Self-Insured Schools of California benefit plan reminder

Limitation of outpatient hospital procedures

Self-Insured Schools of California (SISC) made a change to its benefit plan on October 1, 2018. The change may influence your patient’s choice of place of service for the following elective procedures.

To provide each PPO member with a choice of safe, quality services at a lower total cost for all PPO members, SISC has established a maximum benefit allowance as follows when services are not received at a PPO ambulatory surgery center.

If these routine services are provided in an outpatient hospital setting, without an approved exception form, the following maximums will apply to in-network hospital services:

• Colonoscopy services are limited to a maximum payment of $1,500 per procedure.
• Cataract surgery services are limited to a maximum payment of $2,000 per procedure.
• Arthroscopy services are limited to a maximum payment of $4,500 per procedure.
• Upper GI endoscopy services are limited to a maximum payment of $1,000 per procedure.
• Upper GI endoscopy with biopsy services are limited to a maximum payment of $1,250 per procedure.

Examples for an exception to the services listed above to be performed in an outpatient hospital include the following:

• If no appointment is available for the member at a participating ambulatory surgical center
• If there is no preferred ambulatory surgery center provider within a 30-mile radius of the member’s home
• If the provider can provide clinical documentation supporting the need for an outpatient setting (patient safety)

The member should consult their physician and contact Member Services for instructions on how to receive an exception.