Important Notices and Disclosures
Women ’ s Health & Cancer Rights Act
If you have had or are going to have a mastectomy , you may be entitled to certain benefits under the Women ’ s Health and Cancer Rights Act of 1998 (“ WHCRA ”). For individuals receiving mastectomy-related benefits , coverage will be provided in a manner determined in consultation with the attending physician and the patient , for :
� All stages of reconstruction of the breast on which the mastectomy was performed ; � Surgery and reconstruction of the other breast to produce a symmetrical appearance ; �
Prostheses ; and � Treatment of physical complications of the mastectomy , including lymphedema .
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the plan . Therefore , the following deductibles and coinsurance apply :
Plan 1 : Share Traditional Plan ( Individual : 20 % coinsurance and $ 750 deductible ; Family : 20 % coinsurance and $ 1,500 deductible )
Plan 2 : Share High Deductible Health Plan ( Individual : 20 % coinsurance and $ 2,000 deductible ; Family : 20 % coinsurance and $ 4,000 deductible )
If you would like more information on WHCRA benefits , please call your Plan Administrator at 801.336.1845 or kathih @ dbhutah . org .
Newborns ’ and Mothers ’ Health Protection Act
Group health plans and health insurance issuers generally may not , under Federal law , restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery , or less than 96 hours following a cesarean section . However , Federal law generally does not prohibit the mother ’ s or newborn ’ s attending provider , after consulting with the mother , from discharging the mother or her newborn earlier than 48 hours ( or 96 hours as applicable ). In any case , plans and issuers may not , under Federal law , require that a provider obtain authorization from the plan or insurance issuer for prescribing a length of stay not in excess of 48 hours ( or 96 hours ).
Qualified Medical Child Support Orders
Coverage will be provided to any of your dependent child ( ren ) if a Qualified Medical Child Support Order ( QMCSO ) is issued , regardless of whether the child ( ren ) currently reside with you . A QMCSO may be issued by a court of law or issued by a state agency as a National Medical Support Notice ( NMSN ), which is treated as a QMCSO . If a QMCSO is issued , the child or children shall become an alternate recipient treated as provisions , and procedures as all other plan participants .
Patient Protections Disclosure
The Davis Behavioral Health Plan generally allows the designation of a primary care provider . You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members . Until you make this designation , SelectHealth designates one for you . For information on how to select a primary care provider , and for a list of the participating primary care providers , contact SelectHealth at 800.538.5038 or www . selecthealth . org .
For children , you may designate a pediatrician as the primary care provider . You do not need prior authorization from SelectHealth or from any other person ( including a primary care provider ) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology . The health care professional , however , may be required to comply with certain procedures , including obtaining prior authorization for certain services , following a pre-approved treatment plan , or procedures for making referrals . For a list of participating health care professionals who specialize in obstetrics or gynecology , contact SelectHealth at 800.538.5038 or www . selecthealth . org .
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