BC+ Benchmark Summary of Benefits - final

GUNDERSEN LUTHERAN HEALTH PLAN 2008 - 2009 Summary of BadgerCare Plus Benchmark Plan Covered Services MEMBER BENEFIT AND POLICY MAXIMUMS RESPONSIBILITY Gundersen Lutheran Health Plan covers all medically necessary services as required by the Wisconsin Department of Health and Family Services Administrative Code, HFS 107. HOSPITAL SERVICES $100 Copay per hospital stay • Inpatient Hospital Services (except MH/AODA, refer to MH/AODA section) (medical/ surgical) $50 Copayment per stay for Unlimited days when medically necessary, semi-private room. psychiatric treatment No copayments apply for • Maternity prenatal/maternity care $15 Copay per visit • Outpatient medical services, including diagnostic tests Multiple visits to the same provider on the same day will be treated as a single visit. $15 Copay per visit • Outpatient Surgery $60 Copay • Emergency Room Services (Facility Charges) Copay waived if immediately admitted to inpatient status. PHYSICIAN/CLINICIAN SERVICES $15 Copay per visit • Physician Office Visits or Consultation Additional visits to more than one physician may result in more than one copayment per day. $15 Copay per visit • Urgent Care • Vision Exams $15 Copay per visit • Physical therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) Limited to 20 visits for each type of therapy per enrollment year. BadgerCare 1 GUNDERSEN LUTHERAN HEALTH PLAN 2008 - 2009 Summary ...