AmeriHealth Caritas Next Gold Signature + No Referrals - 72760DE0010004 Health Insurance Plan

Limit: 30.0 Visit(s) per Benefit Period

Limited to 30 visits per benefit period. More available beyond the initial allotment if deemed medically necessary.

The following limits apply: three modalities per visit, one visit per day.

We cover ambulance services (including voluntary services) by ground, air, or water in the event of an emergency. Services must be provided by a licensed ambulance, including volunteer, service provider and must take you to the nearest hospital where emergency care can be provided. Air Ambulance is covered only when no other means of travel is appropriate. We also cover nonemergency ambulance transportation by a licensed ambulance service (either ground, air, or water ambulance) when the transport is: from an acute facility to a subacute facility/setting, from an out-of-network hospital/facility to an in-network hospital/facility, to a hospital that provides a higher level of care than was available at the original hospital/facility, or to a more cost-effective acute care facility.

Limit: 1.0 Item(s) per Benefit Period

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Speech therapy is not covered for attention disorders, behavior problems, conceptual handicaps, learning disabilities, developmental delays.

Combined limit of 30 visits per benefit period for Habilitative Physical Therapy and Occupational Therapy; 30 visits per benefit period for Habilitative Speech Therapy. Applied Behavior analysis for autism spectrum disorder is also covered,.

Limit: 1.0 Item(s) per 3 Years

Benefits are limited to one wearable hearing aid per ear every three (3) years for children less than 24 years of age.

Limit: 100.0 Visit(s) per Benefit Period

Exclusions: Chronic condition care is not covered; drugs; lab tests; imaging services; inhalation therapy; chemotherapy and radiation therapy; dietary care; durable medical equipment; disposable supplies; care not prescribed in the approved treatment plan; volunteer care.

We will cover certain services received in the home from a certified/licensed home health agency when ordered by a physician. Examples of these services include skilled care, physical/ occupational/speech and language/respiratory therapy, social work services, and home infusion. Services must only be provided on a part-time, intermittent basis and cannot be solely for assisting with activities of daily living. There's a limit of one visit per day per specialty. (A nurse and home health aide count as one specialty for this benefit.)

Exclusions: Private duty nursing; respite care; care not prescribed in the approved treatment plan; financial, legal, or estate planning, and; hospice care in an acute care facility, except when a patient in hospice care requires services in an inpatient setting for a limited time

Limit: 6.0 Procedure(s) per Lifetime

Exclusions: For IVF services, retrievals must be completed before the individual is 45 years old and transfers must be completed before the individual is 50 years old. The benefit is limited to six (6) completed egg retrievals per lifetime, with unlimited embryo transfers in accordance with the guidelines of the American Society for Reproductive Medicine, using single embryo transfer (SET) when recommended and medically appropriate.

We will cover services for the diagnosis, treatment, and correction of any underlying causes of infertility when determined to be medically necessary by a network provider. This includes coverage of certain prescription drugs, in vitro fertilization (IVF), Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), and standard fertility preservation services for covered persons who must undergo medically necessary treatment that may cause iatrogenic infertility.

Exclusions: Exclusions include certain mental health and substance abuse services, including: aptitude tests, testing and treatment for learning disabilities, treatment for personality disorders, treatment [of] factitious disorders, treatment of sleep disorders, treatment of sexual and gender identity disorders, care beyond that needed to determine mental deficiency or retardation, marital/relationship counseling, and care at behavioral health facilities. Methadone is not Covered

Exclusions: Exclusions include certain mental health and substance abuse services, including: aptitude tests, testing and treatment for learning disabilities, treatment for personality disorders, treatment [of] factitious disorders, treatment of sleep disorders, treatment of sexual and gender identity disorders, care beyond that needed to determine mental deficiency or retardation, marital/relationship counseling, and care at behavioral health facilities.

Psychological tests (limit of 8 hours of tests per year). Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply.

Also covered per USPSTF guidelines.

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: OT and PT covered only when needed to help your condition improve in a reasonable and predictable time.

Combined limit of 30 visits per benefit period for Rehabilitative Physical Therapy and Occupational Therapy; 30 visits per benefit period for Rehabilitative Speech Therapy.

Colorectal cancer screening must be covered.

Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits

Limit: 240.0 Hours per Benefit Period

Exclusions: This care isn't covered when done in special care units of the hospital, such as: self-care units; selective care units; intensive care units.

Covered health services under this section include medically necessary nursing care provided to a patient one on one by licensed nurses in an inpatient or home setting. Private duty nursing care is covered when you are an inpatient in an acute hospital. This care isn't covered when done in special care units of the hospital such as: self-care units, selective care units, and intensive care units. Inpatient private duty nursing care is not covered when done as a convenience even if authorized by your doctor.

Limit: 36.0 Treatment(s) per Benefit Period

Limited to 2 - 1 hour treatments per day, up to 36 treatments within a benefit period. More available beyond the initial allotment if deemed medically necessary.

Radiation therapy is covered for cancer and neoplastic diseases.

Only for breast reconstruction.

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: OT and PT covered only when needed to help your condition improve in a reasonable and predictable time.

Combined limit of 30 visits per benefit period for Rehabilitative Physical Therapy and Occupational Therapy. Must be needed to help your condition improve in a reasonable and predictable time, or needed to establish an effective home exercise program.

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Speech therapy is not covered for attention disorders, behavior problems, conceptual handicaps, learning disabilities, developmental delays.

Combined Rehabilitative and Habilitative limit of 30 visits per benefit period. Must be needed to improve speech problems caused by disease, trauma, congenital defect, or recent surgery.

Limit: 1.0 Exam(s) per Benefit Period

Limit: 120.0 Days per Admission

Exclusions: Covered health services do not include custodial, domiciliary care, or long-term care admissions.

The skilled nursing facility is a Network Provider. Coverage is limited to 120 days per confinement. A confinement includes all admissions not separated by 180 days.

Dermatology virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits

Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply.

Your health benefit plan has a maximum benefit limit per transplant of $10,000 for each cadaveric organ and up to $45,000 for each organ procured from a living donor including organ harvesting. Kidney and bone marrow transplants do not apply to this limit. For kidney transplants, if there is not a network transplant facility available living donor costs are limited to $50,000 not including harvesting.

Treatment is covered if there is documented organic joint disease, or joint damage resulting from physical trauma

Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits