Summary of Benefits. Plan Feature Employee Co-pay - Network Only Preventive and Diagnostic Services • Examination • Cleaning • x-rays $0 $0 $0 Minor Restorative • Fillings and extractions • Oral surgery • Endodontic services1 • Periodontal services1 $0 $40-$196 based on specific service $45-$310 based on specific service $25-$145 based on specific service 1 Additional employee co-pay if approved specialist performs services. Major Restorative • Crowns • Bridges • Complete Dentures $92-$190 based on specific service $115-$291 based on specific service $249-$264 based on specific service Complete Orthodontics $1,850 co-pay D PPO “Buy Up” Option (Voluntary) Summary of Benefits Plan Feature In Network/Out of Network Class I (Preventative) 100%/100% Class II (Basic/Restorative) 80%/80% Class III (Major) 60%/60% Class IV (Orthodontia - adult ortho is included) 50%/50% Annual Deductible per Member (does not apply to Class I services) $50/$50 Orthodontia Lifetime Max $1,500/$1,500
Summary of Benefits. Benefit Maximum Benefit Payable Medical Emergency Insurance $1,000,000 per Insured Person per Covered Trip.
Summary of Benefits. Medicare Part A helps pay for health care in hospitals, skilled nursing facilities, hospice care, and some home health care services. The table below shows how much Medicare, this plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan Select G. Medicare Part A: Hospital Services per Benefit Period Service Limits Medicare Pays Plan Pays You Pay Hospitalization (*) Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 $1,556 (Part A deductible) $0 Days 61 thru 90 All but $389 per day $389 per day $0 Days 91 and after while using 60 lifetime reserve days All but $778 per day $778 per day $0 Once lifetime reserve days are used, an additional 365 days $0 100% of Medicare eligible expenses (**) $0(**) Beyond the additional 365 days $0 $0 100% Skilled Nursing Facility (SNF) Care (*) You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 Days 21 thru 100 All but $194.50 per day Up to $194.50 per day $0 Days 101 and after $0 $0 100% Blood (inpatient) First 3 pints $0 100% $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment or coinsurance for outpatient drugs and inpatient respite care Medicare copayment or coinsurance for outpatient drugs and inpatient respite care $0 (*) A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. (**) When your Medicare Part A hospital benefits are exhausted, BCBSRI stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. Medicare Part B helps pay for doctors’ services, outpatient hospital care, certain medically necessary home health care services and other medical services that Part A does not cover, such as physical and speech therapy. The table below shows how much Medicare, your plan, and you pay for specific servi...
Summary of Benefits. Such insurance shall provide employees with insurance protection while engaged in the maintenance of order and discipline and the protection of school personnel, students and property. Such insurance must include as a minimum, liability insurance covering injury to persons and property, and insurance protecting the employee from loss or damage of personal property while so engaged.
Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Cost Share concepts in action To recap, you are responsible for all costs for Covered Services until you reach your Deductible. Once you reach your Deductible, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described above.
Summary of Benefits. Crothall Employees Available to Crothall employees with seniority who are continuously scheduled to work 20 or more hours per week. BC Medical Plan 100% of the premium paid by Crothall Life and AD&D Insurance $25,000.00 coverage 100% Crothall paid Dental Plan Basic Prevention Coverage 100% Employer paid Extended Health Care including Hospitalization and Prescription Drugs Semi-private coverage Natural Formulary Drugs with a $2,000.00 per year max and overall $100,000.00 EHC lifetime maximum. 100% Employer paid Eye Exams $50 - every 24 months Vision Care $250.00 per Employee every 24 months Paid Sick days Effective January 15, 2007, Crothall employees shall be entitled to six (6) days sick leave per year to be taken at any time. The year shall be January 15 to January 14 inclusive. Sick leave is not cumulative, i.e., unused sick leave days are not to be carried over to the following year. Sick leave will increase from six (6) to seven (7) days on January 15, 2010 and from seven (7) to eight (8) days on January 15, 2011. An eligible Crothall employee may reapply for benefit coverage once a minimum of six
Summary of Benefits. This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California plan. It is only a summary and it is part of the contract for health care coverage, called the Evi- dence of Coverage (EOC). Please read both documents carefully for details. Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY INDEPENDENCE AND SAFE MOBILITY WITH AAA - Your benefit is provided by American Automobile Associa- tion of Northern California, Nevada & Utah (AAA). The benefit is a Classic AAA membership and includes access to Independent and Safe Mobility tools and services. • Roadwise Driver • Educational Driving Resources • Roadside Assistance $0 FOREIGN TRAVEL – Medically necessary emergency care Services beginning during the first 60 days of each trip outside the United States. First $250 each Calendar Year $250 Remainder of charges 20% plus 100% of additional charges over the $50,000 life- time maximum BASIC GYM ACCESS THROUGH SILVERSNEAKERS® FITNESS $0 HEARING AID SERVICES – Your hearing aid services benefits are provided by EPIC Hearing Healthcare (EPIC). This benefit is designed for you to use EPIC network providers. EPIC Participating Providers are listed at xxxxxxxxxxxx.xxx/XxxxxxxXxxx. If you choose to use out-of-network providers, those services will not be covered. This benefit is separate from diagnostic hearing examinations and related charges as covered by Medicare. Hearing aid benefits every year include: • One routine hearing exam • Hearing aid instrument o Choice of private-labeled Silver (mid-level) or Gold (premium level) technology hearing aid models o Up to two hearing aids in the following styles: in-the-ear; in-the-canal; completely-in-canal; behind-the-ear; or receiver-in-the-ear. o All technology levels include: one consultation; two-year supply of batteries per hearing aid; and three-year extended warranty. o Silver technology level hearing aids include: one behind-the-ear hearing aid (non-ear mold model) delivered directly to your home; and up to three virtual follow-up visits by a participating provider for hearing aid fitting, consultation, device check, and adjustment for no additional cost. o Gold technology level hearing aids include: one hearing aid delivered in-person by a participating provider; up to three in-person follow-up visits for hearing aid fitting, consultation, device check, and adjustment for no additional cost; and standard ear molds & ...
Summary of Benefits. Health Plan shall submit an annual Summary of Benefits of Health Plan’s D-SNP benefits offered under the plan benefit packages, including Supplemental Benefits, for the counties identified in Attachment B, by January 1 each year, and within 15 calendar days of any update or modification.
Summary of Benefits. MTC Full-Time Regular Represented and Confidential Employee Positions (Except as otherwise noted and excluding executive employees) Personal Leave Days Up to 3 personal leave days (24 hours) are granted at the beginning of each calendar year. The number of personal leave days granted to new employees is prorated as follows: January through April – 3 days May through August – 2 days September through November – 1 day December – 0 days In the event that Personal Leave Days are accrued but unused at the end of a calendar year, the employee will receive an amount to start the new calendar year at a maximum of three days. Personal Leave Days are not payable upon employment separation. Transitioned Employees will receive three additional Personal Leave Days at hire on July 1, 2017. These additional days will be available for use through December 31, 2017 only. Vacation Leave Benefits Accrual of Vacation Leave Benefits o One day (8 hours) per month worked starting with the first day of employment. Prorated for new hires based on first working day of employment within the month. o Addition of one more day (8 more hours) each additional year worked up to a maximum of 13 additional days (104 hours) for a total annual benefit of 25 days (200 hours) a year is reached. o Transitioned Employees will start accruing based on their service tenure with ABAG (example, an eight year ABAG employee starts accruing at MTC’s eight year rate). o Accrued to a cap of 62.5 days (500 hours). Once the cap (500 hours) is reached, all vacation accrual stops until such time that the vacation balance falls below the cap (500 hours). If the vacation accrual is larger than the difference between the vacation balance and the 500 hour cap, individuals will receive only a fraction of their bi-weekly vacation accrual for that pay period bringing their vacation balance to 500 hours. o Employees working an average of 40 hours over a two-week pay period, but less than 72 hours over a two-week pay period will receive prorated benefits. o All vacation leave benefits are accrued and available for use with each bi-weekly pay period Summary of Benefits: MTC Full-Time Regular Represented and Confidential Employee Positions (Except as otherwise noted and excluding executive employees) Annual Vacation Cash Out Option Once a twelve month period, employees may cash-out accrued but unused vacation leave over 320 hours up to cap of 500 hours. Payment will be made at the employee’s current hourly rate and is co...
Summary of Benefits. MTC Full-Time Regular Represented and Confidential Employee Positions (Except as otherwise noted and excluding executive employees) Vision Care Insurance Agency pays total premium for Employee Only coverage. Employees may enroll dependents at their sole cost for $7.51 for one dependent and $26.70 for two or more per month. MTC will deduct dependent premium payments from earned wages pre-tax as allowable by law. Domestic Partner Coverage MTC provides group medical insurance, group dental insurance, and group vision coverage for an eligible domestic partner and dependents subject to CalPERS regulations regarding domestic partner coverage. The maximum amount of the Agency contributions shall be the same as that specified under “Group Dental Insurance” and “Group Medical Insurance” provisions referenced above. Life and Related Insurance Agency pays premiums for Employee life insurance policy; life insurance benefit is equal to one times annual salary or a minimum of $55,000, whichever is greater. Agency pays additional premium for employee for Accidental Death and Dismemberment policy equal to the group term life insurance coverage. Agency pays premium for qualified dependents (as defined in current policy) for $2,000 life coverage per dependent. Group Voluntary Life and Related Insurance In addition, Employee may elect to purchase, at his/her expense, supplemental Group Voluntary Life Insurance. Short-Term and Long-Term Disability Agency pays monthly premium for short-term disability coverage for qualifying employee medical disabilities to cover loss of wages. There is a 14-day waiting period with an additional 11 weeks of paid benefits (total 12 week benefit program). Coverage level is 66 2/3% of salary up to a maximum of $2,500 a week. Benefits paid are taxable. Agency pays monthly premium for long-term disability coverage for qualifying employee medical disabilities to cover loss of wages. There is a 90-day waiting period (designed to pick up at the end of the 12-weeks of short-term disability coverage). Coverage level is 67% of monthly salary up to a maximum of $15,000 per month. Benefits paid are taxable. Travel Insurance Agency pays annual premium. Each employee is covered with a policy of $100,000 for loss of life while traveling on MTC business. RETIREMENT
