If you have Medical Mutual of Coverage, male participants age ten and over are allowed one “routine” physical per calendar year. Female participants age ten and over are allowed a routine visit with their General Practioner and one with their OB/GYN, in other words two routine physicals.
Only the following procedures are covered in one “routine” physical and the procedures must be submitted as “routine:”
- Chest x-ray
- Complete blood count (CBC)
- Electrocardiogram (EKG)
- Comprehensive metabolic panel
- Urinalysis (UA)
- Prostate specific antigen (PSA) test
- Mammogram
- PAP smear
Other tests such as sigmoidoscopy, colonoscopy, cholesterol levels, etc, must be submitted under a medical diagnosis to be covered. If they are submitted under “routine,” the claims will be denied.
Immunizations that are covered: tetanus toxoid; rabies vaccine; and meningococcal polysaccharide vaccine; Shingles vaccine. Hepatitis B vaccine is covered for the employee only
Having a baby? Preventative medical coverage for babies from birth to age one is unlimited; age 1 to 9 maxes out at $150.00 and the coverage period is birth date to birth date.
Ambulances, both ground and air(life flight), cost members money. There are no network providers in the case of ambulance services. Therefore, when an ambulance is used, it will usually cost the member. MMOH will pay Usual, Customary, and Reasonable (UCR) fees, but usually the member will have pay a major portion of the bill. In addition, ambulance where you sit up or are in a wheelchair are NOT covered at all.
Urgent Care centers, like the Medgroup or Lake Hospital's urgent care, ("Doc in a box" places) have some doctors working there that are not "in-network." When you have non-emergency treatments you might incur charges depending on who treats you. You might consider asking if the doctor treating you is a network provider or you could face out of network charges. Unfortunately, these are some of the places that are most convenient, but it is a crapshoot about how you might or might not get billed.
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