Arizona Basic Health Benefit Plan

The Basic Health Benefit Plan may be provided through a commercial insurance carrier, a hospital and medical service corporation or a health care services organization that has been approved as an Accountable Health Plan.

The benefits and services of the Plan may be provided through an indemnity plan with or without a preferred provider network or through the restricted provider network of a health care services organization (health maintenance organization).

The Basic Health Benefit Plan may be offered to any employer at any time.

*********


The Basic Health Benefit Plan must include coverage for the following:

Immediate coverage for children newly born, adopted or placed for adoption pursuant to A.R.S. §§ 20-826, 20-1057 or 20-1402.

Continuing coverage beyond the limiting age for a child handicapped or disabled pursuant to A.R.S. §§ 20-826 or 20-1407.

Benefits for surgical service which is covered by the policy regardless of the place the surgery is performed pursuant to A.R.S. §§ 20-826, 20-1051 or 20-1402.

Benefits for home health services prescribed in lieu of inpatient hospital care pursuant to A.R.S. §§ 20-826, 20-1051 or 20-1402.

Benefits for diagnostic services performed outside a hospital in lieu of inpatient service pursuant to A.R.S. §§ 20-826, 20-1051 or 20-1402.

Benefits for services performed in a hospital's outpatient department or in a freestanding surgical facility pursuant to A.R.S. §§ 20-826, 20-1051 or 20-1402.

Benefits for breast reconstructive surgery and external postoperative prosthesis following a covered mastectomy pursuant to A.R.S. §§ 20-826, 20-1057 or 20-1402.

Benefits for mammography screening pursuant to A.R.S. §§ 20-826, 20-1057 or 20-1402.

Reimbursement for services within the lawful scope of practice of a registered nurse practitioner or a certified registered nurse qualified under the rules adopted by the State Board of Nursing pursuant to A.R.S. §§ 20-841.03 or 20-1406.03.

Effective July 13, 1995, pursuant to A.R.S. § 20-2321 the Basic Health Benefit Plan also provides that the maternity benefits apply to the cost of the birth of a child who is legally adopted by the enrollee.

With respect to those benefits, the Basic Health Benefit Plan issued by an Accountable Health Plan must contain benefit definitions, language, certificates of coverage, provider definitions, exclusions and limitations and commission structures that are comparable to its most commonly used, or what is presumed to be its most commonly used, group health plan closest in size to the small employer group health plans currently being offered by that Accountable Health Plan in this state.

Attached is the schedule of benefits for the Basic Health Benefit Plan.

11/95

ARIZONA BASIC HEALTH BENEFIT PLAN SCHEDULE OF BENEFITS
Plan features
and Benefits
Indemnity plan
or
indemnity plan
in preferred
provider network
Indemnity plan
out of preferred
provider network
Health Maintenance
Organization
Calendar Year Deductible Individual $1000 $1500 Not Applicable
Family Aggregate $2000 $3000
$500 additional per hospital admission if pre-Certification not received
Not Applicable
Physician Services Office Visit 80% After Calendar Year Deductible 60% After Calendar Year Deductible $20 Co-Payment
Routine Physical Exams Not Covered Not Covered $20 Co-Payment
Immunizations (Only) Patient Pays
$5 Co-Payment
Not Covered $5 Co-Payment
Well Child Care 80% After Calendar Year Deductible Not Covered $20 Co-Payment
Well Woman Care 80% After Calendar Year Deductible Not Covered $20 Co-Payment
Maternity Services including Pre/Post Natal Care, Labor & Delivery 80% After Calendar Year Deductible 60% After Calendar Year Deductible $20 Co-Payment
Allergy Testing & Treatment 80% After Calendar Year Deductible 60% After Calendar Year Deductible $20 Co-Payment
Diagnostic lab & X-ray services 80% After Calendar Year Deductible 60% After Calendar Year Deductible $20 Co-Payment
Vision Screening Not Covered Not Covered $20 Co-Payment
Hospital Services Inpatient room & board
Lab & X-ray
Medical supplies & miscellaneous hospital services
80% After Calendar Year Deductible (Pre-certification required) 60% After Calendar Year Deductible (Pre-certification required) $500 Co-Payment each admission
Outpatient Hospital 80% After Calendar Year Deductible 60% After Calendar Year Deductible $100 Co-Payment per visit
Emergency Care Physicians Office 80% After Calendar Year Deductible 80% After Calendar Year Deductible $20 Co-Payment
Urgent Care Center 80% After Calendar Year Deductible 80% After Calendar Year Deductible $35 Co-Payment
Hospital 80% After Calendar Year Deductible 80% After Calendar Year Deductible $50 Co-Payment (Waived if admitted)
Ambulance 80% After Calendar Year Deductible 80% After Calendar Year Deductible Covered at 100%
Prescriptions
80% After Calendar Year Deductible (Generic drugs when available) 60% After Calendar Year Deductible (Generic drugs when available) $20 Co-Payment at a participating pharmacy
Durable Medical Equipment
80% After Calendar Year Deductible 60% After Calendar Year Deductible Covered at 100% (Limit of $2000 per calendar year)
Mental Health & Substance Abuse Services Inpatient Care 80% After Calendar Year Deductible (Benefit maximum the lessor of 30 days/calendar year and $10,000/lifetime) 60% After Calendar Year Deductible (Benefit maximum the lessor of 30 days/calendar year and $10,000/lifetime) 30 days in participating hospital ($500 copayment each admission)
Outpatient Care 80% After Calendar Year Deductible
Benefit maximum $1000/calendar year
60% After Calendar Year Deductible
Benefit maximum $1000/calendar year
$20 Co-Payment
Maximum of 20 visits per calendar year
Other Medical Services Skilled Nursing Facility 80% After Calendar Year Deductible (30 days maximum per calendar year) 60% After Calendar Year Deductible (30 days maximum per calendar year) 100% Coverage (30 days maximum covered)
Home Health Care 80% After Calendar Year Deductible 60% After Calendar Year Deductible 100% Coverage(60 days maximum covered)
Hospice 80% After Calendar Year Deductible (6 month maximum) 60% After Calendar Year Deductible (6 month maximum) 100% Coverage (6 month maximum)
Family Planning - Vasectomy Not Covered Not Covered $100 Co-Payment
Family Planning - Tubal Ligation Not Covered Not Covered $250 Co-Payment
Short Term Therapy 80% After Calendar Year Deductible 60% After Calendar Year Deductible $20 Co-Payment
Out of Pocket Limit $1000 per individual, $2000 per family in addition to calendar year deductible and co-payments $1500 per individual, $3000 per family in addition to calendar year deductible and co-payments Individual - 200% Annual Premium
Family - 200% Annual Premium
Lifetime Maximum Benefit $1,000,000 per individual $1,000,000 per individual