DESERET VALUE - DMBA

DESERET VALUEThis summary plan description, or SPD, outlines the majorprovisions of Deseret Value as of January 1, 2022.Table of ContentsDeseret Value Key Points . 3Maximizing Your Benefits . 3Contracted providers. 3Preauthorize when needed . 4Annual Deductible . 4Your Medical Benefits . 5Acupuncture . 5Allergy testing . 5Ambulance—emergency. 5Anesthesia . 6Applied behavior analysis (ABA) therapy . 6Behavioral (mental) health and substance use disorders . 6Cardiac rehabilitation. 7Chemotherapy—provider-administered. 7Chiropractic therapy . 7Colorectal cancer screening or colonoscopy . 7Convenient care clinic . 8Diabetes . 8Dialysis . 9Durable medical equipment . 9Emergency room . 11Emergency room physician . 11Enteral therapy . 12Eye exams . 12Eyewear (glasses or contact lenses) . 12Functional cosmetic surgery . 12Genetic counseling . 13Genetic testing . 13Hearing aids . 13Hearing exams . 13Hearing testing (audiometry) . 13Home healthcare. 14Hospice care . 14Hospital—inpatient . 14Imaging services (radiology) . 15Immunizations. 15Infertility services . 161DESVAL2HBA0122

Injections and IV therapy. 16Laboratory services. 16Lifestyle screenings . 17Mammograms . 17Maternity . 18Medical supplies . 18Nutritional education . 18Obesity surgery . 19Office visits . 19Osteoporosis screening . 19Pain management. 20Physical and occupational therapy. 20Physical exams . 20Prescription drugs . 21Preventive care services . 22Prosthetics. 31Radiation therapy . 31Respiratory education. 31Skilled nursing facility. 31Speech therapy . 32Surgery. 32Telemedicine . 33Temporomandibular joint (TMJ) dysfunction . 33Transplants . 33Transportation . 34Urgent care. 34Well-child care. 34Well-newborn care—physician services . 35Well-woman exams . 35Medical Emergencies . 36Preauthorization . 36Out-of-pocket Maximum . 37For individuals (participants or dependents) . 37For families . 37Errors on Bills or EOB Statements. 38Submitting Claims . 38Financial Disclosure . 39Fraud Policy Statement . 39Coordination of Benefits . 40Coordination of benefits rules . 40Subrogation. 40Eligible Dependents . 40Exclusions . 411.2.3.4.5.2Custodial care . 41Dental care . 41Diagnostic and experimental services . 41Fertility, infertility, family planning, home delivery, surrogate pregnancy, and adoption . 42Government/war . 42DESVAL2HBA0122

6.7.8.9.10.11.12.13.14.15.16.17.18.Hearing . 43Legal exclusions. 43Medical equipment . 43Medical necessity . 43Mental health, counseling, chemical dependency . 44Miscellaneous . 44Education and training . 45Obesity. 45Other insurance/workers’ compensation . 45Prescription drugs . 45Testing . 45Transplants. 46Vision . 46Patient Protection and Affordable Care Act . 46Claims Review and Appeal Procedures . 46Notification of Discretionary Authority. 46Notification of Non-compliance and Abuse of Benefits. 47Notification of Benefit Changes. 47Legal Notice. 47Deseret Value Key Points Generally, Deseret Value covers contracted providers at 70% and non-contractedproviders at 60% of DMBA’s allowable amount. Copayments apply to some benefits, including office visits. Certain preventive services—such as colonoscopies, mammograms, physical exams, andwell-child care—from contracted providers are covered at 100%. Deseret Value has an annual deductible of 400 per person or 800 per family forservices from non-contracted providers. Your annual out-of-pocket maximum is 5,600 per person or 8,400 per family. You or your physician must preauthorize some services with DMBA, such as somesurgeries and home healthcare.Maximizing Your BenefitsContracted providersAll DMBA health plans are preferred provider organizations, or PPOs, meaning you pay lessout of pocket when you receive care from your plan’s contracted providers (physicians,hospitals, etc.).When you receive care from contracted providers, they accept your copayments andcoinsurance, along with what DMBA pays, as payment in full for eligible services. Theywon’t bill you for more than DMBA’s allowable amount.When you receive care from providers not contracted with DMBA, they can bill you for thedifference between the amount they charge and DMBA’s allowable amount. Plus, your3DESVAL2HBA0122

share of the expenses increases and you are responsible for all expenses that exceedallowable amounts.Services from non-contracted providers will apply to your annual deductible.Different DMBA health plans can have different contracted providers. For informationabout contracted providers in your area for your specific plan, go to www.dmba.com. Ourcontracted organizations include the following:HawaiiSoutheast Idaho andUtahOther areasMDX Hawaii NetworkDMBA contracted providersUnitedHealthcare Options PPONetwork808-466-4077800-777-3622 orwww.dmba.com800-777-3622 orwww.dmba.comPreauthorize when neededYou or your provider must preauthorize some services with DMBA.When you preauthorize with DMBA, we verify that your care is medically necessary and tellyou about any length-of-stay guidelines or other limitations.If you don’t preauthorize when required, your benefits may be reduced or denied. You maybe responsible for a preauthorization penalty (usually 200) in addition to the appropriatecoinsurance. If DMBA ultimately denies benefits for the service, you will be responsible forall charges.For more information, see Preauthorization and Your Medical Benefits.Annual DeductibleWhen you receive care from non-contracted providers, the annual deductible is 400 perperson or 800 per family. This deductible is cumulative—you only need to satisfy thedeductible once during the calendar year before normal benefits begin.Submit claims to DMBA while you’re meeting the annual deductible. Through standardclaims submission, we track the amounts applied to your deductible. You can see howmuch has been applied on www.dmba.com.For information about how the annual deductible applies to your benefits, see theindividual benefits in Your Medical Benefits, which follows.4DESVAL2HBA0122

Your Medical BenefitsTo be a covered service, the healthcare you receive must be medically necessary, meet theplan’s guidelines and medical criteria, and be provided by a licensed practitioner of thehealing arts. All benefits are subject to the allowable amounts determined by DMBA.AcupunctureContracted provider: The plan pays 100% after your 35 copayment.Non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your 40 copayment. The annual deductible applies.Up to 12 visits are covered per calendar year.You may receive more than one service in a single visit.Allergy testingContracted provider: The plan pays 70%; you pay 30%.Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%.The annual deductible applies.Some testing, such as ALCAT and LHRT, is not covered. See Exclusion 15.1.For information about injections for allergies, see Injections.Ambulance—emergencyContracted or non-contracted provider: The plan pays 70% of DMBA’s allowableamount; you pay 30%.Covered services when DMBA’s medical criteria are met: Licensed ambulance services to the nearest medical facility equipped to furnish theappropriate care Air ambulance servicesMedical services and supplies provided during the transportation are covered at theappropriate benefit level for those services.Examples of services not covered: Wheelchair van servicesGurney van servicesTransportation not associated with emergency servicesRepatriation from an international location back to the United StatesFor more information about other transportation services, see the Transportation benefit.All benefits are subject to DMBA’s allowable amounts.5DESVAL3HBA0322

AnesthesiaContracted or non-contracted provider: The plan pays 70% of DMBA’s allowableamount; you pay 30%.Applied behavior analysis (ABA) therapyContracted provider: The plan pays 70%; you pay 30%.Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%.The annual deductible applies.You must preauthorize, including the initial assessment.To be covered, a board-certified behavior analyst (BCBA or BCBA-D) must provide therapyfor an individual with a confirmed autism spectrum disorder diagnosis by a qualifiedprovider (i.e., psychiatrist, psychologist, neurologist, or developmental pediatrician).Behavioral (mental) health and substance use disordersTo be covered, an individual must be diagnosed with and treated for a mental disorderincluded in the current Diagnostic and Statistical Manual of Mental Disorders.OutpatientContracted provider: The plan pays 100% after your 20 copayment per visit.Non-contracted provider: The plan pays 100% of DMBA’s allowable amount afteryour 25 copayment per visit.Covered services: Individual therapy Group therapySome therapies, such as educational groups, are not covered. See Exclusion 10.2.Inpatient, partial hospital, intensive outpatient, and outpatient testingContracted provider: The plan pays 70%; you pay 30%.Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay40%. The annual deductible applies.Covered services: Acute inpatient hospitalizationResidential treatment servicesPartial hospitalization programs (PHP)Intensive outpatient programs (IOP)Psychological and neuropsychological testingPreauthorization is required. In case of emergency, call DMBA within two businessdays after the admission or as soon as reasonably possible.All benefits are subject to DMBA’s allowable amounts.6DESVAL3HBA0322

Cardiac rehabilitationContracted provider: The plan pays 70%; you pay 30%.Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%.The annual deductible cted provider: The plan pays 70%; you pay 30%.Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay 40%.The annual deductible applies.You may have to preauthorize.Oral chemotherapy agents and self-administered medications may be covered by thePrescription drugs—specialty pharmacy benefit.Chiropractic therapyContracted provider: The plan pays 100% after your 35 copayment.Non-contracted provider: The plan pays 100% of DMBA’s allowable amount after your 40 copayment. The annual deductible applies.Up to 25 visits per calendar year are covered.If you’re billed for an evaluation and for a therapy treatment in the same visit, you’reresponsible for both copayments.Full-body X-rays are not covered.Colorectal cancer screening or colonoscopyScreenings can be preventive or diagnostic. A preventive screening that results in a diagnosisis considered diagnostic and services will be paid under the diagnostic benefit.PreventiveContracted provider: The plan pays 100%.Non-contracted provider: The plan pays 60% of DMBA’s allowable amount; you pay40%. The annual deductible applies.A preventive exam once every five years is covered for individuals age 45–75.Anesthesia for preventive procedures is covered at 100% of DMBA’s allowableamount.Virtual colonoscopies are not covered.DiagnosticContracted provider: The plan pays 70%; you pay 30%.All benefits are subject to DMBA’s allowable amounts.7DESVAL3HBA0322