Celtic Basic Health Plan Significant Variations in Coverage by State

Below is a synopsis of the major variations in the Celtic Basic product, from that outlined in your sales brochure. Refer to the insurance Certificate or Policy for exact terms and conditions, as it is the primary binding agreement between the insured and Celtic.

ALASKA

• 10 Day Free Look

ARIZONA

• Inherited Metabolic Disorders for protein modified foods if prescribed by a physician. Limited to $5,000 per year.
• Manipulative Therapy - No annual or lifetime maximum.
• Contraceptive Coverage
• Cancer Drug Coverage-prescription drugs prescribed for the treatment of cancer which have not been approved by the FDA for treatment of that specific type of cancer for which they are being prescribed. Drugs must meet certain medical criteria.

ARKANSAS

• 10 Day Free Look
• Contraceptive Coverage
• Children’s Preventive Health Care - Benefits are payable at specific intervals through age 18.
• Immunizations – not subject to deductible, coinsurance or co-pays.
• Temporomandibular Joint Disorder (TMJ) - covered same as sickness.
• Routine Nursery Care & Pediatric Charges – up to 5 days for newborn child.
• Phenylketonuria – treatment and dietary formula if prescribed by a physician.
• Colorectal Cancer Screening
• Dental Anesthesia - General anesthesia and associated hospital or outpatient surgical facility charges for a dependent child under the age of seven or a person with a diagnosed mental or physical condition or a person with a significant behavioral problem, if deemed medically necessary by the primary care physician. Any dental plan would be primary.

CALIFORNIA

• Pre existing – 6/6. Credit given for prior creditable coverage.
• Contraceptive Coverage.
• Phenylketonuria –Enteral formula and special food products when prescribed by a physician.
• Dental General Anesthesia – if medically necessary for an insured who is developmentally disabled or an insured under 7 years of age.
• Severe Mental Illness and Serious Emotional Disturbances – same as any sickness, excluding alcohol, drug and substance abuse.
• Osteoporosis – medically necessary services for the diagnosis, treatment and management of osteoporosis.
• Prosthetic devices -initial and subsequent prosthetic devices needed to restore a method of speaking as a result of a laryngectomy.
• Temporomandibular Joint Disorder (TMJ) – coverage for diagnosis and surgical treatment of TMJ.
• Well Child Care – including immunizations, covered through age 18.
• Cancer Clinical Trials-coverage provided for an insured diagnosed with cancer and accepted into a phase I through IV clinical l for cancer.
• Alcoholism - Inpatient $2,500 annual maximum. Outpatient $1,000 annual maximum. Lifetime maximum $10,000 inpatient and outpatient combined.

COLORADO

• 10 Day Free Look
• Child Health Supervision Services - Covered up to age 13. Deductible does not apply.
• Cancer Screenings – deductible does not apply to mammography or prostate screenings.
• Routine Nursery Care – Newborns covered up to 48/96 hours.
• Cleft Lip and Cleft Palate - for newborns to the extent that is medically necessary.
• Home Health Care - Up to 60 visits per year.
• Dental General Anesthesia -for dental procedures provided in a hospital or outpatient surgical facility for a dependent child who: has a physical, mental, or medically compromising condition; for which local anesthesia is ineffective because of acute infection, anatomic variations, or allergy; the child is an extremely uncooperative, unmanageable, anxious, or uncommunicative child or adolescent with dental needs deemed sufficiently important that dental care cannot be deferred; or the child has sustained extensive orofacial and dental trauma. Such services must be pre-certified.
• Inherited Enzymatic Disorders – for protein modified foods if prescribed by a physician. Including phenylketonuria.
• Cervical Cancer vaccines as recommended by a physician.
• Hospice Care Charges – maximum of $9,100 per episode of hospice care.
• Congenital Defects and Birth Abnormalities – covered for children up to 5 years of age, includes physical, occupational and speech therapy up to 20 visits for each therapy per calendar year.
• Early Intervention Service Charges – for medically necessary services provided by a qualified early intervention service provider to an eligible child in accordance with Part C of the “Individuals with Disabilities Education Act ages birth to 3 years old. Services provided shall have a maximum of $5725 per insured person per calendar year.

DELAWARE

• Baseline Lead Poisoning Screening Test - One test at age 12; screening and diagnostic evaluations under age 6 for those who are at high risk.
• Routine Nursery Care - Covered for newborn child, including a hearing screening prior to discharge.
• Child Immunizations - covered from birth through age 18.
• Serious Mental Illness same as any other sickness, including alcoholism, drug and substance abuse.
• CA – 125 monitoring of ovarian cancer subsequent to treatment.
• Contraceptive coverage.

DISTRICT OF COLUMBIA

• Preventive and Primary Care Services - Covered for dependent children up to 18 years of age.
• Alcohol and Drug Dependency Charges - Twelve days per calendar year for detoxification; additional treatment up to 60 days for inpatient or residential care; outpatient covered at 75% for the first 40 visits, 60% thereafter.
• Psychiatric Care Charges - Inpatient 60 days per calendar year, outpatient covered at 75% for the first 40 visits, 60% thereafter. Lifetime maximum up to one-third of lifetime maximum for physical illness.
• Cancer Screenings – mammography and pap smear deductible and coinsurance do not apply.
• Colorectal Cancer Screening -Coverage for an examination and laboratory tests for any non-symptomatic insured person age 50 years of age or older.

FLORIDA

• Child Health Supervision Services- Birth to age 16. Deductible does not apply
• Transportation costs - of a newborn child up to a maximum of $1,000.
• Osteoporosis -medically necessary diagnosis and treatment
• Dental General anesthesia/hospital services –for medically necessary dental treatment meeting certain criteria
• Cleft Lip and Cleft Palate – covered if under the age of 18.
• Enteral formulas – coverage through age 24, up to $2,500 per calendar year when prescribed by a physician.
• Mammography – not subject to the deductible or coinsurance.

GEORGIA

• 10 Day Free Look
• Child Wellness - From birth through the age of 5 years. Deductible does not apply.
• Contraceptive Coverage.
• Bone Density Test -for the prevention, diagnosis & treatment of osteoporosis.
• Dental Anesthesia -general anesthesia and associated hospital or ambulatory surgical facility charges in conjunction with dental care if an insured is developmentally disabled or for a child under 8 years of age if deemed medically necessary by the primary care physician.
• Cytologic Screening - One screening per calendar year or as recommended by a physician for insureds 18 years and older - subject to deductible and coinsurance.
• Chlamydia screening – test covered along with annual pap test up to age 29.
• Prostate Cancer Screening - One screening per calendar year for insureds 40 years and older – subject to deductible and coinsurance.
• Colorectal Cancer Screening - covered based on standards established by the American Cancer Society as to family history, age and frequency.
• Telemedicine and Telehealth Services - covered in accordance with generally accepted health care practices and services.
• Transplants-heart and bone marrow transplants for breast cancer or Hodgkin’s disease are covered the same as any other sickness.
• Prescription Inhalants- will provide coverage for prescriptions inhalants without limitations on the number of days before an inhaler refill may be obtained if such inhalants have been prescribed by a treating physician (only for plans that have outpatient prescription drug coverage)
• Off Label Drug Use- coverage provided for use of prescription drugs prescribed for the treatment of a particular indication that have not been approved by the FDA for that particular indication for which they are being prescribed for, provided the drug has been recognized as safe and effective for treatment of that indication in one or more of the standard medical reference compendia.
• Temporomandibular Joint Disorder (TMJ) -covered same as sickness.
• Inpatient Psychiatric care – 30 days per calendar year.
• Outpatient Psychiatric Care – up to 48 visits per calendar year. Outpatient prescription drugs are covered at 50% of eligible expenses and limited to $1,000 per year.
• Approved Clinical trials - routine patient care for an insured child diagnosed with cancer prior to their nineteenth birthday.

ILLINOIS

• Alcoholism –up to 30 days while hospital confined same as any other illness.
• Serious Mental Illness – Coverage includes 45 days of hospitalization as an inpatient per calendar year and 60 visits for outpatient treatment including group and individual outpatient treatment per calendar year, excluding visits for the management of medication.
• Dental General Anesthesia – coverage is provided for general anesthesia and related facility charges when the mental/physical condition of the insured requires a hospital setting.
• Contraceptive Coverage Colorectal Cancer Screening -covered based on standards established by the American Cancer Society.

INDIANA

• 30 Day Free Look
• Coverage for pervasive developmental disorders

IOWA

• Contraceptive Coverage
• Dental General Anesthesia – coverage is provided for general anesthesia and related facility charges if an insured is developmentally disabled or for a child under the age of five if deemed medically necessary by the primary care physician.

KANSAS

• 10 Day Free Look
• Inpatient Alcoholism, Drug Abuse, Mental or Nervous Condition Charges –limited to 30 days per calendar year.
• Outpatient Alcoholism, Drug Abuse, Mental or Nervous Condition Charges -100% of the first $100; 80% of the next $100; 50% of the next $1,640 in a year; $7,500 lifetime maximum.
• Immunizations - Covered for dependent children age 0 to 72 months. Deductible, coinsurance and copay amounts do not apply.
• General Dental Anesthesia – charges for the administration and associated facility charges when an insured is severely disabled or for a minor five years of age and under or a person who has a medical or behavioral condition which requires hospitalization or dental anesthesia when dental care is required.
• Osteoporosis -coverage for medically necessary diagnosis and treatment, when services are provided by a licensed medical provider.
• Manipulative Therapy – covered up to $500.00 per calendar year.
• Maternity Coverage – optional.

LOUISIANA

• 10 day Free Look
• Cancer Screenings (mammography, pap smear, and prostate screening – deductible does not apply.
• Colorectal Cancer Screening – covered Cancer Drug - coverage for all medically necessary services associated with the administration of the drug.
• Attention Deficit/Hyperactivity Disorder - Covered up to $2,500 per calendar year/$10,000 lifetime maximum. Outpatient eligible expenses up to $50 per visit. Initial diagnosis paid up to $600.
• Cleft lip and cleft palate - Covered.
• Immunizations - Birth to age 6.
• Inherited Metabolic Disease Disorder – coverage for medically necessary low protein food products, up to $200 per calendar year.
• Dental General Anesthesia – coverage is provided for general anesthesia and related facility charges when the mental/physical condition of the insured requires a hospital setting.
• Osteoporosis – coverage for medically necessary diagnosis and treatment.
• Interpreter / translator -Services performed by a qualified interpreter/translator are covered.
• Speech/language Pathology Therapy -covered when rendered by a licensed speech pathologist or licensed audiologist.
• Manipulative Therapy covered.
• Hearing Aids - coverage hearing aids for an insured person under the age of eighteen. Benefits are limited to $1,400 per hearing aid for each hearing-impaired ear every 36 months.
• Transportation Costs – of a newborn to the nearest available hospital or neonatal special care unit for treatment of illness, injury, congenital defects or complications of premature birth.

MICHIGAN

• Pre-Existing Conditions – 6/12
• 10 Day Free Look
• Substance Abuse - Coverage for intermediate and outpatient care up to $3,500 per calendar year.
• Antineoplastic Therapy Charges – Coverage for any federally approved drug used in antineoplastic therapy.
• Ambulance Benefit – No annual maximum
• Off Label Drug Use - Coverage shall be provided for the use of a drug for clinical indications other than those stated in the labeling approved by the Federal Food and Drug Administration (FDA) if certain criteria is met.

MISSISSIPPI

• Pre-Existing Condition – 6/12
• Manipulative Therapy - No annual or lifetime maximum.
• Temporomandibular Joint Disorder and Craniomandibular Disorder Charges - Diagnostic services and surgery; up to $5,000 per lifetime.
• Dental Anesthesia – charges and associated facility charges when the mental or physical condition of the child or mentally handicapped adult requires dental treatment to be rendered under physician-supervised general anesthesia in a hospital setting, surgical center or dental office.

NEW HAMPSHIRE

• Pre-Existing Conditions - 3/9
• Manipulative Therapy – Covered, no maximum.
• Dental General Anesthesia - for dental procedures meeting certain criteria, rendered in a hospital or outpatient surgical facility for a dependent child under age 6 or a person with a developmental disability.
• Nonprescription Enteral Formulas - and food products if prescribed by a physician, up to $1,800 per year.
• Scalp hair prostheses - resulting from the treatment from any form of cancer or leukemia, or permanent loss of scalp hair due to injury. Coverage limited to $350 per calendar year.
• Maternity Coverage – optional.
• Contraceptive Coverage.

NEW MEXICO

• Immunizations -Coverage for childhood immunizations is provided at a level in accordance with the recommendations of the American Academy of Pediatrics.
• Temporomandibular Joint Disorder (TMJ) - Treatment covered same as sickness.
• Home Health Care: 100 visits per calendar year
• Cancer Clinical Trials - routine patient care for an approved phase II, III or phase IV clinical trial.
• Treatment of genetic inborn errors of metabolism that involve amino acid, carbohydrate and fat metabolism and for which medically standard methods of diagnosis, treatment and monitoring exist.
• Alcoholism – inpatient up to 30 days per year; outpatient – up to 30 visits per year.
• Contraceptive Coverage.

NORTH CAROLINA

• 10 Day Free Look
• Pre-Existing Conditions -Credit given for prior qualifying coverage.
• PPO Plan -There is an out-of-network/out-of­pocket maximum. This amount is double the in­network/out-of-pocket maximum.
• Temporomandibular Joint Disorder (TMJ) -Up to a lifetime maximum of $3,500.
• Newborn Hearing Screening Dental Anesthesia - for dental procedures and general anesthesia rendered in a hospital or outpatient surgical facility, for a dependent child under the age of nine or a person with a developmental disability or behavioral disorder.
• Osteoporosis -– coverage for medically necessary diagnosis and treatment, when services are provided by a licensed medical provider.
• Bone Mass Measurement is covered.
• Colorectal Cancer Screening -covered based on standards established by the American Cancer Society.
• Cancer Clinical Trials - routine patient care for an approved phase II, III or phase IV clinical trial.
• Pastoral Counselor Services -when rendered by a certified fee-based practicing pastoral counselor.
• Transplant benefit – travel and lodging caps removed, however arrangements must be made through the insurer.
• Reconstructive breast surgery – covered regardless of whether or not the mastectomy was performed under our coverage-provision has been expanded to include other services.
• Contraceptive Coverage

OHIO

• Child Health Supervision Services – from the moment of birth through 8 years of age. The maximum amount the first year is $500 and $150 every year after.
• Biologically Based Mental Illness – same as any other illness.
• Outpatient Psychiatric Care Charges – services up to $550 per year.
• Off Label Drug Use – coverage provided for use of prescription drugs prescribed for the treatment of a particular indication that have not been approved by the FDA for that particular indication for which they are being prescribed for, provided the drug has been recognized as safe and effective for treatment of that indication in one or more of the standard medical reference compendia.

OKLAHOMA

• 10 Day Free Look
• Bone Density Test - Up to $150 for any such test.
• Mammography - Benefits are reimbursed at 100% up to $115. Coinsurance and deductible do not apply.
• Child Health Supervision Services -benefits include immunizations and are payable at specific intervals through age 18, deductible, coinsurance or copay will not apply.
• Dental General Anesthesia -for medically necessary dental procedures when an insured person is severely disabled or for a minor 8 years of age or under who has a medical or emotional condition which requires hospitalization.

PENNSYLVANIA

• Routine Nursery Charges – includes hospital charges and care rendered by a licensed medical practitioner.
• Immunizations -At specific intervals through age 20, deductible does not apply.
• Alcohol & Drug Dependency – charges for medically necessary treatment limited to the following: Inpatient Detoxification: 7 days treatment per admission up to a lifetime maximum of 4 admissions.
• Non Hospital Residential Care: 30 days treatment per calendar year up to a lifetime maximum of 90 days. Outpatient 30 visits per calendar year up to a lifetime maximum of 120 visits.
• Nutritional Supplements -If medically necessary for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria, deductible does not apply.
• Annual Gynecological Exam - deductible does not apply -includes pelvic exam, clinical breast exam and pap smear for women 18 years of age and older, or any age if at risk for cancer.

SOUTH CAROLINA

• 10 Day Free Look
• Cleft lip and cleft palate – Covered.
• Organ Transplant - Medical expenses of a live donor, will be reimbursed to the extent that benefits remain and are available under this policy after the insured person’s own eligible expense have been paid.

SOUTH DAKOTA

• 10 Day Free Look
• Alcoholism - Inpatient treatment in approved licensed hospitals and residential facilities covered same as sickness up to 30 days in any six month period and 90 days during the lifetime of policy.
• Phenylketonuria - Coverage for testing, diagnosis and treatment.
• Biologically Based Mental Illness - covered same as any other sickness, excluding alcoholism, drug and substance abuse.
• Dental Anesthesia - coverage is provided for general anesthesia and related facility charges for a child under age 5 or for a severely disabled individual.

TENNESSEE

• 10 Day Free Look
• Chlamydia screening – test covered along with annual pap test up to age 29.
• Phenylketonuria – treatment and formulas.
• Manipulative Therapy - No annual or lifetime maximum.
• Hearing/Speech/Language Disorders – coverage provided if treatment is received from a licensed audiologist or speech pathologist.
• Temporomandibular Joint Disorder (TMJ). Phase I & II covered.

TEXAS

• 10 Day Free Look
• Contraceptive Coverage
• Child Immunization - from birth through age 6. not subject to deductible, coinsurance or co-pay.
• Home Health Care - 60 visits per year.
• Telemedicine and Telehealth Services-covered subject to the definition.
• Off Label Drug Use – coverage provided for treatment of a covered chronic or disabling condition if FDA approved for at least one indication and is recognized for treatment of the indication in peer review medical literature or a prescription drug reference compendium.
• Craniofacial reconstructive surgery – covered for children under 18 years of age. Screening test for hearing impairment-from birth through the date the infant is 30 days old and follow-up care until the child is 24 months. Not subject to the deductible.
• Colorectal Cancer Screening – coverage provided for individual age 30 or over who are considered high risk.
• Acquired Brain Injury – rehabilitative services provided as a result of or related to an acquired brain injury.

WEST VIRGINIA

• 10 Day Free Look
• Contraceptive Coverage
• Temporomandibular/Craniomandibular Disorders (TMJ) -covered unless declined at time of application.
• Alcoholism -Inpatient confinement up to 30 days per year; outpatient paid at 50% up to $750 per calendar year. Lifetime maximum $10,000 inpatient and outpatient combined.
• Home Health Care - 100 visits.
• Immunizations - Covered through age 16, not subject to deductible or co-pay Hearing Loss –coverage for testing for hearing loss in newborns. Subject to deductible and coinsurance.

WISCONSIN

• 10 Day Free Look
• Blood Lead Tests -For children under 6 years of age.
• Immunizations – for dependent children. The deductible, coinsurance or co-payments do not apply.
• Home Health Care - 40 visits.
• Skilled Nursing or Extended Care Facility - Up to 30 days of confinement per occurrence.
• Temporomandibular Joint Disorder (TMJ) – only if the condition is caused by congenital developmental disease or injury.
• Dental General Anesthesia -charges for hospital and ambulatory surgical facilities, including general anesthesia for a child under age 5 or an individual with a chronic disability or a medical condition that requires hospitalization or general anesthesia for dental care.

WYOMING

• Pre-existing Conditions –6/12. Credit given for prior qualifying coverage within 90 days of effective date.

This information is based on a publication dated 3/1/2009 and may change in the future. See your specific policy certificate for details. In the event of a conflict between this information and the details of a policy, the policy will prevail.