Plan C

Kent Health Plan

		*kenthealthplan.org*

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Plan C

The Affordable Healthcare Option for Small Businesses

Plan C is a unique option that allows small businesses to provide healthcare coverage to their employees. The monthly cost of Plan C coverage ($200) is shared equally by eligible employers, their enrolled employees and Kent Health Plan Corporation. In other words, each party contributes one-third or $67 per month for coverage. The result – an affordable healthcare plan.

Choice of Physician through Michigan’s Finest Providers: The PPOM Network
Plan C provides its members access to the healthcare industry’s finest doctors and most respected hospitals. The PPOM Network includes conveniently located Grand Rapids area hospitals and hundreds of area physicians (over 26,000 physicians and 200 hospitals throughout Michigan). The Network carefully reviews the credentials and records of every participating provider.

Simplicity, Convenience and Friendly Customer Service
Plan C makes it easy to navigate the healthcare maze. There are no claims forms to submit when visiting network providers. Members simply present their ID card at the time they receive healthcare services. The provider bills the Plan directly. And friendly, first-rate service means that Plan members get quick responses to questions and concerns.

Comprehensive Healthcare Is Priceless
For most people, healthcare coverage is a precious commodity. It can help keep them feeling their healthy best. And coverage can reduce financial hardship. We’re pleased to offer you affordable healthcare coverage and we look forward to helping your employees stay healthy!

Features, Requirements and Provisions
Group Eligibility

Employer’s primary business location must be in Kent County, Michigan
This plan is for employer groups that have 4 - 50 employees
Eighty percent of employees must reside in Kent County, Michigan
~~Employer must have had no prior healthcare coverage for the immediate past two consecutive years~~. Waived Until September 30, 2007.
The hourly wage of 51% of the group’s participants must average $12.50 or less for the first year of the plan.
The employer is eligible for Plan C for up to six consecutive years.
Employee spouses are eligible for coverage
Child dependents are not eligible; however, they may be eligible for other State of Michigan or Federal programs. For more information on MIChild, click here.

Effective Dates
An employer group is eligible the first of the month following the month in which proper documentation and first month’s premium is submitted to the plan.

Pre-Existing Conditions
For new employees, the plan will not make any payment exceeding $1,000 for a condition for which medical advice, diagnosis, care or treatment, including the use of prescription drugs, was recommended or received during the 6-month period ending on the enrollment date until the follow time has been met:

Six (6) consecutive months without treatment of the condition;
Twelve (12) consecutive months with treatment of the condition

Provider
PPOM Network. No benefits out of PPOM Network.

Maximums
All benefits are applied to one lifetime or annual maximum per insured individual.

Claims Forms
Members do not submit claims forms when they use Network providers. Members simply present their ID card at the time they receive healthcare services. The provider will bill us directly.

Pre-Certification
Covered individuals must obtain authorization before any non-emergency hospital admission. For an emergency hospital admission, notification must occur within 48 hours or on the first business day following the hospital admission. A $300 reduction of the payable benefit amount will apply for non-compliance.

Plan C Schedule of Medical Coverage
(see below) or Click here to download a printable version
(Employee and Spouse Only; Children Not Covered)

In-Network benefits are based on the Preferred Provider Organization's approved amount. Out-of-Network benefits are not provided except for life-threatening emergencies and are then based on the US Health and Life fee schedule. Benefits are determined after an applicable Copay and Coinsurance, and are subject to Daily, Annual, Lifetime, and Other Maximums, General Exclusions and other applicable limitations.

Annual Maximum, All Benefits Combined, regardless of individual service maximums $35,000 Lifetime Maximum, All Benefits Combined, regardless of individual service maximums $200,000
*Benefits are provided Out-of-Network only for Life-Threatening Emergencies	In-Network (PPOM) Plan Pays after Member's Copay and Coinsurance	Out-of-Network *Benefits are provided Out-of-Network only for Life-Threatening Emergencies
Inpatient Hospital Services (Semi-Private Room and Board, Intensive Care Unit, Ancillary Services)
General Conditions $25000 Annual Maximum 20 Day Annual Maximum	$100 Copay per Admission	Not Covered*
Psychiatric Treatment 15 Day Annual Maximum	$100 Copay per Admission	Not Covered*
Substance Abuse care $5000 Annual Maximum 10 Day Annual	$100 Copay per Admission	Not Covered*
Maternity Per Delivery Maximum of $3000, 4 Day Annual Maximum	$100 Copay per Admission	Not Covered*
Newborn, Including Nursery	$100 Copay per Admission	Not Covered*
Emergency Services	$1,000 Annual Maximum, regardless of individual maximum
Emergency Room ($1,000 Per Visit Maximum)	$50 Copay	Not Covered
Outpatient Services	$3,500 Annual Maximum, regardless of individual maximum
Urgent Care Center	$25 Copay per visit	Not Covered*
Ambulance	10% Coinsurance	Not Covered*
Surgery Facility (includes Anesthesia) Charge, $1,500 per Surgery Maximum	No Copay or Coinsurance	Not Covered*
Laboratory, X-ray, Radiology, Pathology	No Copay or Coinsurance	Not Covered*
Prosthetic Devices, Durable Medical Equipment and Medical Supplies - $1,500 Annual Maximum	No Copay	Not Covered*
Physical, Speech and Occupational Therapy	Not Covered	Not Covered*
Private Duty Nursing (R.N. only)	No Copay or Coinsurance	Not Covered*
Extended Care Facility	No Copay or Coinsurance	Not Covered*
Hospice Care Program	No Copay or Coinsurance	Not Covered*
Home Health Agency, 10 visit Annual maximum	No Copay or Coinsurance	Not Covered*
Psychiatric Services (including testing), 10 visits Annual Maximum	$15 Copay	Not Covered*
Physician Surgical procedures, $10,000 Annual Maximum	No Copay or Coinsurance	Not Covered*
Physician Services- anesthesia, $2,500 Annual Maximum	No Copay or Coinsurance	Not Covered*
Physician in Hospital Consultations & Emergency Room	No Copay or Coinsurance	Not Covered*
Physician Office Visits	$15 Copay	Not Covered*
Physician Maternity care including pre & postnatal	No Copay or Coinsurance	Not Covered*
Chiropractic Care, including x-rays, $250 Annual maximum	$15 Copay	Not Covered*
Non-Surgical Podiatric Care, all services $250 Annual maximum	$15 Copay	Not Covered*
Services (not included elsewhere)
Intermediate/Outpatient Substance Abuse Care, $3,500 Annual Maximum	20% Coinsurance	Not Covered*
Wellness/Preventive Care Benefits	Not Covered	Not Covered
Prescription Drugs $2,500 Annual Maximum	CLAIMSPRO
(Kent Health Plan B Formulary Only)
Brand Name	50% Coinsurance	Not Covered
Generic	$5 Copay	Not Covered

Please call (616) 726-8204 ext. 1 if you are interested in more information about Plan C.