2009-2010 State of Illinois - College Insurance Program Participants

HealthLink is pleased to offer the Open Access III network program for the College Insurance Program Participants.

With HealthLink Open Access III network program, you may use any participating physician or hospital in the HealthLink Tier I and Tier II networks. If you prefer to use an out-of-network practitioner, your benefit administrator still pays benefits - but keep in mind, you'll pay less out of pocket when you choose HealthLink participating physicians and hospitals.
This benefit overview is a summary only and it is subject to the benefits, exclusions, modifications and limitations contained in the plan's 'certificate' of coverage.
Benefits effective July 1, 2009 - June 30, 2010

BENEFIT
Tier I
HealthLink HMO Network
Tier II
HealthLink PPO Network
Tier III
Non-HealthLink
Providers
Plan Year Maximum Unlimited Unlimited $1,000,000
Lifetime Maximum
 Unlimited Unlimited $1,000,000

Annual Out-of-Pocket Max*
Per Individual enrollee
Per Family

 $0
$0		 $700
$1,400		 $1,700
$3,600
Annual Deductible
Must be satisfied for all services
 $0
 $300 Per Enrollee**
 $400 Per Enrollee**
HOSPITAL SERVICES (May require pre-authorization. Please refer to your benefit booklet for details.)
Inpatient

Full coverage after $250 copayment per admission
80% of network charges for covered services after $300 copayment per admission
60% of U&C*** for covered services after $400 copayment per admission
Inpatient Psychiatric Full coverage after $250 copayment per admission up to 30 days per plan year 80% of network charges after $300 copayment per admission up to 30 days per plan year
60% of U&C for covered services after $400 copayment per admission up to 30 days per plan year
Inpatient Alcohol and Substance Abuse
Full coverage after $250 copayment per admission up to 10 days rehabilitation per plan year 80% of network charges after $300 copayment per admission up to 10 days rehabilitation per plan year 60% of U&C for covered services after $400 copayment per admission up to 10 days rehabilitation per plan year

Emergency Room
Waived if admitted

 Full coverage after $200 copayment

80% for covered services after $200 copayment 60% of U&C for covered services after lesser $200 copayment or 50% of U&C
Outpatient Surgery

Full coverage after $150 copayment
80% of network charges for covered services after $150 copayment 60% of U&C for covered services after $150 copayment
Outpatient Psychiatric and Substance Abuse

Full coverage after $20 copayment per admission up to 30 days per plan year
80% of network charges for covered services after $20 copayment up to 30 visits per plan year
60% of U&C for covered services after $20 copayment, up to 30 visits per plan year
Diagnostic Lab & X-Ray Full coverage
 80% of network charges for covered services 60% of U&C for covered services
PHYSICIAN AND OTHER PROFESSIONAL SERVICES
Physician Office Visits Full coverage after $15 copayment 80% of network charges for covered services after $15 copayment
60% of U&C for covered services
Preventive Health Services
Including immunizations, allergy testing and treatment
 Full coverage after $15 copayment 80% of network charges for covered services after $15 copayment
 Not covered under Tier III
Chiropractic Care

Full coverage after $15 copayment up to 25 visits per plan year 80% of network charges for covered services up to $25 visits per plan year
60% of U&C for covered services up to 25 visits per plan year
Well Baby Care
Full coverage after $15 copayment 80% of network charges for covered services after $15 copayment
Not covered under Tier III
OTHER SERVICES
Durable Medical Eqpt

 Full coverage 80% of network charges for covered services 60% of U&C for covered services
Skilled Nursing Facility
120 days per plan year		 Full coverage 80% of network charges for covered services Not covered under Tier III
Transplant Coverage Full coverage 80% of network charges for covered services Not covered under Tier III
Home Health Visits Full coverage after $15 copayment 80% of network charges for covered services after $15 copayment Not covered under Tier III

Please Note:
* Your out-of-pocket maximum is the most you will be required to pay for any covered expenses. Plan payments do not count toward the out-of-pocket maximum. Plan copayments

** Annual plan deductible must be met before plan benefits apply. Benefit limits are measured on a plan year.

*** Covered services received from Tier III providers (out-of-network) are covered for “Usual & Customary” (U&C) charges – fees normally charged for comparable treatment in the same geographic area. Participating Tier I and Tier II physicians and facilities usually charge a lower, contracted rate for services. For more information on U&C, consult your Summary Plan Description (SPD) booklet.

HealthLink®, Inc., is an Illinois corporation.  HealthLink, Inc. is an organizer of independently contracted provider networks, which it makes available by contract to a variety of payors of health benefits, including insurers, third party administrators or employers.  HealthLink has no control or right of control over the professional, medical judgment of contracted providers, and is not liable for any acts or failures to act, by contracted providers.  HealthLink, Inc. is not an insurance company and has no liability for benefits under benefit plans offered or administered by payors.  HealthLink® is a registered trademark of HealthLink, Inc. and a separately incorporated and capitalized subsidiary of WellPoint, Inc. Any reference in the material to other organizations or companies, including their Internet sites, is not an endorsement or warranty of the services, information or products provided by those organizations or companies. Discount offerings made available by third-party vendors.