Harken Health – Care Gold PPO Plans


Harken Health
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Harken Health is a new health insurance company offered in Illinois. It is partially owned by United Healthcare but is has an new approach to health insurance and considered a completely separate company in both plan designs and networks than United HealthOne. Harken Health is offering 4 PPO plans in 2016 to the Individual Market to Illinois residents ONLY living in Cook County.

Key features to all Harken Health Plans include:

  • Large PPO Hospital Network
  • They will be the only individual PPO plans that will include Rush University Hospital in-network in 2016
  • Plans includes a nationwide network of approximately 850,000 physicians, hospitals and care facilities
  • All plans include unlimited, no charge health visits at Harken Health Centers
  • 24 hour, 7 days a week access to Harken Health doctors
  • Prescription drug coverage and online ordering
  • Mental health care and wellness classes

Harken Gold Plans

Our Rating: Harken Health - Care Gold PPO Plans

There are 2 Harken Health Gold Plan Options:
  • Care Gold Plan I – $1,750 individual deductible / $3,500 family deductible and 100% coinsurance after deductible
  • Care Gold Plan II – $1,375 individual deductible / $2,750 family deductible and 100% coinsurance after deductible
Key Harken Health Gold Plan features include:
  • unlimited, no charge health visits at Harken Health Centers
  • Prescription drug coverage – including $5 generic copays
  • No referrals to see a specialist
  • Offered both on-exchange and off-exchange
  • Maternity Coverage
  • Well-adult care covered at 100%
  • Well-child care covered at 100%
  • Diagnostic testing
  • Hospital services
  • Access to the UHC Choice Plus national PPO network, which includes coverage while traveling out of state coverage


Harken Health Gold Deductibles
$1,750 single / $3,500 family
$1,375 single / $2,750 family

Harken Health - Care Gold PPO Plans

Care Gold I

Important Questions

Answers

Why this Matters:

What is the overall deductible?

Designated network: $1,750 person /
$3,500 family. Network: $3,500 person / $7,000 family. Non-network: $7,000 person / $14,000 family. Does not apply to copays, prescription drugs and services listed below as “No charge”.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use.  Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.  

Are there other deductibles for specific services?

No. There are no other specific deductibles.   

You don’t have to meet deductiblesfor specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out–of–pocket limit on my expenses?

Yes. Designated network & Network:
$3,500 person / $7,000 family combined.
No, for non-network.

The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out–of–pocket limit?

Penalties for failure to obtain prior authorization, premiums, balance-billed charges, and health care this plan does not cover.

Even though you pay these expenses, they don’t count toward the out-ofpocket limit on your expenses. 

Is there an overall annual limit on what the plan pays?

No.

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. See:
www.harkenhealth.com/providers/OurDo csILor call 1-800-797-9921 for a list of designated and in-network providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network providerfor some services. Plans use the term in-network, preferred, or participating for providersin their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No, you don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services

Common 
Medical Event

Services You May Need

Your Cost If You Use a
Designated
Network
Provider

Your Cost If
You Use a
Network
Provider

Your Cost If
You Use a
Non-Network Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

No charge

No charge after deductible

20% coinsurance after deductible

–––––––––––none–––––––––––

Specialist visit

No charge after deductible

No charge after deductible

20% coinsurance after deductible

–––––––––––none–––––––––––

Other practitioner office visit 

No charge after deductible

No charge after deductible

20% coinsurance after deductible

Per person per calendar year visits limited for manipulative treatment- 16.  You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Preventive care/screening/ immunization

No charge 

No charge

20% coinsurance after deductible

–––––––––––none–––––––––––

If you have a test

Diagnostic test (xray, blood work)

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Imaging (CT/PET scans, MRIs) 

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

If you need drugs to treat your illness or
condition
 
More information about prescription drug coverage is available at: www.harkenhealth. com/benefits/Our
Formulary
Individual

Tier 1

Retail: $5/ prescription   Mail Order: $10/ prescription  

Retail: $5/ prescription   Mail Order: $10/ prescription  

20% coinsurance after deductible 

Limited to a 31 day supply per prescription or refill. Mail order limited to 90 day supply. Certain drugs may have a pre-authorization requirement.

Tier 2

Retail: $35/ prescription   Mail Order: $70/ prescription  

Retail: $35/ prescription   Mail Order: $70/ prescription  

20% coinsurance after deductible 

Tier 3

Retail: $200/ prescription   Mail Order: $400/ prescription  

Retail: $200/ prescription   Mail Order: $400/ prescription  

20% coinsurance after deductible 

Tier 4

Retail: $350/ prescription   Mail Order: $700/ prescription  

Retail: $350/ prescription   Mail Order: $700/ prescription  

20% coinsurance after deductible 

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

No charge after deductible

No charge after deductible

20% coinsurance after deductible

Certain procedures require prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Physician/surgeon fees

No charge after deductible

No charge after deductible

20% coinsurance after deductible

Certain procedures require prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

If you need immediate medical attention

Emergency room
services

No charge after deductible

No charge after deductible

No charge after deductible

–––––––––––none–––––––––––

Emergency medical transportation

No charge after deductible

No charge after deductible

No charge after deductible

–––––––––––none–––––––––––

Urgent care

No charge after deductible

No charge after deductible

20% coinsurance after deductible

–––––––––––none–––––––––––

If you have a hospital stay

Facility fee (e.g., hospital room)

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Physician/surgeon fee

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

No charge

No charge

20% coinsurance after deductible

You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Mental/Behavioral health inpatient services

No charge after deductible

No charge after deductible

20% coinsurance after deductible

Substance use disorder
outpatient services

No charge

No charge

20% coinsurance after deductible

Substance use disorder inpatient services

No charge after deductible

No charge after deductible

20% coinsurance after deductible

If you are pregnant

Prenatal and postnatal care

No charge 

No charge 

20% coinsurance after deductible

Certain postnatal services are subject to deductible and coinsurance. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Delivery and all inpatient services

No charge after deductible

No charge after deductible

20% coinsurance after deductible

If you need help recovering or have other special health needs

Home health care

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Rehabilitation services

No charge after deductible

No charge after deductible

20% coinsurance after deductible

Per person per calendar year visits are limited for pulmonary and cognitive therapy – 20 each; cardiac therapy – 72; and post-cochlear therapy – 30. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Habilitative services

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Skilled nursing care

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

 

Durable medical equipment

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for non-network for equipment that exceeds $1,000 in cost or benefits are reduced by the lesser of 50% or $1,000.

Hospice service

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

If your child needs dental or eye care

Eye exam

No charge 

No charge 

20% coinsurance after deductible

Limited to 1 exam every 12 months.

Glasses

No charge 

No charge 

20% coinsurance after deductible

Limited to 1 pair every 12 months.

Dental check-up

No charge 

No charge 

20% coinsurance

Oral evaluations and cleanings are covered 2 times per 12 months. 

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
  • Abortion (except for rape, incest, life at risk)
  • Acupuncture
  • Cosmetic surgery
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care (Adult)
  • Routine foot care (unless for diabetes management)
  • Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
  • Bariatric Surgery
  • Chiropractic care – limited to 16 visits per calendar year.
  • Hearing aids – covered up to age 19 only, limited to 1 item(s) per 3 years.
  • Infertility treatment – limited to 4 treatments per year, total oocyte retrievals limited to six.
  • Private-duty nursing

Harken Health - Care Gold PPO Plans

Care Gold II

Important Questions

Answers

Why this Matters:

What is the overall deductible?

Designated network: $1,375 person /
$2,750 family. Network: $2,750 person / $5,500 family. Non-network: $5,500 person / $11,000 family. Does not apply to copays, prescription drugs and services listed below as “No charge”.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use.  Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.  

Are there other deductibles for specific services?

No. There are no other specific deductibles.   

You don’t have to meet deductiblesfor specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out–of–pocket limit on my expenses?

Yes. Designated network & Network:
$2,750 person / $5,500 family combined.
No, for non-network.

The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out–of–pocket limit?

Penalties for failure to obtain prior authorization, premiums, balance-billed charges, and health care this plan does not cover.

Even though you pay these expenses, they don’t count toward the out-ofpocket limit on your expenses. 

Is there an overall annual limit on what the plan pays?

No.

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. See:
www.harkenhealth.com/providers/OurDo csILor call 1-800-797-9921 for a list of designated and in-network providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network providerfor some services. Plans use the term in-network, preferred, or participating for providersin their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No, you don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.  

Common 
Medical Event

Services You May Need

Your Cost If You
Use a
Designated 
Network
Provider

Your Cost If
You Use a
Network
Provider

Your Cost If
You Use a
Non-Network Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

No charge

No charge after deductible

20% coinsurance after deductible

–––––––––––none–––––––––––

Specialist visit

No charge after deductible

No charge after deductible

20% coinsurance after deductible

–––––––––––none–––––––––––

Other practitioner office visit 

No charge after deductible

No charge after deductible

20% coinsurance after deductible

Per person per calendar year visits limited for chiropractic care – 16. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Preventive care/screening/ immunization

No charge 

No charge

20% coinsurance after deductible

–––––––––––none–––––––––––

If you have a test

Diagnostic test (xray, blood work)

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000.

Imaging (CT/PET scans, MRIs) 

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000.

If you need drugs to treat your illness or
condition
 
More information about prescription drug coverage is available at: www.harkenhealth. com/benefits/Our
Formulary
Individual

Tier 1

Retail: $5/ prescription   Mail Order: $10/ prescription  

Retail: $5/ prescription   Mail Order: $10/ prescription  

20% coinsurance after deductible 

Limited to a 31 day supply per prescription or refill. Mail order limited to 90 day supply. Certain drugs may have a pre-authorization requirement.

Tier 2

Retail: $35/ prescription   Mail Order: $70/ prescription  

Retail: $35/ prescription   Mail Order: $70/ prescription  

20% coinsurance after deductible 

Tier 3

Retail: $200/ prescription   Mail Order: $400/ prescription  

Retail: $200/ prescription   Mail Order: $400/ prescription  

20% coinsurance after deductible 

Tier 4

Retail: $350/ prescription   Mail Order: $700/ prescription  

Retail: $350/ prescription   Mail Order: $700/ prescription  

20% coinsurance after deductible 

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

No charge after deductible

No charge after deductible

20% coinsurance after deductible

Certain procedures require prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Physician/surgeon fees

No charge after deductible

No charge after deductible

20% coinsurance after deductible

Certain procedures require prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

If you need immediate medical attention

Emergency room
services

No charge after deductible

No charge after deductible

No charge after deductible

–––––––––––none–––––––––––

Emergency medical transportation

No charge after deductible

No charge after deductible

No charge after deductible

–––––––––––none–––––––––––

Urgent care

No charge after deductible

No charge after deductible

20% coinsurance after deductible

–––––––––––none–––––––––––

If you have a hospital stay

Facility fee (e.g., hospital room)

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000.

 

Physician/surgeon fee

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000.

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

No charge

No charge

20% coinsurance after deductible

You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000.

Mental/Behavioral health inpatient services

No charge after deductible

No charge after deductible

20% coinsurance after deductible

Substance use disorder
outpatient services

No charge

No charge

20% coinsurance after deductible

Substance use disorder inpatient services

No charge after deductible

No charge after deductible

20% coinsurance after deductible

If you are pregnant

Prenatal and postnatal care

No charge 

No charge 

20% coinsurance after deductible

Certain postnatal services are subject to deductible and coinsurance. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Delivery and all inpatient services

No charge after deductible

No charge after deductible

20% coinsurance after deductible

If you need help recovering or have other special health needs

Home health care

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000.

Rehabilitation services

No charge after deductible

No charge after deductible

20% coinsurance after deductible

Per person per calendar year visits are limited for pulmonary and cognitive therapy – 20 each; cardiac therapy – 72; and post-cochlear therapy – 30. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000.

Habilitative services

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000.

Skilled nursing care

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000.

 

Durable medical equipment

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for nonnetwork for equipment that exceeds $1,000 in cost or benefits are reduced by the lesser of 50% or $1,000.

Hospice service

No charge after deductible

No charge after deductible

20% coinsurance after deductible

You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000.

If your child needs dental or eye care

Eye exam

No charge 

No charge 

20% coinsurance after deductible

Limited to 1 exam every 12 months.

Glasses

No charge 

No charge 

20% coinsurance after deductible

Limited to 1 pair every 12 months.

Dental check-up

No charge 

No charge 

20% coinsurance

Oral evaluations and cleanings are covered 2 times per 12 months. 

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
  • Abortion (except for rape, incest, life at risk)
  • Acupuncture
  • Cosmetic surgery
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outide the U.S.
  • Routine eye care (Adult)
  • Routine foot care (unless for diabetes management)
  • Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
  • Bariatric Surgery
  • Chiropractic care – limited to 16 visits per calendar year.
  • Hearing aids – covered up to age 19 only, limited to 1 item(s) per 3 years.
  • Infertility treatment – limited to 4 treatments per year, total oocyte retrievals limited to six.
  • Private-duty nursing