Comprehensive Major Medical. Continuation of 18 existing plan without modification of benefits, except as noted. 19 20 (a) Effective January 1, 2016, $300/$600 deductible; 20% co- 21 insurance; $1,000 individual/$2,000 family per year out-of- 22 pocket limit (in addition to deductible). 24 (b) Effective January 1, 2016, $500/$1,000 deductible; 40% co- 25 insurance; $5,000 individual/$10,000 family per year out-of- 26 pocket limit (in addition to deductible).
Comprehensive Major Medical. The City shall maintain preferred provider organization(s) (PPO) for both medical and prescription drug services.
(1) A two hundred dollar ($200.00) annual single deductible with an eighty/twenty percent (80/20%) coinsurance of the next fifteen hundred dollars ($1,500.00) in reasonable charges or three hundred dollars ($300.00), for a total out-of-pocket maximum of five hundred dollars ($500.00) per single contract per year. Effective January 1, 2018, a three hundred dollar ($300.00) annual single deductible with an eighty/twenty percent (80/20%) coinsurance of the next two thousand dollars ($2,000.00) in reasonable charges or four hundred dollars ($400.00), for a total out-of-pocket maximum of seven hundred dollars ($700.00) per single contract per year.
(2) A four hundred dollars ($400.00) annual family deductible with an eighty/twenty percent (80/20%) coinsurance of the next two thousand dollars ($2,000.00) of reasonable charges or four hundred dollars ($400.00), for a total out-of-pocket maximum of eight hundred dollars ($800.00) per family contract per year. Effective January 1, 2018, a six hundred dollar ($600.00) annual family deductible with an eighty/twenty percent (80/20%) coinsurance of the next three thousand dollars ($3,000.00) of reasonable charges or six hundred dollars ($600.00), for a total out-of-pocket maximum of one thousand two hundred dollars ($1,200.00) per family contract per year.
(3) If an employee and/or an eligible dependent receive services from a preferred provider (PPO), reimbursements will be paid at the current coinsurance rate of eighty/twenty percent (80/20%) of reasonable charges. If the participating providers are not used, coinsurance will reduce to sixty/forty percent (60/40%) of reasonable charges. The additional twenty-percent (20%) coinsurance will be the employee's responsibility and is not counted toward the deductible or out-of- pocket maximum. Effective January 1, 2018, if an in-network provider is not used, coinsurance will reduce to sixty/forty percent (60/40%) of one hundred forty percent (140%) of the published reimbursement rates allowed by Medicare; the annual deductible will be increased to eight hundred dollars ($800.00) per single contract per year and one thousand six hundred dollars ($1,600.00) per family contract per year; and the out of pocket maximum will be increased to one thousand six hundred dollars ($1,600.00) per single contract per year and three thousand two hundred dollars ($3,200.00) per...
Comprehensive Major Medical. The City shall maintain preferred provider organization(s) (PPO) for both medical and prescription drug services.
(1) A two hundred dollar ($200.00) annual deductible with an eighty/twenty percent (80/20%) coinsurance of the next fifteen hundred dollars ($1,500.00) in reasonable charges or three hundred dollars ($300.00), for a total out-of-pocket maximum of five hundred dollars ($500.00) per single contract per year.
(2) A four hundred dollars ($400.00) annual family deductible with an eighty/twenty percent (80/20%) coinsurance of the next two thousand dollars ($2,000.00) of reasonable charges or four hundred dollars ($400.00), for a total out-of-pocket maximum of eight hundred dollars ($800.00) per family contract per year.
(3) If an employee and/or an eligible dependent receive services from a preferred provider (PPO), reimbursements will be paid at the current coinsurance rate of 80/20 percent of reasonable charges. If the participating providers are not used, coinsurance will reduce to 60/40 percent of reasonable charges. The additional twenty-percent (20%) coinsurance will be the employee's responsibility and is not counted toward the deductible or out-of-pocket maximum.
(4) The employee's annual out-of-pocket maximum for individual coverage shall be five hundred dollars ($500), and the employee's annual out-of-pocket maximum for family coverage shall be eight hundred dollars ($800).
(5) The plan will cover routine physicals, exams and immunizations up to a maximum of $150.00 per individual for covered persons age nine and over; a $300.00 family maximum, subject to deductibles, coinsurance, and out-of-pocket maximums will apply.
(6) A mental health/substance abuse case management benefit whereby an eligible participant may elect to exchange unused mental health or substance abuse inpatient days for other needed mental health or substance abuse benefits as determined medically necessary by the plan administrator. The medical necessity and exchange rate shall be determined by the plan administrator.
(7) Outpatient alcohol or drug treatment (substance abuse) payments will be limited to 50% of 25 visits per calendar year per individual when provided by a non-network provider. Outpatient alcohol or drug treatment (substance abuse) payments will continue to be limited to a total of twenty-five (25) visits per calendar year per individual when provided by a network provider. An office co- payment of twenty-five dollars ($25.00) per in-network visit will app...
Comprehensive Major Medical. If the employee and/or dependent receive services from a preferred provider (PPO), reimbursements will remain at the current eighty/twenty percent (80/20%) coinsurance and will be subject to the single and family deductibles and out-of- pocket maximums listed in Appendix D. The reimbursement rate will be determined based on reasonable charges, not usual, customary and reasonable. Deductibles, Out-of-Pocket Maximums and visit limits will fully reset on January 1st of each year.
Comprehensive Major Medical. (1) A $200 annual deductible with an 80/20 percent co-insurance of the next $1,500 of reasonable charges or $300, for a total out-of-pocket maximum of $500 per single contract per year.
(2) A $400 annual family deductible, with an 80/20 percent co-insurance of the next $2,000 of reasonable charges or $400, for a total out-of-pocket maximum of $800 per family contract.
(3) The reimbursement rate will be determined based on reasonable charges, not usual, customary and reasonable. Effective January 1, 2018, if the employee and/or dependent receive services from a preferred provider (PPO), reimbursements will remain at the current eighty/twenty percent (80/20%) coinsurance and will be subject to the single and family deductibles and out-of-pocket maximums listed in Appendix D.
Comprehensive Major Medical. (1) A $200 annual deductible with an 80/20 percent co-insurance of the next $1,500 of reasonable charges or $300, for a total out-of-pocket maximum of $500 per single contract per year.
(2) A $400 annual family deductible, with an 80/20 percent co-insurance of the next $2,000 of reasonable charges or $400, for a total out-of-pocket maximum of $800 per family contract.
(3) The reimbursement rate will be determined based on reasonable charges, not usual, customary and reasonable.
Comprehensive Major Medical. This section has been superseded and replaced by the parties' December 13, 2018 Memorandum of Understanding (MOU). With respect to insurance (Topics 1-4), the MOU remains in effect for Benefit Year 2020. Pursuant to Article 19, Section 1, the topic of insurance is subject to reopening for Benefit Year 2021.
Comprehensive Major Medical. This plan includes a mandatory hospital pre-admission certification requirement which must be followed to prevent a reduction in benefits payable by the plan. Failure to contact the medical review organization as specified in this pre-admission certification requirement will result in a $200 reduction in benefits payable for hospital expenses incurred during a non-certified hospital confinement. This plan will pay, after satisfaction of the specified deductible amount, the benefit percentage indicated in the schedule of benefits, subject to the specified maximums. The plan provides for a preferred provider organization (network provider) as recommended by the insurance committee to the board of education. Overall Annual Maximum Unlimited Network ndividual $300 Non-Network ndividual $600 Coinsurance (Paid by the Plan) Network 80% of the allowed amount Non-Network 60% of allowed amount Coinsurance Maximum Network ndividual $1,000 .................................................................................................................Family $2,000 Non-Network ndividual $4,000 .................................................................................................................Family $8,000 Network/Non-Network Integration – Costs incurred for a non-network provider will only apply to the non-network deductible, coinsurance limits and vice versa. When admitted to an In-Network Hospital all services administered by the facility and physicians attached to that facility shall be paid according to the In-Network schedule of benefits. Out-of-Pocket Maximum (Includes coinsurance paid by the employee, medical copayments and the calendar year deductible amount) Network Individual Family Non-Network Individual Family Benefit Limits & Maximums (subject to Overall Annual Maximum) Spinal Manipulation Treatment 20 visits per Calendar Year Treatment of Infertility -------------------------- No coverage for treatment of infertility. Coverage will include tests and treatment necessary to determine diagnosis of infertility. Outpatient Occupational & Physical Therapy 40 visits combined per Calendar Year Outpatient Speech Therapy 20 visits per Calendar Year Physician Office Visits (non-routine) Network Primary Care Network Specialty Care Telemedicine $20.00 co-pay per visit $50.00 co-pay per visit $20.00 co-pay per visit Non-Network Subject to deductible and coinsurance Physician Office Visits (preventive care as defined by Affordable Care Act) Network Non-Netw...
Comprehensive Major Medical. Lifetime 5 maximum of one million dollars ($1,000,000). Continuation 6 of existing plan without modification of benefits, except as 7 noted. 9 (a) Preferred Provider - $200/$400 deductible; 20% co- 10 insurance; $500 individual/$1,000 family per year out- 11 of- pocket limit (in addition to deductible). 12 13 (b) Out-of-Network Provider - $400/$800 deductible; 14 40% co-insurance; $3,000 individual/$6,000 family 15 per year out-of-pocket limit (in addition to deductible). 16
Comprehensive Major Medical. ACTIVE EMPLOYEES AND ELIGIBLE DEPENDENTS Comprehensive major medical benefits including hospital, surgical, medical, laboratory, X-ray and ancillary services for each full-time permanent employee and eligible dependents described below, who has been in the employ of the Authority continuously for not less than three (3) months, while necessarily confined in a hospital, as defined in the master policy, because of bodily injuries, sickness or disease and on the advice and under the care of a licensed physician or surgeon, providing eighty (80) percent of full payment of the usual and customary cost of a semi-private hospital room; eighty (80) percent of full payment of the usual and customary cost for services rendered and hospital supplies furnished by the hospital and not included in the hospital room charges; full hospital benefits paid in accordance with above for maternity; provided in all of the above situations the employee or dependent fully complies with the Utilization Review Program (pre- certification, continued stay, utilization review, discharge planning and for surgical procedures in which a second opinion was obtained or waived); eighty (80) percent of full payment for usual and customary cost of emergency hospital out-patient services incurred within seventy-two (72) hours on account of accidental bodily injuries; payment of medical expense incurred by the employee for any treatment rendered to the employee by the attending licensed physician while so confined, but not in excess of (a) eighty (80) percent of usual and customary charges for one
(1) visit; (b) one (1) visit in any one (1) day; (c) three hundred and sixty-five (365) visits during any calendar year; however, without limitation of other exceptions and exclusions contained in the master policy of insurance, the aforesaid medical expense shall not include any expense incurred by the employee for: (a) treatment in connection with any dental work or procedure; (b) eye examination for the fitting of glasses or for drugs or medicines; (c) treatment for or on account of: (1) injury sustained while doing any act or thing pertaining to any occupation or employment for remuneration or profit or (2) disease for which the employee is entitled to indemnity in accordance with provisions of any Worker's Compensation or similar law; diagnostic laboratory and X-ray out- patient examination expense benefits will be paid at eighty (80) percent of usual and customary charges. In the event the employ...
