Table of Benefits HealthPlus Extra
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1 Table of enefits HealthPlus Extra pplicable to new registrations or renewals on/or after 1 st December, This Table of enefits must be read in conjunction with your Hospital Plan Terms and onditions and the directories of approved facilities. Facilities may change from time to time, so log on to Vhi.ie or phone us on (056) if you are planning treatment. ~ enefit Provision Section 1 - Hospital charges enefit Public 1 & 2 hospitals Day care, side room, semi-private & private accommodation Private hospitals and treatment centres Private 1, 2 & 3 hospitals (other than for certain investigations & treatments referred to in Section 1c) Day care, side room & semi-private accommodation Private accommodation - Private 1 hospitals - Private 2 & 3 hospitals Semi-private rate Radiotherapy (day care & out-patient) Private 4 hospitals (other than for certain investigations & treatments referred to in Section 1c) Day care & side room Semi-private accommodation 55% Private accommodation 45% Radiotherapy (day care & out-patient) ertain investigations and treatments - herein referred to as Fixed Price Procedures (FPPs), (contact us for details) Private 3 & 4 hospitals Day care & in-patient cardiac FPPs Level 1 Day care non-cardiac FPPs Level 1 (other than Radiotherapy & hemotherapy, refer to Section 1) In-patient non-cardiac FPPs Level 1 (other than Radiotherapy & 90% hemotherapy, refer to Section 1) In-patient cardiac FPPs Level 2 Section 2 - onsultants' fees/gp procedures In-patient treatment, day-care/side room/out-patient & GP procedures Participating consultant/gp Non-participating consultant/gp Standard benefit Denotes benefit changes to this plan since the last renewal date. If you have moved to or purchased this plan for the first time, benefit differences with your old plan, if applicable, are not highlighted.
2 Section 3 - Psychiatric cover (read in conjunction with Section 1) In-patient psychiatric cover 180 days Day care psychiatric treatment for approved day care programmes ontact us for further details In-patient treatment for alcoholism, drug or other substance abuse in any 5 year period Section 4 - Maternity 91 days Normal confinement Public hospital benefit (up to 3 days) aesarean delivery (as per hospital benefits listed) Refer Section 1 Home birth benefit 3,150 In-patient maternity consultant fees (per Schedule of enefits for Professional Fees) Section 5 - ancer care and other benefits greed charges Genetic testing for cancer Initial consultation for genetic testing for cancer * 50% cover Genetic test - for specified genetic mutations to be carried out in an approved clinic * Preventative (Prophylactic) treatment following on from the genetic test overed up to the levels for hospital treatment listed in Section 1 * These benefits are available immediately for existing Vhi customers with no waiting periods. There is a 26 week new conditions waiting period for new joiners. Mammograms in an approved mammogram centre in each 24 month period, covered in accordance with our rules (contact us for details) ancer care support - one night's accommodation for each treatment 100 per night D Manual lymph drainage following cancer treatment - 10 visits 50 per visit E F linical psychology counselling for oncology treatment (psycho oncology counselling) - 10 visits dditional cancer support benefits Wig/ hairpiece, post-mastectomy bra, swimsuit, surgical prosthesis following cancer treatment No excess applies, but subject to the benefit maximum for medical and surgical appliances set out below G Other benefits in Section 5 onvalescent care - first 14 nights Refer section 9 51 per night
3 Vhi Healthcare approved medical and surgical appliances - subject to an excess of 300 per member per year (contact us for details of eligible appliances) Vhi Hospital@Home hild home nursing - 14 days per calendar year Parent accompanying child - 14 days per calendar year, following a stay in excess of 3 days in hospital 6,400 per member year 100 per day 40 per day Vhi Visionare Vhi Visionare E-Screen (available through Vhi.ie/myvhi) omprehensive eye exam carried out by a VSP eye-care professional in each 24 month period - subject to Vhi Visionare E-Screen referral Section 6 - Transport costs Transport costs (covered in accordance with our rules) greed charges Section 7 - over outside Ireland Emergency treatment abroad 100,000 Elective treatment abroad (subject to prior approval) Surgical procedures available in Ireland (as per level of cover in Ireland) 100,000 Treatment not available in Ireland 100,000 Section 8 - Out-patient scans, covered in accordance with our rules (refer to the Directory of pproved Out-patient Scan entres) MRI scans entres with direct pay arrangements (Vhi pay directly) Pay & claim back centres (subject to an excess of 125 per scan) overed PET-T scans (covered in accordance with our rules) T scans Non-oncology direct pay centres (Vhi pay directly) Oncology direct pay centres (Vhi pay directly) Section 9 Out-patient medical expenses (benefits are per visit, per member, unless otherwise indicated) General practitioner 35 onsultant consultation 70 Pathology - consultants fees (per referral) 70 D Radiology - consultants fees for professional services (per procedure) 70 E Pathology/Radiology or other diagnostic tests (refer to Section 8 for out-patient MRI benefits) - 50% of agreed charges in an approved out-patient centre. ontact us for details of eligible diagnostic tests and reimbursements 500 per year F Physiotherapist 35 G Pre- and post-natal care (combined visits) 385
4 H cupuncturists, hiropractors, Osteopaths, Physical therapists, Reflexologists - 12 combined visits I J hiropodists/podiatrists, Dieticians, Occupational therapists, Speech therapists, Orthoptists, linical Psychology - 12 combined visits linical psychology counselling for oncology treatment (psycho oncology counselling)* - 10 visits per visit K ccident & emergency cover - 1 visit 75 L M Out-patient mental health therapy - 12 visits in an approved out-patient mental health centre Health screening - in each 24 month period, covered in accordance with our rules (contact us for details) * Heart check in a Vhi Medical entre ancer check in a Vhi Medical entre Lifestage screening programme in a Vhi Medical entre 350 per screen Dexa scans in an approved dexa scan centre N Dental practitioner - 1 visit 20 O Optical eye tests and glasses/contact lenses - in each 24 month period (^Payment will be made directly to the provider if attending a VSP network provider, and will not be subject to the annual excess or the annual maximum) P Practice nurse visit 20 Q R ardiac are Programme* Medfit cardiac care programme - in each 24 month period 250 Urgent cardiac care benefit 250 per year Medfit cardiac rehabilitation programme 250 per year Joint are Programme* Joint are Screening to assess your mobility levels carried out by a Physiotherapist employed by The Physio ompany in each 24 month period, covered in accordance with our rules. To make a booking, contact The Physio ompany at (01) Details available at Vhi.ie/members Joint are Physiotherapy carried out by a Physiotherapist employed by The Physio ompany subject to referral from Joint are Screening - up to 3 visits 40 55^ S Vhi Online Doctor 12 visits (available through the Vhi pp)* T U Vhi Swiftare exclusive benefit to Vhi customers* Initial consultation (charge is 125 you pay 50) 75 Follow-up treatment package after this consultation for x-rays, tests & medical 50% of total aids (maximum you will pay is 100 for this follow-up treatment) costs Vhi Swiftare appointment services* onsultant consultation (orthopaedic, oral maxillofacial & sports medicine) 75% Dental practitioner 7 visits 20 Physiotherapist 7 visits 35 Vhi paediatric clinic*
5 Initial onsultant consultation 75% Follow up paediatric treatment and services after this consultation including 50% of total lactation consultant, dietician, ultrasound, blood tests and x-ray costs nnual excess - per member, per year 100 nnual maximum - per member, per year 4,000 * These benefits are not subject to the annual excess or annual maximum Vhi Healthcare D trading as Vhi Healthcare is regulated by the entral ank of Ireland. Vhi Healthcare is tied to Vhi Insurance D for health insurance in Ireland which is underwritten by Vhi Insurance D. TOHXTR V26 Dec18
Section 3 - Psychiatric cover (read in conjunction with Section 1)
Table of enefits pplicable to new registrations or renewals on/or after 1 st December, 2018. This Table of enefits must be read in conjunction with your Hospital Plan Terms and onditions and the directories
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Section 3 - Psychiatric cover (read in conjunction with Section 1)
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PLAN DESIGN Customer Name: High Desert & Inland Employee-Employer Trust Plan: HMO Plan Location(s): California Organization Name: Aetna PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum