State Coverage Insurance
Summary of Benefits and Cost Sharing Limits*
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The benefit package is limited to $100,000 in benefits payable per member per benefit
year.
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Premiums: Employers may pay $75.00 per month/per employee depending on member income
and employee pays $0 - $35 per month depending on income. Individual members (without
an employer sponsor) may pay both the employer and employee premiums. The State
assists eligible individuals who meet the 0-100% FPL income guideline with premium
payments for the program.
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Service
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Co-pay at 0%-100% FPL
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Co-pay at 101%-150% FPL
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Co-pay at 151%-200% FPL
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Physician/Provider Visits (no co-pay for preventive services)
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$0
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$5
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$7
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Pre/Post Natal Care
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$0
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$0
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$0
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Preventive Services
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$0
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$0
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$0
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Hospital Inpatient Medical/Surgical**
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$0/per admission
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$25/per admission
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$30/per admission
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Hospital Inpatient Maternity**
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$0/per admission
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$25/per admission
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$30/per admission
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Hospital Outpatient Surgery/Procedures
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$0
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$5
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$7
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Home Health**
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$0
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$5
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$7
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Physical Therapy, Occupational Therapy & Speech Therapy
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$0
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$5
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$7
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Diagnostics
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$0 (included in office visit)
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$0 (included in office visit)
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$0 (included in office visit)
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Durable Medical Equipment/Supplies
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$0
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$5
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$7
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Diabetes Treatment
Equipment and Supplies
Diabetes Management
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$3
$0
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$3
$5
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$3
$7
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Emergency Services
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$0
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$15 per visit, waived if admitted to a hospital within 24 hours
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$20 per visit, waived if admitted to a hospital within 24 hours
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Urgent Care
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$0
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$5
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$7
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Prescription Drugs:
Generic
Name Brand
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$3 per prescription
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$3 per prescription
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$3 per prescription
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Behavioral Health and Substance Abuse:
Outpatient office visit and outpatient substance abuse treatment
Inpatient behavioral health and inpatient detoxification
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$0
$0
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$5
$25
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$7
$30
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Limits on Out-of-Pocket Expenses
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Out-of-pocket charges for all participants will be limited to 5 percent of countable
family income per benefit year.
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* Subject to plan limitations and plan prior authorization requirements; there are
no copayment requirements for services provided to Native Americans in the SCI program.
** Inpatient hospitalization coverage is limited to 25 days per benefit year. This
25-day limitation is combined with home health services and inpatient physical health
rehabilitation.
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