Comprehensive Hospitalization and Major Medical Insurance Program. The Board shall offer a Comprehensive Hospitalization and Major Medical Insurance Program for members of the bargaining unit no less than the specifications of Appendix A except when a specific benefit is no longer offered through the Consortium.
1. As part of this program, the employee is responsible for out-of-pocket expenses as per the employee Benefit Plan.
2. The Plan as administered will have a maximum out-of-pocket of One Thousand/Two Thousand ($1,000/$2,000) in network and Two Thousand/Four Thousand ($2,000/$4,000) out-of-network.
Comprehensive Hospitalization and Major Medical Insurance Program a. The Board of Education shall provide a comprehensive hospitalization and major medical insurance program for members of the bargaining unit with no less than the current specifications. The Board of Education shall pay ninety-five percent (95%) of the single premium or eighty-five percent (85%) of the family premium cost.
(1) As part of this program, the employee is responsible for out-of- pocket expenses as per the insurance plan.
(2) The plan as administered will have a maximum out-of-pocket of five hundred dollars/one thousand dollars ($500.00/$1,000.00) in- network and nine hundred dollars/eighteen hundred dollars ($900.00/$1,800.00) out-of-network for 2013-14 and 2014-15. See chart below for 2015-16 amounts.
(3) After each December 31, any employee who has incurred annual out-of-pocket expenses totaling more than Three Hundred Dollars/Six Hundred Dollars ($300.00/$600.00) will be reimbursed by the Board of Education to a maximum of Six Hundred Dollars/Eight Hundred Dollars ($600.00/$800.00) in- network and out-of-network.
(4) The deductible shall be $300 single/$600 family (in-network) for 2013-14 and 2014-15. See chart below for 2015-16 amounts.
(5) There shall be a $15 co-pay for each primary care doctor visit only (in-network) for 2013-14 and 2014-15. See chart below for 2015- 16 amounts.
b. The parties recognize the necessity to contain the cost of the insurance program. Therefore, the parties agree that the following cost containment provisions shall be implemented in the hospitalization insurance plan:
(1) Voluntary second opinion.
(2) Pre certification and pre admission testing for outpatient surgery as well as inpatient surgery.
(3) No weekend hospital entrance except in cases of emergency.
(4) Extension of the pre-existing condition exclusion to both basic hospital and major medical benefits for all employees hired after September 1, 1992. (This provision not valid effective July 1, 2014.)
(5) Expansion of rules for spouse coverage, along with Board option to pay the spouse’s share of any contributory plan.
(6) Requirement that spouses take worker’s compensation benefits, where applicable.
(7) Limitation of penalty for failure to pre-certify to a maximum penalty of five hundred dollars ($500.00).
Comprehensive Hospitalization and Major Medical Insurance Program a. The Board of Education shall provide a Comprehensive Hospitalization and Major Medical Insurance Program for members of the bargaining unit with no less than the specifications in Exhibit K. The Board of Education shall pay 89% (2022-23), 88% (2023- 24), 87% (2024-25), of the Single premium or eighty-five (85%) of the Family premium cost provided that the annual fringe benefit cost increase is 14% or less. Fringe benefit increases above the 14% cap shall be paid entirely by the participating employees.
(1) As part of this Program, the employee is responsible for out- of-pocket expenses as per the Insurance Plan.
b. The parties recognize the necessity to contain the cost of the Insurance Program. Therefore, the parties agree that the following Cost Containment provisions shall be implemented in the Hospitalization Insurance Plan:
(1) Voluntary second opinion.
(2) Pre-certification and pre-admission testing for outpatient surgery as well as inpatient surgery.
(3) No weekend hospital entrance except in cases of emergency.
(4) Expansion of rules for spouse coverage, along with Board option to pay the spouse’s share of any contributory plan.
(5) Requirement that spouses take Workers’ Compensation benefits, where applicable.
(6) Limitation of penalty for failure to pre-certify to a maximum penalty of Five Hundred Dollars ($500.00). In Network Out of Network Deductible-Single/Family $250/$500 $500/$1000 Coinsurance 90% 70% Coinsurance Max (Excl.Ded.) $750/$1500 $1500/$3000 Total Out of Pocket Maximum $1000/$2000 $2000/$4000 Physician/Office Services Office Visit PCP/Specialist Surgical Services Urgent Care Allergy Testing $10/$20 30% after deductible $10/$20 30% after deductible $35 30% after deductible $10/$20 30% after deductible Preventative Services Routine Physical Exam (18+) Well Child Care Immunizations Routine Mammogram Routine Pap Test 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Out Patient Services Surgical Services Diagnostic Services Emergency Room-Emergency Speech Therapy Physical/chiro/occupational (see summary) 10% after deductible 30% after deductible 10% after deductible 30% after deductible $75 Co-pay $75 Co-pay $20 per visit 30% after deductible $20 per visit 30% after deductible Inpatient Facility Semi-Private Room & Board Maternity Skilled Nursing Facility (see summary) 10% after deductible 30% after deductible 10% after deductible 30% after deductible 10% after deductible 30% after deductible Additional Services Durable Medical Equi...
