Individual Elect PPO Plan
Individual Elect PPO Plan
EXCLUSIONS AND LIMITATIONS:
WHAT THE PLAN DOES NOT PAY FOR
Excluded Services
The Plan does not provide benefits for:
A. Any amounts in excess of maximum
amounts of Covered Expenses stated in
this Plan.
B.
Services not specifically listed in this Plan
as Covered Services.
C. Services or supplies that are not Medically
Necessary as defined by Us.
D. Services or supplies that We consider to
be Experimental or Investigative.
HEALTH INSURANCE
ROOTED IN HOUSTON
Memorial Hermann Insurance Co is backed by Memorial Hermann Health System, the health system Houston
has counted on for more than 100 years. By aligning care delivery, physicians and health insurance, Memorial
E.
Services received before the Effective
Date or during an inpatient stay that
began before that Effective Date.
F.
Services received after coverage ends.
G. Services for which You have no legal
obligation to pay or for which no charge
would be made if You did not have health
plan or insurance coverage, except to the
extent that the availability of insurance or
health plan coverage may be considered
by a tax supported institution of the
State of Texas providing treatment of
Mental Illness or mental retardation to
determine if a patient is non-indigent,
as provided in Article 3196a of Vernon’s
Texas Civil Statutes.
H. Any condition for which benefits are
recovered or can be recovered, either by
adjudication, settlement or otherwise,
under any workers’ compensation,
employer’s liability law or occupational
disease law, even if You do not claim
those benefits.
I.
Hermann has built Houston’s first and only truly integrated health system. And together, we’re committed to
delivering health care that’s safer, smarter and more cost-effective.
To learn about how Memorial Hermann Health Insurance Co is transforming health insurance and advancing
J.
health care in our community, visit healthplan.memorialhermann.org. Or call (713) 338-6556 today.
K.
INDIVIDUALS & FAMILIES
An Individual Elect PPO Plan from Memorial Hermann Health Insurance Co offers
individuals and families the high quality Memorial Hermann doctors you already know,
L.
Conditions caused by or contributed by (a)
an act of war; (b) The inadvertent release
of nuclear energy when government funds
are available for treatment of Illness or
Injury arising from such release of nuclear
energy; (c) An Insured Person participating
in the military service of any country; (d)
An Insured Person participating in an
insurrection, rebellion, or riot; (e) Services
received for any condition caused by
an Insured Person’s commission of, or
attempt to commit a felony.
Any services provided by a local, state
or federal government agency except (a)
when payment under this Plan is expressly
required by federal or state law; or (b)
services provided for the treatment of
Mental or Nervous Disorders by a tax
supported institution of the State of Texas.
Professional services received or supplies
purchased from Yourself, a person who
lives in the Insured Person’s home or who
is related to the Insured Person by blood,
marriage or adoption, or the Insured
Person’s employer, unless the employer is
a Hospital or a Doctor of Medicine.
Inpatient or outpatient services of a
private duty nurse.
M. Inpatient room and board charges in
connection with a Hospital stay primarily
for environmental change, Physical
Therapy or treatment of chronic pain;
Custodial Care or rest cures; services
provided by a rest home, a home for
the aged, a nursing home or any similar
facility service.
V.
N. Inpatient room and board charges in
connection with a Hospital stay primarily
for diagnostic tests which could have been
performed safely on an outpatient basis.
W. Treatment of sexual dysfunction,
impotence and/or inadequacy.
O. Dental services, dentures, bridges,
crowns, caps or other Dental Prostheses,
extraction of teeth or treatment to the
teeth or gums, except as specifically
stated under Dental Care and Pediatric
Dental Care in the Comprehensive
Benefits section of this Plan, including
dental services for Temporomandibular
Joint Dysfunction (TMJ), and except
as specifically stated under Services
and Supplies Provided by a Hospital or
Ambulatory Surgical Center.
P.
Orthodontic Services, braces and
other orthodontic appliances
including orthodontic services for
Temporomandibular Joint Dysfunction
(TMJ), except as specifically stated
under Pediatric Dental Care in the
Comprehensive Benefits section of
this Plan.
Q. Dental Implants: Dental materials
implanted into or on bone or soft tissue
or any associated procedure as part of
the implantation or removal of dental
implants, except as specifically stated
under Pediatric Dental Care in the
Comprehensive Benefits section of
this Plan.
R.
Optometric services, eye exercises
including orthoptics, eyeglasses, contact
lenses, routine eye exams, and routine eye
refractions, except as specifically stated in
this Plan.
S.
An eye surgery solely for the purpose
of correcting refractive defects of the
eye, such as near-sightedness (myopia),
astigmatism and/or farsightedness
(presbyopia).
T.
Any drugs, medications, or other
substances dispensed or administered
in any outpatient setting except as
specifically stated in this Plan. This
includes, but is not limited to, items
dispensed by a Physician.
U. Cosmetic Surgery or other services for
beautification, including any medical
complications that are generally
predictable and associated with such
services by the organized medical
community. This exclusion does not apply
to Medically Necessary Reconstructive
Surgery to restore a bodily function or
to correct a deformity caused by Injury
or congenital defect of a Newborn child,
or to breast reconstruction performed
to restore or achieve breast symmetry
incident to a mastectomy, or abnormal
craniofacial structure caused by congenital
defects, developmental deformities,
trauma, tumors, infections or disease.
X.
Y.
Procedures or treatments to change
characteristics of the body to those of the
opposite sex. This includes any medical,
surgical or psychiatric treatment or study
related to sex change.
All services related to the evaluation or
treatment of fertility and/or Infertility,
including, but not limited to, all
tests, consultations, examinations,
medications, invasive, medical,
laboratory or surgical procedures
including sterilization reversals and In
vitro fertilization, except as specifically
stated under Comprehensive Benefits.
All non-prescription contraceptive
devices and supplies including but
not limited to all consultations,
examinations, evaluations,
medications, medical, laboratory,
devices, Prescription Drugs or surgical
procedures except as specifically stated
in this Plan. Oral contraceptives and
Prescription contraceptive devices
available through a pharmacy are
covered under the Prescription Drug
benefit of this Plan.
Z. Cryopreservation of sperm or eggs.
AA. Services primarily for weight reduction
or treatment of obesity including morbid
obesity, or any care which involves weight
reduction as a main method for treatment,
except as provided under the Child and
Adult Preventive Care Services provision.
AB. Routine physical exams or tests that
do not directly treat an actual Illness,
Injury or condition, including those
required by employment or government
authority except as specifically stated
under the Professional and Other
Services, Child and Adult Preventive
Care Services and Routine Care
Services sections of this Plan.
AC. Charges by a provider for telephone
consultations and for Telemedicine or
Telehealth Services. (Note: a Telemedicine
Medical Service or Telehealth Service
will not be excluded solely because the
service is not provided through a face to
face consultation.)
AD. Items which are furnished primarily for
personal comfort or convenience (air
purifiers, air conditioners, humidifiers,
exercise equipment, treadmills, spas,
elevators and supplies for hygiene or
beautification including wigs, etc.).
AE. Educational services except as specifically
provided for Diabetes Self-Management
Training or as provided or arranged by Us.
AF. Nutritional counseling or food
supplements, except for formulas
necessary for the treatment of
phenylketonuria and as provided under
the Child and Adult Preventive Care
Services provision.
AG. Durable medical equipment except
as specifically stated in this Policy.
Excluded durable medical equipment
includes, but is not limited to: air
purifiers, air conditioners, humidifiers;
exercise equipment, treadmills; spas;
elevators; and supplies for comfort,
hygiene or beautification.
AH. Physical and/or Occupational Therapy/
Medicine, except when provided during
an inpatient Hospital confinement or as
specifically provided under the benefits
for Physical and/or Occupational
Therapy/Medicine.
AI. All Infusion Therapy together with any
associated supplies, Drugs or professional
services are excluded except as
specifically provided under the benefit for
Infusion Therapy described in this Plan.
AJ. All Foreign Country Provider charges
are excluded under this Plan except
as specifically stated under Treatment
received from Foreign Country Providers
under the Benefits section of this Plan.
AK. Routine foot care including the cutting
or removal of corns or calluses; the
trimming of nails, routine hygienic care
and any service rendered in the absence
of localized Illness, Injury, symptoms
involving the feet, diabetes, circulatory
disorders of the lower extremities,
peripheral vascular disease, peripheral
neuropathy, or chronic arterial or
venous insufficiency.
AL. Charges for which We are unable to
determine Our liability because You or
an Insured Person failed, within 60 days,
or as soon as reasonably possible to (a)
authorize Us to receive all the medical
records and information We requested
or, (b) provide Us with information We
requested regarding the circumstances of
the claim or other insurance coverage.
AM.Charges for the services of a
standby Physician.
AN. Charges for animal to human
organ transplants.
AO. Self-administered injectable Drugs
and syringes, except as stated in the
Prescription Drug Benefits section of
this Plan.
AP. Claims received more than 12 months
after the date service was rendered.
AQ.Acupuncture/Acupressure.
at a price you can afford. Plus, our health coverage offers something no other insurance
provider can: a unique relationship with Memorial Hermann, one of the largest and most
trusted nonprofit health systems in the nation.
Form # 10002COV(10/15)
Copyright © 2015 Memorial Hermann. All rights reserved.
INDIVIDUAL ELECT
PPO PLAN OVERVIEW
Individual Elect PPO Plan
Individual Elect PPO Plan
EXCLUSIONS AND LIMITATIONS:
WHAT THE PLAN DOES NOT PAY FOR
Excluded Services
The Plan does not provide benefits for:
A. Any amounts in excess of maximum
amounts of Covered Expenses stated in
this Plan.
B.
Services not specifically listed in this Plan
as Covered Services.
C. Services or supplies that are not Medically
Necessary as defined by Us.
D. Services or supplies that We consider to
be Experimental or Investigative.
HEALTH INSURANCE
ROOTED IN HOUSTON
Memorial Hermann Insurance Co is backed by Memorial Hermann Health System, the health system Houston
has counted on for more than 100 years. By aligning care delivery, physicians and health insurance, Memorial
E.
Services received before the Effective
Date or during an inpatient stay that
began before that Effective Date.
F.
Services received after coverage ends.
G. Services for which You have no legal
obligation to pay or for which no charge
would be made if You did not have health
plan or insurance coverage, except to the
extent that the availability of insurance or
health plan coverage may be considered
by a tax supported institution of the
State of Texas providing treatment of
Mental Illness or mental retardation to
determine if a patient is non-indigent,
as provided in Article 3196a of Vernon’s
Texas Civil Statutes.
H. Any condition for which benefits are
recovered or can be recovered, either by
adjudication, settlement or otherwise,
under any workers’ compensation,
employer’s liability law or occupational
disease law, even if You do not claim
those benefits.
I.
Hermann has built Houston’s first and only truly integrated health system. And together, we’re committed to
delivering health care that’s safer, smarter and more cost-effective.
To learn about how Memorial Hermann Health Insurance Co is transforming health insurance and advancing
J.
health care in our community, visit healthplan.memorialhermann.org. Or call (713) 338-6556 today.
K.
INDIVIDUALS & FAMILIES
An Individual Elect PPO Plan from Memorial Hermann Health Insurance Co offers
individuals and families the high quality Memorial Hermann doctors you already know,
L.
Conditions caused by or contributed by (a)
an act of war; (b) The inadvertent release
of nuclear energy when government funds
are available for treatment of Illness or
Injury arising from such release of nuclear
energy; (c) An Insured Person participating
in the military service of any country; (d)
An Insured Person participating in an
insurrection, rebellion, or riot; (e) Services
received for any condition caused by
an Insured Person’s commission of, or
attempt to commit a felony.
Any services provided by a local, state
or federal government agency except (a)
when payment under this Plan is expressly
required by federal or state law; or (b)
services provided for the treatment of
Mental or Nervous Disorders by a tax
supported institution of the State of Texas.
Professional services received or supplies
purchased from Yourself, a person who
lives in the Insured Person’s home or who
is related to the Insured Person by blood,
marriage or adoption, or the Insured
Person’s employer, unless the employer is
a Hospital or a Doctor of Medicine.
Inpatient or outpatient services of a
private duty nurse.
M. Inpatient room and board charges in
connection with a Hospital stay primarily
for environmental change, Physical
Therapy or treatment of chronic pain;
Custodial Care or rest cures; services
provided by a rest home, a home for
the aged, a nursing home or any similar
facility service.
V.
N. Inpatient room and board charges in
connection with a Hospital stay primarily
for diagnostic tests which could have been
performed safely on an outpatient basis.
W. Treatment of sexual dysfunction,
impotence and/or inadequacy.
O. Dental services, dentures, bridges,
crowns, caps or other Dental Prostheses,
extraction of teeth or treatment to the
teeth or gums, except as specifically
stated under Dental Care and Pediatric
Dental Care in the Comprehensive
Benefits section of this Plan, including
dental services for Temporomandibular
Joint Dysfunction (TMJ), and except
as specifically stated under Services
and Supplies Provided by a Hospital or
Ambulatory Surgical Center.
P.
Orthodontic Services, braces and
other orthodontic appliances
including orthodontic services for
Temporomandibular Joint Dysfunction
(TMJ), except as specifically stated
under Pediatric Dental Care in the
Comprehensive Benefits section of
this Plan.
Q. Dental Implants: Dental materials
implanted into or on bone or soft tissue
or any associated procedure as part of
the implantation or removal of dental
implants, except as specifically stated
under Pediatric Dental Care in the
Comprehensive Benefits section of
this Plan.
R.
Optometric services, eye exercises
including orthoptics, eyeglasses, contact
lenses, routine eye exams, and routine eye
refractions, except as specifically stated in
this Plan.
S.
An eye surgery solely for the purpose
of correcting refractive defects of the
eye, such as near-sightedness (myopia),
astigmatism and/or farsightedness
(presbyopia).
T.
Any drugs, medications, or other
substances dispensed or administered
in any outpatient setting except as
specifically stated in this Plan. This
includes, but is not limited to, items
dispensed by a Physician.
U. Cosmetic Surgery or other services for
beautification, including any medical
complications that are generally
predictable and associated with such
services by the organized medical
community. This exclusion does not apply
to Medically Necessary Reconstructive
Surgery to restore a bodily function or
to correct a deformity caused by Injury
or congenital defect of a Newborn child,
or to breast reconstruction performed
to restore or achieve breast symmetry
incident to a mastectomy, or abnormal
craniofacial structure caused by congenital
defects, developmental deformities,
trauma, tumors, infections or disease.
X.
Y.
Procedures or treatments to change
characteristics of the body to those of the
opposite sex. This includes any medical,
surgical or psychiatric treatment or study
related to sex change.
All services related to the evaluation or
treatment of fertility and/or Infertility,
including, but not limited to, all
tests, consultations, examinations,
medications, invasive, medical,
laboratory or surgical procedures
including sterilization reversals and In
vitro fertilization, except as specifically
stated under Comprehensive Benefits.
All non-prescription contraceptive
devices and supplies including but
not limited to all consultations,
examinations, evaluations,
medications, medical, laboratory,
devices, Prescription Drugs or surgical
procedures except as specifically stated
in this Plan. Oral contraceptives and
Prescription contraceptive devices
available through a pharmacy are
covered under the Prescription Drug
benefit of this Plan.
Z. Cryopreservation of sperm or eggs.
AA. Services primarily for weight reduction
or treatment of obesity including morbid
obesity, or any care which involves weight
reduction as a main method for treatment,
except as provided under the Child and
Adult Preventive Care Services provision.
AB. Routine physical exams or tests that
do not directly treat an actual Illness,
Injury or condition, including those
required by employment or government
authority except as specifically stated
under the Professional and Other
Services, Child and Adult Preventive
Care Services and Routine Care
Services sections of this Plan.
AC. Charges by a provider for telephone
consultations and for Telemedicine or
Telehealth Services. (Note: a Telemedicine
Medical Service or Telehealth Service
will not be excluded solely because the
service is not provided through a face to
face consultation.)
AD. Items which are furnished primarily for
personal comfort or convenience (air
purifiers, air conditioners, humidifiers,
exercise equipment, treadmills, spas,
elevators and supplies for hygiene or
beautification including wigs, etc.).
AE. Educational services except as specifically
provided for Diabetes Self-Management
Training or as provided or arranged by Us.
AF. Nutritional counseling or food
supplements, except for formulas
necessary for the treatment of
phenylketonuria and as provided under
the Child and Adult Preventive Care
Services provision.
AG. Durable medical equipment except
as specifically stated in this Policy.
Excluded durable medical equipment
includes, but is not limited to: air
purifiers, air conditioners, humidifiers;
exercise equipment, treadmills; spas;
elevators; and supplies for comfort,
hygiene or beautification.
AH. Physical and/or Occupational Therapy/
Medicine, except when provided during
an inpatient Hospital confinement or as
specifically provided under the benefits
for Physical and/or Occupational
Therapy/Medicine.
AI. All Infusion Therapy together with any
associated supplies, Drugs or professional
services are excluded except as
specifically provided under the benefit for
Infusion Therapy described in this Plan.
AJ. All Foreign Country Provider charges
are excluded under this Plan except
as specifically stated under Treatment
received from Foreign Country Providers
under the Benefits section of this Plan.
AK. Routine foot care including the cutting
or removal of corns or calluses; the
trimming of nails, routine hygienic care
and any service rendered in the absence
of localized Illness, Injury, symptoms
involving the feet, diabetes, circulatory
disorders of the lower extremities,
peripheral vascular disease, peripheral
neuropathy, or chronic arterial or
venous insufficiency.
AL. Charges for which We are unable to
determine Our liability because You or
an Insured Person failed, within 60 days,
or as soon as reasonably possible to (a)
authorize Us to receive all the medical
records and information We requested
or, (b) provide Us with information We
requested regarding the circumstances of
the claim or other insurance coverage.
AM.Charges for the services of a
standby Physician.
AN. Charges for animal to human
organ transplants.
AO. Self-administered injectable Drugs
and syringes, except as stated in the
Prescription Drug Benefits section of
this Plan.
AP. Claims received more than 12 months
after the date service was rendered.
AQ.Acupuncture/Acupressure.
at a price you can afford. Plus, our health coverage offers something no other insurance
provider can: a unique relationship with Memorial Hermann, one of the largest and most
trusted nonprofit health systems in the nation.
Form # 10002COV(10/15)
Copyright © 2015 Memorial Hermann. All rights reserved.
INDIVIDUAL ELECT
PPO PLAN OVERVIEW
Individual Elect PPO Plan
INDIVIDUAL ELECT PPO PLAN
PLATINUM
from Memorial Hermann Health Plan
PLATINUM
Deductible
Family Deductible
GOLD
SILVER
BRONZE
Elect Platinum
500 PPO
Elect Gold
1250 PPO
Elect Gold
2000 PPO
Elect Silver
2600 HSA PPO
Elect Silver
3000 PPO
Elect Silver
4000 PPO
Elect Bronze
5000 HSA PPO
Elect Bronze
5250 HSA PPO
Elect Bronze
6850 PPO
$500
$1,250
$2,000
$2,600
$3,000
$4,000
$5,000
$5,250
$6,850
$1,000
$2,500
$4,000
$5,200
$6,000
$8,000
$10,000
$10,500
$13,700
Out-of-Pocket Maximum (Individual)
$1,500
$3,500
$3,000
$6,350
$5,000
$6,000
$6,250
$6,450
$6,850
Out-of-Pocket Maximum (Family)
$3,000
$7,000
$6,000
$12,700
$10,000
$12,000
$12,500
$12,900
$13,700
20%
20%
20%
15%
20%
30%
20%
30%
0%
Member Coinsurance
PCP
$15
20% coinsurance
after deductible
$30
15% coinsurance
after deductible
20% coinsurance
after deductible
$50
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
Specialist
$30
20% coinsurance
after deductible
$50
15% coinsurance
after deductible
20% coinsurance
after deductible
$75
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
Telemedicine/Telehealth
$0
$0
$0
$40 applies
to deductible
$0
$0
$40 applies
to deductible
$40 applies
to deductible
$0
Urgent Care
$30
20% coinsurance
after deductible
$50
15% coinsurance
after deductible
20% coinsurance
after deductible
$75
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
Emergency Room
Hearing & Speech Exams
Independent & Outpatient Lab/
Pathology
Radiology/X-rays
MRI/Scans/Nuclear Medicine
Inpatient Hospital
PT/OT/Chiro
Retail Generic Rx
Retail Brand Rx
Retail Non-Formulary Brand Rx
Retail Specialty Rx
* Special Pharmacy Deductible for
Brand Name, Non-Formulary Brand
Name & Specialty Rx
$500
20% coinsurance
after deductible
15% coinsurance
after deductible
20% coinsurance
after deductible
$30
15% coinsurance
after deductible
20% coinsurance
after deductible
$500
GOLD
SILVER
BRONZE
Age
Elect
Platinum
500 PPO
Elect Gold
1250 PPO
Elect Gold
2000 PPO
Elect Silver
2600 HSA
PPO
Elect Silver
3000 PPO
Elect Silver
4000 PPO
Elect Bronze Elect Bronze
Elect Bronze
5000 HSA
5250 HSA
6850 PPO
PPO
PPO
0-20
$253.51
$229.50
$226.73
$187.41
$198.20
$192.59
$161.52
$158.46
$159.19
21
$399.23
$361.41
$357.05
$295.14
$312.12
$303.29
$254.36
$249.55
$250.69
22
$399.23
$361.41
$357.05
$295.14
$312.12
$303.29
$254.36
$249.55
$250.69
23
$399.23
$361.41
$357.05
$295.14
$312.12
$303.29
$254.36
$249.55
$250.69
24
$399.23
$361.41
$357.05
$295.14
$312.12
$303.29
$254.36
$249.55
$250.69
25
$400.83
$362.86
$358.48
$296.32
$313.37
$304.50
$255.38
$250.55
$251.69
26
$408.81
$370.08
$365.62
$302.22
$319.61
$310.57
$260.46
$255.54
$256.71
27
$418.39
$378.76
$374.19
$309.31
$327.10
$317.85
$266.57
$261.53
$262.72
28
$433.96
$392.85
$388.11
$320.82
$339.27
$329.68
$276.49
$271.26
$272.50
29
$446.74
$404.42
$399.54
$330.26
$349.26
$339.38
$284.63
$279.25
$280.52
30
$453.13
$410.20
$405.25
$334.98
$354.26
$344.23
$288.70
$283.24
$284.53
31
$462.71
$418.87
$413.82
$342.07
$361.75
$351.51
$294.80
$289.23
$290.55
32
$472.29
$427.55
$422.39
$349.15
$369.24
$358.79
$300.91
$295.22
$296.57
33
$478.28
$432.97
$427.75
$353.58
$373.92
$363.34
$304.72
$298.96
$300.33
34
$484.67
$438.75
$433.46
$358.30
$378.91
$368.19
$308.79
$302.95
$304.34
35
$487.86
$441.64
$436.32
$360.66
$381.41
$370.62
$310.83
$304.95
$306.34
36
$491.05
$444.53
$439.17
$363.02
$383.91
$373.05
$312.86
$306.95
$308.35
37
$494.25
$447.43
$442.03
$365.38
$386.40
$375.47
$314.90
$308.94
$310.35
38
$497.44
$450.32
$444.88
$367.74
$388.90
$377.90
$316.93
$310.94
$312.36
39
$503.83
$456.10
$450.60
$372.47
$393.90
$382.75
$321.00
$314.93
$316.37
40
$510.22
$461.88
$456.31
$377.19
$398.89
$387.60
$325.07
$318.92
$320.38
41
$519.80
$470.56
$464.88
$384.27
$406.38
$394.88
$331.18
$324.91
$326.40
42
$528.98
$478.87
$473.09
$391.06
$413.56
$401.86
$337.03
$330.65
$332.16
43
$541.76
$490.43
$484.52
$400.50
$423.55
$411.56
$345.17
$338.64
$340.19
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
$75
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
44
$557.72
$504.89
$498.80
$412.31
$436.03
$423.70
$355.34
$348.62
$350.21
45
$576.49
$521.88
$515.58
$426.18
$450.70
$437.95
$367.30
$360.35
$362.00
20% coinsurance
after deductible
$50
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
46
$598.85
$542.12
$535.58
$442.71
$468.18
$454.94
$381.54
$374.33
$376.04
$500
$15
20% coinsurance
after deductible
$15
20% coinsurance
after deductible
$30
15% coinsurance
after deductible
47
$624.00
$564.88
$558.07
$461.30
$487.84
$474.04
$397.56
$390.05
$391.83
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
15% coinsurance
after deductible
20% coinsurance
after deductible
30% coinsurance
after deductible
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
48
$652.74
$590.91
$583.78
$482.55
$510.32
$495.88
$415.88
$408.01
$409.88
49
$681.09
$616.57
$609.13
$503.51
$532.48
$517.41
$433.94
$425.73
$427.68
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
15% coinsurance
after deductible
20% coinsurance
after deductible
30% coinsurance
after deductible
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
50
$713.02
$645.48
$637.69
$527.12
$557.45
$541.68
$454.29
$445.70
$447.73
51
$744.56
$674.03
$665.90
$550.44
$582.10
$565.64
$474.38
$465.41
$467.54
0% after
deductible
52
$779.30
$705.47
$696.96
$576.11
$609.26
$592.02
$496.51
$487.12
$489.35
53
$814.43
$737.28
$728.38
$602.09
$636.72
$618.71
$518.89
$509.08
$511.41
0% after
deductible
54
$852.36
$771.61
$762.30
$630.12
$666.38
$647.52
$543.06
$532.79
$535.22
55
$890.28
$805.94
$796.22
$658.16
$696.03
$676.34
$567.22
$556.50
$559.04
56
$931.40
$843.17
$833.00
$688.56
$728.18
$707.58
$593.42
$582.20
$584.86
57
$972.92
$880.76
$870.13
$719.26
$760.64
$739.12
$619.88
$608.15
$610.93
58
$1,017.24
$920.87
$909.76
$752.02
$795.28
$772.78
$648.11
$635.85
$638.76
59
$1,039.20
$940.75
$929.40
$768.25
$812.45
$789.46
$662.10
$649.58
$652.55
60
$1,083.51
$980.87
$969.03
$801.01
$847.09
$823.13
$690.33
$677.28
$680.37
61
$1,121.84
$1,015.56
$1,003.31
$829.34
$877.06
$852.24
$714.75
$701.24
$704.44
62
$1,146.99
$1,038.33
$1,025.80
$847.94
$896.72
$871.35
$730.78
$716.96
$720.23
63
$1,178.53
$1,066.88
$1,054.01
$871.25
$921.38
$895.31
$750.87
$736.67
$740.04
64+
$1,197.69
$1,084.23
$1,071.15
$885.42
$936.36
$909.87
$763.08
$748.65
$752.07
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
15% coinsurance
after deductible
15% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
30% coinsurance
after deductible
30% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
30% coinsurance
after deductible
30% coinsurance
after deductible
$0
$0
$0
$0 after
deductible
$0
$0
20% coinsurance
after deductible
30% coinsurance
after deductible
$0
$25*
$30
$30*
$50 after
deductible
$50
$50
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
$50*
$100*
$250*
$60
$100
$0
$60*
$100*
$250*
$85 after
deductible
$85
$100 after
deductible
$100
$0
$0
$85
$100
$0
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
20% coinsurance
after deductible
30% coinsurance
after deductible
0% after
deductible
$0
$0
$0
Rates are valid from 1/1/2016 – 12/31/2016
PPO Service Area: Harris, Fort Bend, Montgomery, Brazoria, Galveston, Walker and Wharton counties
For individuals, find the rate that matches your age for the plan you’re interested in.
For families, find the rate that matches the age for all members of your family and add them together. If you have more than three (3) children, only add the rate for the three (3) oldest up to age 26.
The PPO is a Limited Hospital Care Network.
Individual Elect PPO Plan
Individual Elect PPO Plan
EXCLUSIONS AND LIMITATIONS:
WHAT THE PLAN DOES NOT PAY FOR
Excluded Services
The Plan does not provide benefits for:
A. Any amounts in excess of maximum
amounts of Covered Expenses stated in
this Plan.
B.
Services not specifically listed in this Plan
as Covered Services.
C. Services or supplies that are not Medically
Necessary as defined by Us.
D. Services or supplies that We consider to
be Experimental or Investigative.
HEALTH INSURANCE
ROOTED IN HOUSTON
Memorial Hermann Insurance Co is backed by Memorial Hermann Health System, the health system Houston
has counted on for more than 100 years. By aligning care delivery, physicians and health insurance, Memorial
E.
Services received before the Effective
Date or during an inpatient stay that
began before that Effective Date.
F.
Services received after coverage ends.
G. Services for which You have no legal
obligation to pay or for which no charge
would be made if You did not have health
plan or insurance coverage, except to the
extent that the availability of insurance or
health plan coverage may be considered
by a tax supported institution of the
State of Texas providing treatment of
Mental Illness or mental retardation to
determine if a patient is non-indigent,
as provided in Article 3196a of Vernon’s
Texas Civil Statutes.
H. Any condition for which benefits are
recovered or can be recovered, either by
adjudication, settlement or otherwise,
under any workers’ compensation,
employer’s liability law or occupational
disease law, even if You do not claim
those benefits.
I.
Hermann has built Houston’s first and only truly integrated health system. And together, we’re committed to
delivering health care that’s safer, smarter and more cost-effective.
To learn about how Memorial Hermann Health Insurance Co is transforming health insurance and advancing
J.
health care in our community, visit healthplan.memorialhermann.org. Or call (713) 338-6556 today.
K.
INDIVIDUALS & FAMILIES
An Individual Elect PPO Plan from Memorial Hermann Health Insurance Co offers
individuals and families the high quality Memorial Hermann doctors you already know,
L.
Conditions caused by or contributed by (a)
an act of war; (b) The inadvertent release
of nuclear energy when government funds
are available for treatment of Illness or
Injury arising from such release of nuclear
energy; (c) An Insured Person participating
in the military service of any country; (d)
An Insured Person participating in an
insurrection, rebellion, or riot; (e) Services
received for any condition caused by
an Insured Person’s commission of, or
attempt to commit a felony.
Any services provided by a local, state
or federal government agency except (a)
when payment under this Plan is expressly
required by federal or state law; or (b)
services provided for the treatment of
Mental or Nervous Disorders by a tax
supported institution of the State of Texas.
Professional services received or supplies
purchased from Yourself, a person who
lives in the Insured Person’s home or who
is related to the Insured Person by blood,
marriage or adoption, or the Insured
Person’s employer, unless the employer is
a Hospital or a Doctor of Medicine.
Inpatient or outpatient services of a
private duty nurse.
M. Inpatient room and board charges in
connection with a Hospital stay primarily
for environmental change, Physical
Therapy or treatment of chronic pain;
Custodial Care or rest cures; services
provided by a rest home, a home for
the aged, a nursing home or any similar
facility service.
V.
N. Inpatient room and board charges in
connection with a Hospital stay primarily
for diagnostic tests which could have been
performed safely on an outpatient basis.
W. Treatment of sexual dysfunction,
impotence and/or inadequacy.
O. Dental services, dentures, bridges,
crowns, caps or other Dental Prostheses,
extraction of teeth or treatment to the
teeth or gums, except as specifically
stated under Dental Care and Pediatric
Dental Care in the Comprehensive
Benefits section of this Plan, including
dental services for Temporomandibular
Joint Dysfunction (TMJ), and except
as specifically stated under Services
and Supplies Provided by a Hospital or
Ambulatory Surgical Center.
P.
Orthodontic Services, braces and
other orthodontic appliances
including orthodontic services for
Temporomandibular Joint Dysfunction
(TMJ), except as specifically stated
under Pediatric Dental Care in the
Comprehensive Benefits section of
this Plan.
Q. Dental Implants: Dental materials
implanted into or on bone or soft tissue
or any associated procedure as part of
the implantation or removal of dental
implants, except as specifically stated
under Pediatric Dental Care in the
Comprehensive Benefits section of
this Plan.
R.
Optometric services, eye exercises
including orthoptics, eyeglasses, contact
lenses, routine eye exams, and routine eye
refractions, except as specifically stated in
this Plan.
S.
An eye surgery solely for the purpose
of correcting refractive defects of the
eye, such as near-sightedness (myopia),
astigmatism and/or farsightedness
(presbyopia).
T.
Any drugs, medications, or other
substances dispensed or administered
in any outpatient setting except as
specifically stated in this Plan. This
includes, but is not limited to, items
dispensed by a Physician.
U. Cosmetic Surgery or other services for
beautification, including any medical
complications that are generally
predictable and associated with such
services by the organized medical
community. This exclusion does not apply
to Medically Necessary Reconstructive
Surgery to restore a bodily function or
to correct a deformity caused by Injury
or congenital defect of a Newborn child,
or to breast reconstruction performed
to restore or achieve breast symmetry
incident to a mastectomy, or abnormal
craniofacial structure caused by congenital
defects, developmental deformities,
trauma, tumors, infections or disease.
X.
Y.
Procedures or treatments to change
characteristics of the body to those of the
opposite sex. This includes any medical,
surgical or psychiatric treatment or study
related to sex change.
All services related to the evaluation or
treatment of fertility and/or Infertility,
including, but not limited to, all
tests, consultations, examinations,
medications, invasive, medical,
laboratory or surgical procedures
including sterilization reversals and In
vitro fertilization, except as specifically
stated under Comprehensive Benefits.
All non-prescription contraceptive
devices and supplies including but
not limited to all consultations,
examinations, evaluations,
medications, medical, laboratory,
devices, Prescription Drugs or surgical
procedures except as specifically stated
in this Plan. Oral contraceptives and
Prescription contraceptive devices
available through a pharmacy are
covered under the Prescription Drug
benefit of this Plan.
Z. Cryopreservation of sperm or eggs.
AA. Services primarily for weight reduction
or treatment of obesity including morbid
obesity, or any care which involves weight
reduction as a main method for treatment,
except as provided under the Child and
Adult Preventive Care Services provision.
AB. Routine physical exams or tests that
do not directly treat an actual Illness,
Injury or condition, including those
required by employment or government
authority except as specifically stated
under the Professional and Other
Services, Child and Adult Preventive
Care Services and Routine Care
Services sections of this Plan.
AC. Charges by a provider for telephone
consultations and for Telemedicine or
Telehealth Services. (Note: a Telemedicine
Medical Service or Telehealth Service
will not be excluded solely because the
service is not provided through a face to
face consultation.)
AD. Items which are furnished primarily for
personal comfort or convenience (air
purifiers, air conditioners, humidifiers,
exercise equipment, treadmills, spas,
elevators and supplies for hygiene or
beautification including wigs, etc.).
AE. Educational services except as specifically
provided for Diabetes Self-Management
Training or as provided or arranged by Us.
AF. Nutritional counseling or food
supplements, except for formulas
necessary for the treatment of
phenylketonuria and as provided under
the Child and Adult Preventive Care
Services provision.
AG. Durable medical equipment except
as specifically stated in this Policy.
Excluded durable medical equipment
includes, but is not limited to: air
purifiers, air conditioners, humidifiers;
exercise equipment, treadmills; spas;
elevators; and supplies for comfort,
hygiene or beautification.
AH. Physical and/or Occupational Therapy/
Medicine, except when provided during
an inpatient Hospital confinement or as
specifically provided under the benefits
for Physical and/or Occupational
Therapy/Medicine.
AI. All Infusion Therapy together with any
associated supplies, Drugs or professional
services are excluded except as
specifically provided under the benefit for
Infusion Therapy described in this Plan.
AJ. All Foreign Country Provider charges
are excluded under this Plan except
as specifically stated under Treatment
received from Foreign Country Providers
under the Benefits section of this Plan.
AK. Routine foot care including the cutting
or removal of corns or calluses; the
trimming of nails, routine hygienic care
and any service rendered in the absence
of localized Illness, Injury, symptoms
involving the feet, diabetes, circulatory
disorders of the lower extremities,
peripheral vascular disease, peripheral
neuropathy, or chronic arterial or
venous insufficiency.
AL. Charges for which We are unable to
determine Our liability because You or
an Insured Person failed, within 60 days,
or as soon as reasonably possible to (a)
authorize Us to receive all the medical
records and information We requested
or, (b) provide Us with information We
requested regarding the circumstances of
the claim or other insurance coverage.
AM.Charges for the services of a
standby Physician.
AN. Charges for animal to human
organ transplants.
AO. Self-administered injectable Drugs
and syringes, except as stated in the
Prescription Drug Benefits section of
this Plan.
AP. Claims received more than 12 months
after the date service was rendered.
AQ.Acupuncture/Acupressure.
at a price you can afford. Plus, our health coverage offers something no other insurance
provider can: a unique relationship with Memorial Hermann, one of the largest and most
trusted nonprofit health systems in the nation.
Form # 10002COV(10/15)
Copyright © 2015 Memorial Hermann. All rights reserved.
INDIVIDUAL ELECT
PPO PLAN OVERVIEW