Health Insurance in California

Wording regarding the PPO Providers (when applicable) are the same as with individual Major Medical plans. As a rule, Provider-type plans are established the same for Group and Individual plans.  Note the illustrated Schedule of Benefits on the first page shows a difference in approved and non-approved Providers in coinsurance percentages.  Since some groups are multi-state, there can be special consideration given if there are employees in an area not served by participating Providers.  Some plans allow a choice with higher co-payments or some other added cost if approved Providers are not used.  Again, because the size of the group determines the type of plan and the benefits provided, there are more alternatives to this and other similar provisions than could be outlined in a text of this size and type.


Hospital Care, Physician Care, Ambulatory Surgical Center Care, Accident Care, Accident Dental Care, Prescription Drugs, Complications of Pregnancy, Sterilization, Newborn Child and Well-Child Care, Organ Transplant, Mental-Nervous Disorder treatment, Alcohol-Drug Dependency treatment, Therapeutic Services, Mammogram, Skilled Nursing Care, Home Health Care, Ambulance Services, Prosthetic & Orthotic Devices & Durable Medical Equipment, are all comparable to the provisions and terminology of the individual Major Medical plans.  The only two sections of interest that are not defined under Major Medical provisions, are Maternity and Hospice Care.  (See below)

Maternity Health care services and supplies, including prenatal care, delivery and postnatal care, provided to an Insured other than the Certificateholder’s child, by a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Hospital, Birth Center, midwife or Certified Nurse Midwife may be Covered Services.
Maternity benefits are provided for a Certificateholder’s Dependent daughter only when: 1) the  Certificateholder has employee/children or employee/family type coverage; 2) the Contractholder has purchased the optional Dependent daughter maternity benefits Rider from YOUR INSURANCE COMPANY; and 3) the Dependent daughter was covered under such Rider for at least 30 days prior to the date of conception of such Dependent’s pregnancy, as determined by a Physician.

Complications of Pregnancy: Health care services and supplies provided to an Insured for the treatment of complications of pregnancy may be Covered Services.  Coverage for complications of pregnancy is limited to Covered Services to treat the Condition covered by the complication, and does not include maternity coverage.
Additionally, coverage for complications of pregnancy is subject to any Pre-existing Condition limitations. For purposes of this Section, the phrase complications of pregnancy” means a Condition which is diagnosed as a separate Condition from the pregnancy.

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