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PPO (LOW DEDUCTIBLE) PLANMASTER PLAN DOCUMENTPLAN YEAR 2023(EFFECTIVE JULY 1, 2022 – JUNE 30, 2023)Public Employees’ Benefits Program901 S. Stewart Street, Suite 1001Carson City, Nevada 89701
Table of ContentsTable of ContentsAmendment Log. viiWelcome PEBP Participant . 1Introduction. 2Suggestions for Using this Document: . 3Accessing Other Benefit Information: . 3Participant Rights and Responsibilities . 5You have the right to: . 5You have the responsibility to: . 5The plan is committed to: . 6Summary of the LD PPO Components . 7Highlights of the Plan . 7Deductibles . 8In-Network Individual Deductible . 8Out-of-Network Individual Deductible . 8In-Network Family Deductible . 9Out-of-Network Family Deductible. 9Coinsurance . 9Out-of-Pocket Maximums. 10In-Network Out-of-Pocket Maximums . 10Out-of-Network Out-of-Pocket Maximum. 10Description of In-Network and Out-of-Network. 12Provider Network. 12In-Network Provider Benefits . 12Out-of-Network Provider Benefits . 13Other Providers. 13Out-of-Network Benefit Exceptions. 13Emergency Care . 13Confinement in an Out-of-Network Hospital Following an Emergency . 14Other Exceptions. 14When Out-of-Network Providers May be Paid as In-Network Providers . 14Preferred Provider Organizations (PPO Network) . 15Service Area . 15Public Employees' Benefits ProgramiLow-Deductible PPO Plan
Table of ContentsDirectories of Network Providers . 15Eligible Medical Expenses . 16A Person Whose Status Changes from Employee/Retiree to Dependent or from Dependent to Employee . 16Non-Eligible Medical Expenses. 17PPO Network Health Care Provider Services . 17Out-of-Country Medical, Prescription and Vision Purchases . 18Utilization Management . 20Delivery of Services . 21Concurrent Review . 21Retrospective Review . 22Case Management . 22Precertification (Prior Authorization) Process . 22Services Requiring Precertification (Prior Authorization) . 23Services Not Requiring Precertification (Prior Authorization) . 24How to Request Precertification (Prior Authorization). 25Second Opinion . 26Hospital Admission . 26Emergency and Urgent Hospital Admission. 26Confinement in an Out-of-Network Hospital Following an Emergency Admission . 27Other Exceptions. 27Elective Knee and Hip Joint Replacement. 27Inpatient or Outpatient Surgery . 28Outpatient Infusion Services. 28Air Ambulance Services . 28Air/Flight Schedule Inter-Facility Transfer . 28Emergency Air Ambulance . 29Gender-Related Surgery . 29Health Care Services and Supplies Review . 30Failure to Follow Required UM Procedures. 30Coronavirus (COVID-19) Benefits . 31Summary of Medical Benefits . 32Schedule of Medical Benefits . 45Acupuncture and Acupressure Services . 45Alcohol and Substance Abuse Services (inpatient and outpatient) . 45Public Employees' Benefits ProgramiiLow-Deductible PPO Plan
Table of ContentsAllergy Testing and Treatment. 46Autism Spectrum Disorders . 46Blood Services for Surgery . 48Chemotherapy . 48Clinical Trials . 48Diabetic Services for Type 1, Type 2, and Gestational Diabetes. 50Family Planning, Fertility, Sexual Dysfunction Services and Male Contraception . 51Bariatric/Weight Loss Surgery . 51Gender Reassignment . 54Genetic Counseling/Testing . 57Hearing Aids . 58Home Health Care. 59Infertility Services . 59Mastectomy Reconstructive Surgery . 60Medical Care . 60Mental Health Services . 60Maternity and Newborn Services . 61Obesity Care Management Program . 61Oral Surgery, Dental Services, and Temporomandibular Joint Disorder . 65Orthopedic Devices and Prosthetic Devices . 67Ostomy Care Supplies . 67Partial Hospitalization Services . 67Podiatry Services . 68Preventive Services . 68Women’s Contraceptives. 69Colorectal Cancer Screening . 69Screening Mammograms (2-D or 3-D) . 70Healthy Diet/Physical Activity Counseling and Obesity Screening/Counseling . 70Radiation Therapy . 71Rehabilitative and Habilitative Therapy. 71Skin Lesions . 71Spinal Manipulation (non-surgical) . 71Transplant Services (Organ and Tissue) . 71Hospital, Skilled Nursing Care, and Services in an Outpatient Surgical Center . 73Public Employees' Benefits ProgramiiiLow-Deductible PPO Plan
Table of ContentsInpatient Care . 73Outpatient Care . 74Emergency and Urgent Care Services . 75Out-of-Network Emergency Inpatient Admission Notification . 76Extended Notification . 76Follow-Up Care (Outside of the Service Area/Non-Contracted Facility) . 76Follow-up Care if Temporarily Outside the Geographic Service Area . 76Limitations . 77Balance Billing . 77Ambulance Services . 77Durable Medical Equipment (DME) . 77Enteral Formulas and Special Food Products . 78Hospice Services . 79Lab and Diagnostic Services . 792nd.MD Opinion . 80Telemedicine or Telehealth (Doctor on Demand) . 80Continued Coverage Following Termination of a Provider Contract . 80Transplants (Organ and Tissue) . 81Use of Centers of Excellence for Transplant and Gastric (Bariatric) Procedures. 82Travel Expenses. 82Pre-Approval of your Travel Expenses . 85Submitting your Travel Expense Receipts . 85Schedule of Prescription Drug Benefits . 86Preventive Drug Benefit Program . 87Prescription Retail Drugs . 8730-Day Retail Program Express Advantage Network Program . 87Smart90 Retail and Home Delivery Program . 88Smart90 Retail Pharmacy. 88Express Scripts Home Delivery. 88Specialty Drug Program . 89SaveonSP Program . 90Extended Absence Benefit . 90Out-of-Country Emergency Medication Purchases . 91Out-of-Network Pharmacy Benefit . 92Public Employees' Benefits ProgramivLow-Deductible PPO Plan
Table of ContentsOther Limitations: . 92Benefit Limitations and Exclusions . 93Expenses That Do Not Accumulate Toward Your Out-of-Pocket Maximum . 93Benefit Limitations . 93Lifetime Maximum . 93Exclusions Under the Medical Plan . 94Medical Claims Administration . 119How Medical Benefits are Paid . 119How to File a Medical Claim . 119Where to Send the Claim Form . 121Appeals . 122Discretionary Authority of PEBP and Designee . 122Medical and Dental Claims Appeals. 122Written Notice of Adverse Benefit Determination . 122Level 1 Claim Appeal . 122Level 2 Claim Appeal . 123External Claim Review. 123Appealing a Utilization Management Determination . 124Internal UM Appeal Review . 125External UM Appeal Review . 125Experimental and/or Investigational Claim/UM External Review . 127Prescription Drug Review and Appeals . 127Clinical Coverage Review . 127Administrative Coverage Review . 128Level 1 Appeal or Urgent Appeal . 128Level 2 Appeal . 129External Reviews . 130Coordination of Benefits . 132Which Benefits are Subject to Coordination?. 132When and How Coordination of Benefits (COB) Applies . 132Which Plan Pays First: Order of Benefit Determination Rules. 133The Overriding Rules . 133Administration of COB . 135Coordination with Medicare . 136Public Employees' Benefits ProgramvLow-Deductible PPO Plan
Table of ContentsEntitlement to Medicare Coverage (Retirees and their Covered Dependents). 137Retirees Ineligible for Premium-Free Medicare Part A . 137Coverage under Medicare and This Plan when You Have End-Stage Renal Disease (ESRD) . 137How Much This Plan Pays When It Is Secondary to Medicare. 137Coordination with Other Government Programs . 138Medicaid . 138Tricare . 138Veterans Affairs Facility Services . 138Workers’ Compensation . 138Disability . 138Prescription Drug Plan . Error! Bookmark not defined.Subrogation and Third-Party Recovery . 140Participant Contact Guide. 141Key Terms and Definitions . 143Public Employees' Benefits ProgramviLow-Deductible PPO Plan
Amendment LogAmendment LogAny amendments, changes or updates to this document will be listed here. The amendment logwill include what sections are amended and where the changes can be found.Public Employees' Benefits ProgramviiLow-Deductible PPO Plan
WelcomeWelcome PEBP ParticipantWelcome to the State of Nevada Public Employees’ Benefits Program (PEBP). PEBP offersmedical, vision, dental, and life insurance, in addition to flexible spending accounts, and othervoluntary benefits for eligible state and local government employees, retirees, and their eligibledependents.As a PEBP participant, you may access whichever benefit plan offered in your geographical areathat best meets your needs, subject to specific eligibility and Plan requirements. These plansinclude the Consumer Driven Health Plan (CDHP) with a Health Savings Account (HSA) or a HealthReimbursement Arrangement (HRA), Premier Plan, Low Deductible PPO Plan, and the Health Planof Nevada HMO Plan. You are also encouraged to research plan provider access and quality ofcare in your service area.All PEBP participants choosing the Low Deductible Health Plan should examine this document,the PEBP Self-Funded PPO Dental Plan Master Plan Document (MPD), the Active Employee Healthand Welfare Wrap Plan, Retiree Health and Welfare Wrap Plan, Section 125 Document, and thePEBP Enrollment and Eligibility Master Plan Document. These documents are available atwww.pebp.state.nv.us or by calling 775-684-7000 or 1-800-326-5496.Master Plan Documents are a comprehensive description of the benefits available to you.Relevant statutes and regulations are noted in the Active Employee Health and Welfare PlanDocument and Retiree Health and Welfare Wrap Plan Document for reference. In addition,helpful material is available from PEBP or any PEBP vendor listed in the Participant Contact Guide.PEBP encourages you to stay informed of the most up to date information regarding your healthcare benefits. It is your responsibility to know and follow the requirements as described in PEBP’sMaster Plan Documents.Sincerely,Public Employees’ Benefits ProgramPublic Employees' Benefits Program1Low-Deductible PPO Plan Year 2023
IntroductionIntroductionThis Master Plan Document describes the Low Deductible PPO Plan (also referred to as the LDPPO Plan). The LD PPO Plan offers In-Network and Out-of-Network benefits and is a self-fundedplan administered by PEBP and governed by the State of Nevada. The Plan is available to eligibleemployees, re
PPO (LOW DEDUCTIBLE) PLAN MASTER PLAN DOCUMENT PLAN YEAR 2023 (EFFECTIVE JULY 1, 2022 JUNE 30, 2023)- Public Employees' Benefits Program . 901 S. Stewart Street, Suite 1001 . Carson City, Nevada 89701. Table of Contents . Public Employees' Benefits Program Low-Deductible PPO Plan i .
