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Atlantis Health Plan Riders

The following rider products can only be purchased as additions to a basic medical program.  More detailed information on the specific benefits and limitations of  each rider will be explained when you select your basic program.


Outpatient Mental Health Rider

40 Visits - 50% Co-payment
The following rider is an addendum to the "Subscriber Contract" which provides for the provision of all basic health services.

Benefits
The "Benefits" section of the Subscriber Contract is amended as follows:

Outpatient Mental Health
This rider provides an additional forty (40) outpatient visits per calendar year for the diagnosis and treatment of acute mental, nervous or emotional disorders and ailments. Treatment is limited to short-term therapy for conditions likely to result in significant clinical improvement. An Atlantis case manager will arrange referrals to Participating Providers for medically necessary therapy.

Co-payments
Each visit is subject to a co-payment of 50% of the cost of the visit.

Limitations and Exclusions
All of the terms, conditions and limitations of your Atlantis Health Plan Health Plan or POS Subscriber Contract to which this rider is attached also apply to this Rider, except where specifically changed by this Rider.

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Inpatient Mental Health Rider

30 days

The following rider is an addendum to the "Subscriber Contract" which provides for the provision of all basic health services.

Benefits
The "Benefits" section of the Subscriber Contract is amended as follows:

Inpatient Mental Health
This rider provides an additional thirty (30) inpatient hospital days per calendar year for the diagnosis and treatment of acute mental, nervous or emotional disorders and ailments. Treatment is limited to short-term therapy for conditions likely to result in significant clinical improvement. An Atlantis case manager will arrange referrals to a Participating Facility for medically necessary therapy.

Co-payments
Inpatient admissions may be subject to a co-payment per continuous confinement. Please see the subscriber contract "Summary of Benefits" to determine if an admission co-payment is applicable to inpatient Mental Health services.

Limitations and Exclusions
All of the terms, conditions and limitations of your Atlantis Health Plan Health Plan Subscriber Contract to which this rider is attached also apply to this Rider, except where specifically changed by this Rider.

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Inpatient Alcohol & Substance Abuse Rider

30 days

The following rider is an addendum to the "Subscriber Contract" which provides for the provision of all basic health services.

Benefits
The "Benefits" section of the Subscriber Contract is amended as follows:

Inpatient Alcohol/Substance Abuse
This rider provides coverage for up to thirty (30) inpatient days per calendar year for the diagnosis and treatment of alcoholism and alcohol abuse and substance abuse and substance dependence. An Atlantis case manager will arrange referrals to Participating Facilities. The rehabilitation services must be received in a participating hospital based or free standing facility certified by the New York State Division of Alcoholism and Alcohol Abuse or by the Division of Substance Abuse Services as applicable.

Co-payments
Inpatient admissions may be subject to a co-payment per continuous confinement. Please see the subscriber contract "Summary of Benefits" to determine if an admission co-payment is applicable to inpatient services.

Limitations and Exclusions
All of the terms, conditions and limitations of your Atlantis Health Plan Health Plan or POS Subscriber Contract to which this rider is attached also apply to this Rider, except where specifically changed by this Rider.

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Skilled Nursing Facility

60 days

The following rider is an addendum to the "Subscriber Contract" which provides for the provision of all basic health services.

Benefits
The "Benefits" section of the Subscriber Contract is amended as follows:

Skilled Nursing
This rider provides an additional sixty (60) inpatient days per calendar year for medically necessary services in a Participating Skilled Nursing Facility. Services must constitute Skilled Nursing care as defined by Medicare Law.

Co-payments
There is no co-payment for skilled nursing facility services.

Limitations and Exclusions
All of the terms, conditions and limitations of your Atlantis Health Plan Health Plan or POS Subscriber Contract to which this rider is attached also apply to this Rider, except where specifically changed by this Rider.

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Vision Rider

High Option

The following rider is an addendum to the "Subscriber Contract" which provides for the provision of all basic health services.

Benefits
The "Benefits" section of the Subscriber Contract is amended as follows:

Vision Care
This rider entitles the Member to an eye examination once every twelve (12) months, with the benefit period measured from the date of service. Exams are defined by statutory "minimum exam" standards.

In addition, the member is entitled to a $150.00 (retail) total eyewear allowance once every twenty-four (24) months, with the benefit period measured from the date of service. Eyewear consists of a frame and/or lens combination or contact lenses. Atlantis will reimburse the member once claim is submitted.

If the Member elects to purchase contact lenses in lieu of eyeglasses, the Member is required to pay the usual and customary charge for professional services beyond the standard eye exam for testing specific to contact lenses and evaluation.

Co-payments
There is no co-payment for vision services.

Limitations and Exclusions

  1. All services must be obtained from a licensed optometrist.
  2. All of the terms, conditions and limitations of your Atlantis Health Plan Health Plan or POS Subscriber Contract to which this rider is attached also apply to this Rider, except where specifically changed by this Rider.

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Vision Rider

Low Option

The following rider is an addendum to the "Subscriber Contract" which provides for the provision of all basic health services.

Benefits
The "Benefits" section of the Subscriber Contract is amended as follows:

Vision Care
This rider entitles the member to an eye examination once every twelve (12) months, with the benefit period measured from the date of service. Exams are defined by statutory "minimum exam" standards.

In addition, the Member is entitled to a $75.00 (retail) eyewear allowance once every twenty-four (24) months, with the benefit period measured from the date of service. Eyewear consists of a frame and/or lens combination or contact lenses. Atlantis will reimburse member once claim is submitted.

Co-payments
There is a $10 co-payment for vision services.

Limitations and Exclusions

  1. All services must be obtained from a licensed optometrist.
  2. All of the terms, conditions and limitations of your Atlantis Health Plan Health Plan or POS Subscriber Contract to which this rider is attached also apply to this Rider, except where specifically changed by this Rider

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GROUP RIDER

Student Coverage to Age 23

The following rider is an addendum to the "Subscriber Contract" which provides for the provision of all basic health services.

Benefits
The "Eligibility and Family Coverage" section of the Subscriber Contract is amended as follows:

Dependent Eligibility
This rider increases the age of dependent eligibility to age 23 as long as the dependent attends school on a full time basis at an accredited high school or college. The dependent becomes ineligible for coverage the first day of the month in which he/she is no longer enrolled on a full time basis or attains age 23.

Limitations and Exclusions
All of the terms, conditions and limitations of your Atlantis Health Plan Health Plan or POS Subscriber Contract to which this rider is attached also apply to this Rider, except where specifically changed by this Rider.

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GROUP RIDER

Student Coverage to Age 25

The following rider is an addendum to the "Subscriber Contract" which provides for the provision of all basic health services.

Benefits
The "Eligibility and Family Coverage" section of the Subscriber Contract is amended as follows:

Dependent Eligibility
This rider increases the age of dependent eligibility to age 25 as long as the dependent attends school on a full time basis at an accredited high school or college. The dependent becomes ineligible for coverage the first day of the month in which he/she is no longer enrolled on a full time basis or attains age 25.

Limitations and Exclusions
All of the terms, conditions and limitations of your Atlantis Health Plan Health Plan or POS Subscriber Contract to which this rider is attached also apply to this Rider, except where specifically changed by this Rider.

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