered as part of the mother’s delivery charges, including routine inpatient Hospital nursery charges incurred immediately after birth, and one routine inpatient examination by a physician, other than the physician who delivered the child or administered anesthesia. If treatment is needed for an ill or injured newborn child, benefits will be paid for that care if there is family coverage. Certified nurse-midwife care is covered.	In-network: 80% Out-of-network: 65%
Dental Accident Care Benefits will be paid for medical services that a dentist or physician provides after an accidental injury to the jaws, teeth, mouth or face. These services are covered only if the injury occurred on or after your coverage begins.	80%
Mental Health Services – Inpatient Covers partial psychiatric Hospital treatment if medically necessary and pre-certified. If you don’t pre-certify, benefits may be reduced.	In-network: 80% Out-of-network: 65%
Mental Health Services – Outpatient Covers psychotherapy, group therapy, marriage and family therapy and psychological testing. Counseling for family members is covered when necessary to assist in treating the patient. Services must be provided by a physician, clinical psychologist, licensed clinical professional counselor, licensed marriage and family therapist or licensed social worker.	In-network: 80% Out-of-network: 65% Limited to 30 visits each year (combined for mental health and substance abuse).
Oral Surgery Benefits for surgery performed by a dentist are limited to: Excision of tumors or cysts of the jaws, cheeks, lips, tongue, and roof and floor of the mouth. Surgical procedures to correct accidental injuries of the jaws, cheeks, lips, tongue, and roof and floor of the mouth if the injury occurred after your coverage began. Excision of exostosis (bony outgrowth) of the jaws and hard palate, provided this procedure is not done in preparation for dentures or other prostheses. Treatment of facial bone fractures. External excision and drainage of cellulitis. Incision of accessory sinuses, salivary glands or ducts. Reduction of dislocation or excision of the temporomandibular joints. Effective July 1, 2003 removal of bony impacted wisdom teeth.	In-network: 80% Out-of-network: 65%
Other Covered Services Services provided by a physician or Hospital including radiation therapy; chemotherapy; renal dialysis treatments in a Hospital, dialysis facility, or your home under the supervision of a dialysis facility; shock therapy; physical therapy provided by a registered physical therapist; occupational therapy provided by a registered occupational therapist; chiropractic therapy provided under a physician’s referral to a state-licensed chiropractor; allergy shots and surveys; and mammograms.	In-network: 80% Out-of-network: 65%
Other Equipment, Supplies and Appliances Benefits cover the following when ordered by a physician: Oxygen and its administration. Blood and blood components. Leg, back, arm and neck braces when required because of an illness beginning or injury occurring on or after coverage date. Medical and surgical dressings, supplies, casts and splints. Durable medical equipment such as cardiac valves, internal pacemakers, bone screws, bolts, nails, plates, and other internal and permanent devices as reasonably approved by the claims administrator.	80%
Physical and Occupational Therapy Must be provided by a licensed professional therapist. Maintenance therapy and educational training designed to develop a physical function are not covered. For each condition, the utilization review organization will review treatment to determine medical necessity after 20 therapy sessions.	In-network: 80% Out-of-network: 65%
Physician’s Services Covers services provided at your doctor’s office or in your home; while you are an inpatient in a Hospital, Skilled Nursing Facility or substance abuse treatment facility; or are a patient in a partial hospitalization psychiatric treatment program or coordinated home care program.	In-network: 80% Out-of-network: 65%
Pre-admission Testing Covers outpatient tests given by a Hospital in preparation for scheduled inpatient surgery.	100%
Pre-existing Conditions	Covered at same level as any other medical condition.
Prescription Drugs Covers prescription drugs and medicines dispensed by a licensed pharmacist or physician with a written prescription at a participating pharmacy or through the mail order program. Drugs must be approved by the U.S. Food and Drug Administration for general use by humans, including oral contraceptives. Most contraceptives that you receive from your physician, such as intrauterine devices (IUD’s), diaphragms, implants (e.g., Norplant) and non-self-administered injectables (e.g., Depo Provera), are covered by your medical plan. Contact your medical plan for more information.	Participating Retail Pharmacy: For 30-day supply – 100% after $8 Copayment for generic, $20 Copayment for preferred brand-name or $35 Copayment for non-preferred brand-name Mail Order: For 90-day supply – 100% after $16 Copayment for generic, $40 Copayment for preferred brand-name or $70 Copayment for non-preferred brand-name
Private Duty Nursing Services Benefits cover services for an inpatient when the claims administrator determines that the regular nursing staff would not provide necessary care, and home services could not be provided by non-professional personnel. Expenses for nursing services provided by immediate members of family are not covered by the plan.	80%
Prosthetic Appliances Covers prosthetic appliances, devices and surgical implants required to replace: All or part of an organ or tissue of the human body, or All or part of the function of an organ or tissue of the human body. Benefits also cover adjustments, repair and replacements of these appliances when necessary because of wear or change in condition.	80%
Second or Third Opinions If your doctor recommends surgery, you can call the utilization review organization for the names of doctors who can provide you with a second opinion. If the second surgical opinion does not confirm the need for surgery, benefits will be provided for a third opinion. Your benefits for a second or third opinion are the same as for a first surgical opinion.	In-network: 80% Out-of-network: 65%
Skilled Nursing Facility Care Covers bed, board and routine nursing care at the most common semi-private room rate, as well as ancillary services such as drugs, surgical dressings or supplies at an approved Skilled Nursing Facility. You must be admitted within 14 days of discharge from a Hospital or coordinated home care program. Custodial care services are not covered. Call the claims administrator for approval or no expenses will be covered by the plan.	100% up to 120 days each year.
Speech Therapy Must be provided by a licensed or American Speech and Hearing Association-certified therapist. Covers services for an inpatient admitted to a Hospital for another reason. Maintenance therapy and educational training is not covered. Speech therapy is reviewed after 20 therapy sessions to determine medical necessity.	In-network: 80% Out-of-network: 65%
Substance Abuse Treatment Benefits cover all services already described in this section, if treatment for substance abuse takes place in a Hospital or substance abuse treatment facility.	In-network: 80% Out-of-network: 65%
Surgery and Related Services Includes inpatient and outpatient surgery performed by a physician, dentist or podiatrist; anesthesia; and assistant surgical services performed by a physician, dentist or podiatrist if a Hospital intern or resident is not available to provide such assistance.	In-network: 80% Out-of-network: 65%
Wellness Care Covers annual routine physical exams and related diagnostic tests (such as digital rectal exam, colorectal cancer screening and prostate test), immunizations, influenza vaccinations and routine gynecological exams (such as Pap tests but excluding mammograms) provided by a physician.	100% up to $300 per calendar year for each covered person. There is no additional coverage for wellness care once the $300 wellness benefit has been provided.

While this Summary Plan Description summarizes the major provisions of this plan, it does not provide you with every plan detail. The plan documents, which govern this plan, provide full details. If there are any discrepancies between this Summary Plan Description and the legal plan documents, the legal plan documents control.