Common use of Comprehensive Major Medical Clause in Contracts

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 family contract per year. Any network modifications made by the plan administrator will apply. (4) Physical therapy, occupational therapy and/or chiropractic visits will be covered up to a combined annual maximum of thirty (30) visits per person, based upon medical necessity. (5) Physician office visits will be subject to a fifteen dollar ($15.00) co- payment per in-network primary care physician visit (includes Family, General, Internal, Pediatrician, mental health and OB/GYN physicians). Eligible services, which shall include diagnostic, surgical and/or specialty services, routine prostate/colon rectal cancer tests subject to the limits provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. Effective January 1, 2018, the co-pay for in-network primary care physician office visits will be twenty dollars ($20.00) per visit. A specialty care physician office visit will be subject to a twenty-five dollar ($25.00) co-payment per in-network specialist visit. Eligible services, which shall include diagnostic, surgical and/or specialty services, routine prostate/colon rectal cancer tests subject to the limits specified in the paragraph above provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. Effective January 1, 2018, the co-pay for specialty care physician office visits will be thirty dollars ($30.00) per visit. The co-payment does not apply to the annual deductible and coinsurance; however, office co-payments will apply to the annual out- of-pocket maximum. The annual medical plan deductible will not apply to office visit charges for which the office co-payment applies. Preventive care services, as defined and updated under the Affordable Care Act (“ACA”), will be provided by doctors and health care professionals within the City’s plan provider network without cost- sharing (copayments, coinsurance and deductibles). Preventive services that are not originally defined or eventually included in the ACA shall be subject to the annual deductible, co- insurance, and out-of-pocket maximum as specified in Section 18.1 (A)(1), (2), (3) and (4). Preventive services rendered by non-network providers shall be subject to the annual deductible, co-insurance, and out-of-pocket maximum for non-network providers as specified in Section 18.1 (A)(1), (2), (3) and (4). Insured members should contact the City’s health plan administrator prior to obtaining preventive services for determination of preventive services coverage. In addition to the preventive services provided for under the ACA, the City shall maintain preventive coverage and limits for the following services: (a) provide coverage for an annual (one (1) per calendar year) routine prostate/colon rectal cancer tests for men age 40 and over up to a maximum of eighty-five dollars ($85.00). (b) for men age 40 and over, an annual (one per calendar year) PSA blood test will be covered up to a maximum of one hundred dollars ($100.00). (c) provide coverage for one (1) baseline mammogram for women 35-39 years old.

Comprehensive Major Medical. The City shall maintain a 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 ($2,000.002000.00) 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. Deductibles, out-of-pocket maximums, and visit limits will fully reset on January 1 of each 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. Deductibles, out-of-pocket maximums, and visit limits will fully reset on January 1 of each 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 family contract per year. Any network modifications made by the plan administrator will apply. An emergency room visit will be subject to a seventy-five dollar ($75.00) co-pay per visit and twenty percent (20%) co-insurance after the co-pay and deductible. If admitted, the co-pay will be waived. An in-network urgent care visit will be subject to a thirty dollar ($30.00) co-pay per visit and twenty percent (20%) co-insurance after the co-pay and deductible. A non-network urgent care visit will be subject to a thirty dollar ($30.00) co-pay per visit and forty percent (40%) co-insurance after the co-pay and deductible. Mental health services will not be subject to emergency room or urgent care co- pays. (4) Physical therapy, occupational therapy and/or chiropractic visits will be covered up to a combined annual maximum of thirty (30) visits per person, based upon medical necessity. With prior authorization, an employee may receive additional occupational therapy and/or chiropractic visits beyond the annual maximum. (5) Physician office visits will be subject to a fifteen twenty dollar ($15.0020.00) co- payment per in-network primary care physician visit (includes Family, General, Internal, Pediatrician, mental health and OB/GYN physicians). Eligible services, which services shall include diagnostic, surgical and/or specialty services, routine prostate/colon rectal cancer tests subject to the limits provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. Effective January 1, 2018, the co-pay for in-network primary care physician office visits will be twenty dollars ($20.00) per visit. A specialty care physician office visit will be subject to a twenty-five thirty dollar ($25.0030.00) co-payment per in-network specialist visit. Eligible services, which services shall include diagnostic, surgical and/or specialty services, routine prostate/colon rectal cancer tests subject to the limits specified in the paragraph above provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. Effective January 1, 2018, the co-pay for specialty care physician office visits will be thirty dollars ($30.00) per visit. The co-payment does not apply to the annual deductible and coinsurance; however, office co-payments will apply to the annual out- out-of-pocket maximum. The annual medical plan deductible will not apply to office visit charges for which the office co-payment applies. Preventive care services, as defined and updated under the Affordable Care Act (“ACA”), will be provided by doctors and health care professionals within the City’s plan provider network without cost- cost-sharing (copayments, coinsurance and deductibles). Preventive services that are not originally defined or eventually included in the ACA shall be subject to the annual deductible, co- insurance, and out-of-pocket maximum as specified in Section 18.1 (A)(1), (2), (3) and (4). Preventive services rendered by non-network providers shall be subject to the annual deductible, co-insurance, and out-of-pocket maximum for non-network providers as specified in Section 18.1 (A)(1), (2), (3) and (4). Insured members should contact the City’s health plan administrator prior to obtaining preventive services for determination of preventive services coverage. In addition to the preventive services provided for under the ACA, the City shall maintain preventive coverage and limits for the following services: (a) provide coverage for an annual (one (1) per calendar year) routine prostate/colon rectal cancer tests for men age 40 and over up to a maximum of eighty-five dollars ($85.00)tests. (b) for men age 40 and over, an annual (one per calendar year) PSA blood test will be covered up to a maximum of one hundred dollars ($100.00)covered. (c) provide coverage for one (1) baseline mammogram for women 35-39 years old. (6) Up to a two hundred dollar ($200.00) life-time maximum will continue to be paid for temporomandibular joint pain dysfunction, syndrome or disease or any related conditions collectively referred to as TMJ or TMD on the basis of medical necessity. This limit does not apply to surgical services on the jaw hinge. The City reserves the right to change or offer alternative insurance carriers or to self- insure as it deems appropriate. The parties agree to the UnitedHealthcare “UHC” “medical necessity” program as it exists as of the execution of the 2020-2023 Agreement. The City shall provide the Union with at least sixty (60) days advance written notice of any material changes to the “medical necessity” program. Employees will not be adversely impacted by any such change unless such advanced notice has been given.

Comprehensive Major Medical. The City shall maintain a 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 A three hundred dollar ($300.00) annual single deductible with an eighty/twenty percent (80/20%) coinsurance of the next two thousand dollars ($2,000.002000.00) in reasonable charges or four hundred dollars ($400.00), for a total out-out- of-pocket maximum of seven hundred dollars ($700.00) per single contract per year. Deductibles, out-of-pocket maximums, and visit limits will fully reset on January 1 of each 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- of-pocket maximum. Effective January 1, 2018, if 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 family contract per year. Any network modifications made by the plan administrator will apply. (4) Physical therapy, occupational therapy and/or chiropractic visits will be covered up to a combined annual maximum of thirty (30) visits per person, based upon medical necessity. (5) Physician office visits will be subject to a fifteen dollar ($15.00) co- payment per in-network primary care physician visit (includes Family, General, Internal, Pediatrician, mental health and OB/GYN physicians). Eligible services, which shall include diagnostic, surgical and/or specialty services, routine prostate/colon rectal cancer tests subject to the limits provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. Effective January 1, 2018, the co-pay for in-network primary care physician office visits will be twenty dollars ($20.00) per visit. A specialty care physician office An emergency room visit will be subject to a twentyseventy-five dollar ($25.0075.00) co-payment pay per in-network specialist visit. Eligible services, which shall include diagnostic, surgical and/or specialty services, routine prostate/colon rectal cancer tests subject to the limits specified in the paragraph above provided in the network physician’s office visit and billed by that office shall be covered at one hundred twenty percent (10020%) after office visit co-paymentinsurance after the co-pay and deductible. Effective January 1, 2018If admitted, the co-pay for specialty care physician office visits will be waived. An in-network urgent care visit will be subject to a thirty dollars dollar ($30.00) per visit. The co-payment does not apply to pay per visit and twenty percent (20%) co- insurance after the annual deductible and coinsurance; however, office co-payments pay and deductible. A non-network urgent care visit will apply to the annual out- of-pocket maximum. The annual medical plan deductible will not apply to office visit charges for which the office co-payment applies. Preventive care services, as defined and updated under the Affordable Care Act (“ACA”), will be provided by doctors and health care professionals within the City’s plan provider network without cost- sharing (copayments, coinsurance and deductibles). Preventive services that are not originally defined or eventually included in the ACA shall be subject to a thirty dollar ($30.00) co-pay per visit and forty percent (40%) co-insurance after the annual co-pay and deductible, co- insurance, and out-of-pocket maximum as specified in Section 18.1 (A)(1), (2), (3) and (4). Preventive Mental health services rendered by non-network providers shall will not be subject to the annual deductible, emergency room or urgent care co-insurance, and out-of-pocket maximum for non-network providers as specified in Section 18.1 (A)(1), (2), (3) and (4). Insured members should contact the City’s health plan administrator prior to obtaining preventive services for determination of preventive services coverage. In addition to the preventive services provided for under the ACA, the City shall maintain preventive coverage and limits for the following services: (a) provide coverage for an annual (one (1) per calendar year) routine prostate/colon rectal cancer tests for men age 40 and over up to a maximum of eighty-five dollars ($85.00)pays. (b) for men age 40 and over, an annual (one per calendar year) PSA blood test will be covered up to a maximum of one hundred dollars ($100.00). (c) provide coverage for one (1) baseline mammogram for women 35-39 years old.

Comprehensive Major Medical. The City shall maintain a 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 A three hundred dollar ($300.00) annual single deductible with an eighty/twenty percent (80/20%) coinsurance of the next two thousand dollars ($2,000.002000.00) in reasonable charges or four hundred dollars ($400.00), for a total out-out- of-pocket maximum of seven hundred dollars ($700.00) per single contract per year. Deductibles, out-of-pocket maximums, and visit limits will fully reset on January 1 of each 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- of-pocket maximum. Effective January 1, 2018, if 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 five thousand two hundred dollars ($3,200.00) per family contract per year. Any network modifications made by the plan administrator will apply. (4) Physical therapy, occupational therapy and/or chiropractic visits will be covered up to a combined annual maximum of thirty (30) visits per person, based upon medical necessity. (5) Physician office visits will be subject to a fifteen dollar ($15.00) co- payment per in-network primary care physician visit (includes Family, General, Internal, Pediatrician, mental health and OB/GYN physicians). Eligible services, which shall include diagnostic, surgical and/or specialty services, routine prostate/colon rectal cancer tests subject to the limits provided in the network physician’s office and billed by that office shall be covered at one hundred percent (100%) after office visit co-payment. Effective January 1, 2018, the co-pay for in-network primary care physician office visits will be twenty dollars ($20.00) per visit. A specialty care physician office An emergency room visit will be subject to a twentyseventy-five dollar ($25.0075.00) co-payment pay per in-network specialist visit. Eligible services, which shall include diagnostic, surgical and/or specialty services, routine prostate/colon rectal cancer tests subject to the limits specified in the paragraph above provided in the network physician’s office visit and billed by that office shall be covered at one hundred twenty percent (10020%) after office visit co-paymentinsurance after the co-pay and deductible. Effective January 1, 2018If admitted, the co-pay for specialty care physician office visits will be waived. An in-network urgent care visit will be subject to a thirty dollars dollar ($30.00) per visit. The co-payment does not apply to pay per visit and twenty percent (20%) co- insurance after the annual deductible and coinsurance; however, office co-payments pay and deductible. A non-network urgent care visit will apply to the annual out- of-pocket maximum. The annual medical plan deductible will not apply to office visit charges for which the office co-payment applies. Preventive care services, as defined and updated under the Affordable Care Act (“ACA”), will be provided by doctors and health care professionals within the City’s plan provider network without cost- sharing (copayments, coinsurance and deductibles). Preventive services that are not originally defined or eventually included in the ACA shall be subject to a thirty dollar ($30.00) co-pay per visit and forty percent (40%) co-insurance after the annual co-pay and deductible, co- insurance, and out-of-pocket maximum as specified in Section 18.1 (A)(1), (2), (3) and (4). Preventive Mental health services rendered by non-network providers shall will not be subject to the annual deductible, emergency room or urgent care co-insurance, and out-of-pocket maximum for non-network providers as specified in Section 18.1 (A)(1), (2), (3) and (4). Insured members should contact the City’s health plan administrator prior to obtaining preventive services for determination of preventive services coverage. In addition to the preventive services provided for under the ACA, the City shall maintain preventive coverage and limits for the following services: (a) provide coverage for an annual (one (1) per calendar year) routine prostate/colon rectal cancer tests for men age 40 and over up to a maximum of eighty-five dollars ($85.00)pays. (b) for men age 40 and over, an annual (one per calendar year) PSA blood test will be covered up to a maximum of one hundred dollars ($100.00). (c) provide coverage for one (1) baseline mammogram for women 35-39 years old.