File ANNUAL_BENEFITS(355.4) Data List
| BENEFIT YEAR BEGINNING ON |
HEALTH INSURANCE POLICY |
MAX. OUT OF POCKET |
AMBULANCE COVERAGE (%) |
DATE ENTERED |
ENTERED BY |
DATE LAST VERIFIED |
VERIFIED BY |
DATE LAST EDITED |
LAST EDIT BY |
PERSON CONTACTED |
COMMENTS |
CONTACT'S PHONE NUMBER |
ANNUAL DEDUCTIBLE (OPT) |
PER VISIT DEDUCTIBLE |
OUTPATIENT LIFETIME MAXIMUM |
OUTPATIENT ANNUAL MAXIMUM |
MH LIFETIME OUTPATIENT MAX. |
MH ANNUAL OUTPATIENT MAX. |
DENTAL COVERAGE TYPE |
DENTAL COVERAGE $ OR % |
OUTPATIENT VISIT (%) |
EMERGENCY OUTPATIENT (%) |
MENTAL HEALTH OUTPATIENT (%) |
PRESCRIPTION (%) |
OUTPATIENT SURGERY (%) |
MH OPT. MAX DAYS PER YEAR |
OUTPATIENT VISITS PER YEAR |
ADULT DAY HEALTH CARE |
HOME HEALTH CARE LEVEL |
HOME HEALTH VISITS PER YEAR |
HOME HEALTH MAX DAYS PER YEAR |
HOME HEALTH MED. EQUIPMENT (%) |
HOME HEALTH VISIT DEFINITION |
OCCUPATIONAL THERAPY # VISITS |
PHYSICAL THERAPY # VISITS |
SPEECH THERAPY # VISITS |
MEDICATION COUNSELING # VISITS |
HOSPICE ANNUAL DEDUCTIBLE |
HOSPICE INPATIENT ANNUAL MAX |
HOSPICE INPT. LIFETIME MAX |
ROOM AND BOARD (%) |
OTHER INPATIENT CHARGES (%) |
IV INFUSION OPT. |
IV INFUSION INPT. |
IV ANTIBIOTICS OPT. |
IV ANTIBIOTICS INPT. |
ANNUAL DEDUCTIBLE (INPATIENT) |
PER ADMISSION DEDUCTIBLE |
INPATIENT LIFETIME MAXIMUM |
INPATIENT ANNUAL MAXIMUM |
MH LIFETIME INPATIENT MAXIMUM |
MH ANNUAL INPATIENT MAXIMUM |
DRUG & ALCOHOL LIFETIME MAX |
DRUG & ALCOHOL ANNUAL MAX |
NURSING HOME (%) |
MENTAL HEALTH INPATIENT (%) |
MH INPT. MAX DAYS PER YEAR |