CeltiCare II Health Plan Significant Variations in Coverage by State

Below is a synopsis of the major variations in the CeltiCare 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.

MARYLAND

• 10 Day Free Look
• Term Life Option – Not available
• Contraceptive Coverage
• Mammogram –deductible does not apply.
• Home Health Care-up to 40 visits per calendar year.
• Cleft Lip and Cleft Palate medically necessary treatment in a newborn child.
• Child Wellness – deductible does not apply. Eligible expense include office visits, developmental assessments, immunizations, hearing and vision screenings as determined by the American Academy of Pediatrics.
• TMJ – covered.
• Colorectal Cancer Screening-– covered based on standards established by the American Cancer Society.
• Inherited Metabolic Disease.
• Morbid Obesity.
• Hair Prosthesis – up to $350.
• Hearing Aids – for minor children up to $1,400 per hearing aid.
• Manipulative Therapy – no calendar year maximum.
• Mental Illness, Drug Abuse, Alcoholism – partial Hospitalization –covered up to 60 days per calendar year. Outpatient – 80% of the first 5 visits, 65% through 30th visit. 50% for 31st visit and over in a calendar year.
• Hospice Care -$5,000 maximum removed.
• Maternity – up to 48/96 hours of inpatient hospitalization.
• In Vitro Fertilization – up to a lifetime maximum of $100,000.
• Dental General Anesthesia –facility and general anesthesia charges rendered in a hospital or outpatient surgical facility for a dependent child or a person with a developmental disability, subject to limitations.
• Clinical Cancer Trials
• Osteoporosis- for medically necessary prevention, diagnosis and treatment. One annual chlamydia screening.
• Human Papillomavirus Screening at the testing intervals outlined in certain recommendations developed by the American college of Obstetrician & Gynecologists.
• Nicotine Replacement Therapy – covered to a maximum of two 90-day courses of nicotine replacement therapy.

NEVADA

(CeltiCare 3.1)

• Pre-Existing Condition – 6/12. Credit given for prior creditable coverage.
• Alcoholism and Drug Dependency - Treatment for withdrawal from physiological effects, $1,500 per calendar year.
• Inpatient Treatment - $9,000 per calendar year.
• Outpatient Counseling - $2,500 per calendar year.
• Severe Mental Illness – limited to 40 days of inpatient hospitalization and 40 outpatient visits (does not include visits for medication management)
• Temporomandibular Joint Disorder (TMJ) - 50% of reasonable and customary, excluding dental procedures.
• Enteral formula charges prescribed by a physician up to $2,500 per calendar year.
• Contraceptive Coverage & Hormone Replacement therapy coverage.
• Dental Anesthesia - charges and associated facility charges–for medically necessary dental treatment of a child. This is not Dental Coverage.
• Cancer Drug Charges - includes coverage for any other use of a drug for the treatment of cancer.
• Colorectal Cancer Screening - covered based on standards established by the American Cancer Society.
• Approved Clinical trials – coverage for Phase I-IV cancer clinical trials & Phase II-IV chronic fatigue syndrome clinical trials.

PENNSYLVANIA

• Term Life Option - Not available.
• Immunizations -At specific intervals through age 20, deductible does not apply.
• Routine Nursery Charges – includes hospital charges and care rendered by a licensed medical practitioner.
• 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.
• Nutritional Supplements -If medically necessary for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria, 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.

VIRGINIA

(CC 2.1)

• Contraceptive Coverage
• Temporomandibular/Craniomandibular Disorders (TMJ) – covered same as sickness.
• Early intervention services – medically necessary speech & language therapy, occupational & physical therapy up to $5,000 per calendar year.
• Hemophilia and other congenital bleeding disorders.
• Hearing Screening – for newborns.
• Mental Nervous and Substance Abuse Services – inpatient and partial hospitalization up to 20 days per calendar year for an adult and 25 days for children under the age of 19.
• Outpatient mental nervous and substance abuse services – up to 20 outpatient visits for an adult or child per calendar year.
• Lymphedema – includes benefits for equipment, supplies, complex decongestive therapy, and outpatient self-management training and education for the treatment, if prescribed by a health care professional legally authorized to prescribe or provide such items.
• Hysterectomy Charge-Coverage is provided for laparoscopy-assisted vaginal hysterectomy and vaginal hysterectomy including a minimum stay in the hospital of not less than twenty-three hours for a laparoscopy-assisted vaginal hysterectomy and forty-eight hours for a vaginal hysterectomy.
• Mastectomy Charges- Coverage is provided for at least 48 hours of inpatient care following a radical or modified radical mastectomy and at least 24 hours of inpatient care following a total mastectomy or a partial mastectomy with lymph node dissection for the treatment of breast cancer.

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.