Hospital Room/Ancillary Services

The information below applies to the HPH/HMO Commercial Copay Table.

General Provisions Applicable to All Coverage Codes Listed

Benefit coverage includes hospital room and board for inpatient semi-private room, newborn nursery, isolation, intermediate care, intensive care and coronary care units. Operating room services are covered, including surgical supplies, anesthesia services and supplies, blood transfusion services, drugs, dressings and oxygen. Also covered are antibiotics, laboratory tests, X-rays, radiotherapy, chemotherapy for malignancy, hemodialysis, and physical and occupational therapy. Copayments expressed as percentages represent the member's portion of HMSA's eligible charge.

Footnotes

1. This plan requires a member copayment of 20 percent of the eligible charge for physical therapy, occupational therapy and malignancy-related chemotherapy.
2. This plan provides a benefit maximum of five days of hospital inpatient services per calendar year. This plan requires $100 copayment per day based on the highest semi-private room rate and $100 copayment per day for intermediate care, isolation, intensive care and coronary care units, and newborn nursery. Included as part of the $100 per day copayment for hospital room and board are operating room services (surgical supplies, anesthesia supplies, blood transfusion services, drugs, dressings, and oxygen) and other ancillary services (antibiotics, laboratory tests, X-rays, antibiotics, physical therapy and speech therapy).
3. This plan covers 100 percent of eligible charge for private room rate when admitted to Wilcox Hospital.
4. This plan has a 12-month waiting period for any preexisting illness or condition, including conditions resulting from an injury. The waiting period also applies to a complication resulting from a preexisting illness or condition.
5. This plan has a 12-month waiting period for any preexisting illness or condition, including conditions resulting from an injury. The waiting period also applies to a complication resulting from a preexisting illness or condition. This plan has 12-month waiting period for maternity benefits, pregnancy, childbirth and related conditions.
6. This plan has a nine-month waiting period for maternity care, pregnancy, childbirth and related conditions.
7. The exception is that benefit for inpatient hospital room and board and ancillary services for treatment of mental illness, alcohol or drug dependence, or detoxification services will be covered at 100 percent of Eligible Charges.

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