2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 40
MEDICAL SCHEDULE OF BENEFITS: VALUE MEDICAL PLAN
IMPORTANT: Meritain Health Medical Management must pre-certify all acute inpatient stays (including acute
inpatient rehabilitation and subacute care provided in a facility that has nursing staff on-site 24 hours a day, 7 days
a week, and a Physician on call 24 hours a day, 7 days a week), transplants, and all Chemotherapy and Radiation
Therapy treatment. See Medical Management and Precertification Program of the Medical Plan for details on
precertification. If these procedures are not followed, eligible expenses will be reduced by $500 per occurrence,
per individual.
The Institute of Excellence (IOE) is a facility that is contracted with Aetna to furnish particular services and supplies
to you in connection with one or more highly specialized medical procedures. The maximum charge made by the
IOE for such services and supplies will be the amount agreed to between Aetna and the IOE. Your Participating
Provider should confirm if there is an Institute of Excellence (IOE) for your condition.
AETNA POS PROVIDERS
OVERALL LIFETIME MAXIMUM BENEFIT
NON POS PROVIDERS
(Subject to Usual &
Customary Charges)
Unlimited
OVERALL CALENDAR YEAR MAXIMUM
Unlimited
CALENDAR YEAR DEDUCTIBLE
$450
Individual
$1,350
Family
CALENDAR YEAR OUT OF POCKET LIMIT
(does not include Deductibles)
$2,250
$3,900
Individual
$4,500
$7,800
Family
Expenses for obtaining medical records will be paid in full to a maximum benefit of $100 per provider.
AETNA POS PROVIDERS
MEDICAL BENEFITS
Plan Pays
Allergy Services
100%
after
Copay
Ambulance Services
80%
Chiropractic Care
100%
Calendar Year
Maximum Benefit
Durable Medical Equipment
20 visits
80%
Emergency Room Services
80%
Covered Person
Pays
$25 Copay;
Deductible waived
(Part of Physician
Office Visit benefit)
20% after
Deductible
$25 Copay;
Deductible waived
20% after
Deductible
20% after
Deductible
36
NON POS PROVIDERS
(Subject to Usual &
Customary Charges)
Plan Pays
Covered Person
Pays
60%
40% after
Deductible
80%
60%
20 visits
80%
80%
20% after
Deductible; subject
to POS Out-ofPocket Limits
40% after
Deductible
20% after
Deductible; subject
to POS Out-ofPocket Limits
20% after
Deductible