HOSPITAL BENEFITS

Hospital benefits are provided to all eligible participants and dependents. The Plan uses the following managed care networks for hospital benefits:

IMPORTANT: In California, Plan II and Lower Cost Self-Pay participants must use a Prudent Buyer facility in order to receive any hospital benefits, except for emergency treatment as outlined on page 31.

Deductible
Hospital charges are subject to a calendar year deductible. This is a separate deductible from the deductibles for the other benefits provided by the Plan, including the major medical deductible. The deductible is lower if you use network hospitals. Refer to the chart on the following page.

The family deductible is satisfied when at least two or more family members have paid the amount of the family deductible in covered expenses. However, the Plan will not apply more than the individual deductible amount to any one family member. For example, if a Plan II participant who has a spouse and two children uses PHCS hospitals outside of California, the $1,000 family deductible will be satisfied once he and his family have paid a total of $1,000 in covered expenses. However, the Plan will not apply more than $500 towards the deductible for any one family member.

The Plan applies expenses toward your deductible as it processes claims, rather than according to the date of service. Providers submit their claims in accordance with their own billing schedules and claims are frequently not received in the order of their date of service, particularly when multiple providers are used.

Hospital Deductibles

* Coverage will be provided in the event of an emergency. See page 31 for a description of emergency treatment.

If your eligibility changes from Plan I to Plan II or Lower Cost Self-Pay during a calendar year, any charges that applied toward your deductible under Plan I will apply toward your Plan II or Lower Cost Self-Pay deductible. If your eligibility changes from Plan II or Lower Cost Self-Pay to Plan I during a calendar year, the reverse is also true.

Co-insurance and Out-of-Pocket Maximums

Once the deductible has been satisfied, the Plan will provide reimbursement of covered expenses as shown in the table below.

The out-of-pocket maximum is the maximum amount you and your family must pay for covered expenses, after your deductible is satisfied. For example, a participant in Plan I who is single and who has satisfied his deductible is responsible for 10% of the first $10,000 in covered non-network hospital expenses. After that the Plan will provide reimbursement at 100% of covered hospital expenses.

Plan II and the Lower Cost Self-Pay Plan have no out-of-pocket maximum for non-network hospital coverage outside of California. This means that after the deductible is satisfied, you must pay 20% of all covered non-network hospital expenses for the remainder of the calendar year.

Hospital Co-insurance

	Network	Non-Network
	Co-insurance	Co-insurance	Your Out-of-Pocket Maximum
Plan I	100%	90%	$1,000 per person/ $2,000 per family
Plan II and Lower Cost Self-Pay	100%	California – No coverage Non-California – 80%	California – Not applicable Non-California – No maximum

Emergency Room Co-payment
There is a co-payment for the emergency room when you use a network facility. This co-payment is waived if there is immediate confinement for the same accident or illness.

Emergency Room Co-payment

	Network Co-payment
Plan I	$100 per visit
Plan II and Lower Cost Self-Pay	$200 per visit

Hospital Benefits
Hospital benefits include the following:

• Emergency treatment is covered within 72 hours after an accident, or within 24 hours of a sudden and serious illness. Emergency treatment includes services billed by the hospital on their statement of charges. Any services that are not included on the hospital bill and are billed separately, such as professional charges for reading pathology or radiology reports, may be covered under the major medical portion of your benefits. Urgent care centers are covered under the major medical benefit.
• Hospice care provided by a Medicare certified program, when an individual is terminally ill with a life expectancy of less than 12 months.
• Outpatient surgery and hospital charges for services connected with surgery that are billed by the hospital. Services not billed by the hospital may be recognized by the major medical coverage of the Plan.
• Semi-private room, board, hospital services and supplies for acute care for a covered diagnosis. For stays in a private room, the Plan pays the hospital’s most common semi-private room rate. You are responsible for the difference between the semi-private and private room rate.

Hospital services and supplies include:

– Administration of blood or blood plasma. (The actual charge for blood is covered under the major medical benefit.)
– Anesthesia.
– Basal metabolism studies.
– Cardiac testing.
– Drugs and medicines.
– Intensive care.
– Operating, delivery and treatment rooms.
– Oxygen.
– Physiotherapy and hydrotherapy.
– Special diets.
– Splints, casts and dressings.
– Staff nursing care.
– X-ray and laboratory exams.

Hospital Stays for Maternity
A stay related to childbirth, miscarriage, ectopic pregnancy, or premature termination of pregnancy is only covered if the patient is a participant or the spouse or same-sex domestic partner of a participant. A newborn’s ordinary nursing care in the hospital is also covered. For dependent children, only complications of pregnancy are covered.

In compliance with federal law, the Plan allows hospital stays of at least 48 hours for a normal delivery and at least 96 hours for cesarean sections. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). You are not required to obtain pre-authorization from the Plan for stays that do not exceed these guidelines.

Non-Covered Hospital Expenses

• All expenses for a California Plan II or Lower Cost Self-Pay participant or dependent at a non-network hospital,
  except for emergency treatment as described on page 31.
• A stay in a facility or hospital that is not registered as a general hospital by the American Hospital Association and does not meet accreditation standards of the Joint Commission on Accreditation of Hospitals.
• A stay primarily for diagnostic tests, pulmonary tuberculosis, convalescent care, rest cure or custodial care.
• A stay primarily for physical or rehabilitative therapy. If a patient is transferred to a hospital’s rehabilitation wing (either from the same acute care hospital or from another acute care hospital), and the care is still considered acute care, the Plan may consider benefits.
• Hospitalization for alcoholism, drug addiction or mental and nervous disorders, except through ValueOptions as outlined on page 52, or when the Plan is secondary to another plan with a managed mental health and/or chemical dependency benefit as outlined on page 55.
• Care that is covered under other portions of the Plan, such as ambulance, blood and blood plasma, x-ray or radiation therapy, special braces, appliances or equipment, or outpatient care.
• Services of doctors, surgeons, anesthesiologists, and technicians not employed by the hospital. (These are covered under the major medical benefits.)
• Convalescent facilities.
• Charges in connection with cosmetic surgery, except under the limited circumstances described on pages 35 and 38.
• Non-network birthing centers. (Limited coverage for these services is provided under the major medical benefits.)
• Personal comfort items such as TV or telephone.
• Physician’s surgical suite or a non-network surgery center. (Limited coverage for these services is provided under the major medical benefits.)
• Skilled nursing facilities.
• Urgent care centers. (These are covered under the major medical benefits.)

See also “General Exclusions “ on page 64.