Overview of Medical Benefits - Medical Choice Plan Effective 04/01/2015.

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Presentation transcript:

Overview of Medical Benefits - Medical Choice Plan Effective 04/01/2015

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Annual Deductible $ per person; maximum of $2, per family. After annual deductible has been met, the Plan pays the percentage of covered charges as shown. When the annual out- of-pocket amount for network providers has been met, the Plan will pay 100% of covered charges for that calendar year. There is no out-of-pocket maximum for non-network providers.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Annual Out-of-Pocket Limit In-P.H.A.-network: $3, per individual, $11, per family. Note: The calendar year deductibles are included in the out-of-pocket limits Out-of-P.H.A.-network: None. Note: The prescription drug program has a separate individual and family out-of-pocket limit of $1,950.00

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Lifetime Maximum Lifetime Maximum: No Lifetime maximum per person.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Life Insurance Life Insurance: $25, term life insurance for active participants only.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Physician (Surgery, Home, Office, Hospital) In-P.H.A.-network: 70% of contracted rates for surgeon/anesthetist. 70% for hospital visits and home visits. $20.00 co-payment for office visits (deductible does not apply). Out-of-P.H.A.-network: 50% of U.C.R. charges.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Access to Specialists In-P.H.A.-network: 70% of contracted rates for specialists. (Direct access to specialists allowed.) Out-of-P.H.A.-network: 50% of U.C.R. charges. (Direct access to specialists allowed.)

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Anesthesia In-P.H.A.-network: 70% of contracted rates. Out-of-P.H.A.-network: 50% of U.C.R. charges.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Hospital Services (slide 1 of 4) M.B.P.E.T. Hospitals of Distinction: 90% of contracted rates. (Natividad Medical Center, George L. Mee Memorial Hospital, Hazel Hawkins Memorial Hospital, Salinas Valley Memorial Hospital, Watsonville Community Hospital and Community Hospital of the Monterey Peninsula.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Hospital Services (slide 2 of 4) M.B.P.E.T. Centers of Excellence: 100% of contracted rates; $ daily per diem for family expenses for each day of in-patient medically necessary care (must be pre-approved by Executive Director). (Stanford Medical Center and other pre- approved facilities for specialized procedures or treatments).

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Hospital Services (slide 3 of 4) Network Hospitals: 80% of contracted rates. Non-Network Hospitals- 60% of U.C.R. covered expenses.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Hospital Services (slide 4 of 4) Non-Network Hospitals: 60% of U.C.R. charges

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Skilled Nursing Facility In-P.H.A.-network: 70% of contracted rates for the first ten (10) days and 60% of contracted rates for the next ninety (90) days - annual maximum of one-hundred (100) days. Pre- certification required; otherwise, penalties applied. Out-of-P.H.A.-network: None.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan X-Ray and Laboratory Services In-P.H.A.-network: 70% of contracted rates. Out-of-P.H.A.-network: 50% of U.C.R. charges.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Maternity and Interrupted Pregnancy In-P.H.A.-network: Covered as any other medical condition. Out-of-P.H.A.-network: Covered as any other medical condition.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Vasectomy In-P.H.A.-network: Covered as any other medical condition. Out-of-P.H.A.-network: Covered as any other medical condition.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Emergency Room In-P.H.A.-network: 70% of contracted rates after a $ co-payment. 90% of contracted rates in Hospitals of Distinction after a $ co-payment. Out-of-P.H.A.-network: 50% of U.C.R. charges after a $ co-payment.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Wellness / Well Baby In-P.H.A.-network: 100% of contracted rates. Well Baby Care is listed under the Affordable Care Act. There is no deductible or coinsurance. Out-of-P.H.A.-network: No coverage.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Immunizations In-P.H.A.-network: 100% of contracted rates as listed by the Affordable Care Act. There is no deductible or coinsurance. Out-of-P.H.A.-network: No coverage.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Physical Exams and Mammograms In-P.H.A.-network: 100% of contracted rates for routine gynecological exams and routine health exams as listed under the Affordable Care Act. There is no deductible or coinsurance. Out-of-P.H.A.-network: No coverage.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Allergy Testing / Administration of Serum In-P.H.A.-network: 70% of contracted rates for testing/treatment with allowance of up to $ per year for allergy serum. Out-of-P.H.A.-network: 50% of U.C.R. charges for testing/ treatment with allowance of up to $ per year for allergy serum.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Home Health Care In-P.H.A.-network: 70% of contracted rates up to $6, annual maximum. Pre-certification required for more than ten (10) visits. Out-of-P.H.A.-network: 50% of U.C.R. charges up to $6, annual maximum. Pre-certification required for more than ten (10) visits.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Hospice Care In-P.H.A.-network: 70% of contracted rates up to $7, lifetime maximum. Two (2) visits for bereavement counseling. Pre-certification required; otherwise, penalties apply. Out-of-P.H.A.-network: None.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Durable Medical Equipment / Prosthetics In-P.H.A.-network: 70% of contracted rates. Out-of-P.H.A.-network: 50% of U.C.R. charges.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Hearing Services / Hearing Aids In-P.H.A.-network: 80% of contracted rates. Hearing Aid benefit up to $1, annual maximum provided once every thirty-six (36) months. Out-of-P.H.A.-network: 60% of U.C.R. charges. Hearing Aid benefit up to $1, annual maximum provided once every thirty-six (36) months.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Acupuncture In-P.H.A.-network: 70% of contracted rates to a maximum allowance of $50.00 per visit for up to fifteen (15) visits per calendar year. Out-of-P.H.A.-network: 70% of U.C.R. charges to a maximum allowance of $50.00 per visit for up to fifteen (15) visits per calendar year.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Chiropractic Care In-C.H.P.C.-network: $10.00 co-payment per visit up to forty-five (45) annual visits per calendar year. Out-of-C.H.P.C.-network: None.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Prescription Drugs – Retail Store (slide 1 of 3) Generic: $10.00 co-payment for up to a thirty (30) day supply; Formulary Brand: $30.00 co-payment for up to a thirty (30 day supply; Non-Formulary Brand: $50.00 co-payment for up to a thirty (30) day supply.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Prescription Drugs – CVS Pharmacy Stores (slide 2 of 3) Generic: $0.00 co-payment for up to a thirty (30) day supply; Formulary Brand: $30.00 co-payment for up to a thirty (30) day supply; Non-Formulary Brand: $50.00 co-payment for up to a thirty (30) day supply. Note: Ninety (90) day supply solely at CVS Pharmacy Stores at same co-payments as the prescription mail order program except there is a zero co-pay for generics.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Prescription Drugs - Mail Order (slide 2 of 2) Generic: $20.00 co-payment for up to a ninety (90) day supply; Formulary Brand: $60.00 co-payment for up a to ninety (90) day supply; Non-Formulary Brand: $ co-payment for up to a ninety (90) day supply.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Rates for active employees (effective 4/01/2014) Single: $ per month. Two-Party: $1, per month. Family: $1, per month.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Rates for retirees under 65 (effective 4/01/2014) Single: $ per month. Two-Party: $1, per month. Family: $1, per month.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Rates for retirees 65 and older (effective 4/01/2014) Single: $ per month. Two-Party: $ per month. Family: $ per month.

Medical Choice Plan Monterey Bay Public Employees Trust Overview of Medical Benefits Medical Choice Plan Disclaimer This presentation provides only a general overview of the Medical benefits for the Medical Choice Plan; For complete information, consult your copy of the Summary Plan Description or call Health Services & Benefit Administrators ( or ).