Cost Sharing Plan and Cost Coverage Restrictions Sample Clauses

Cost Sharing Plan and Cost Coverage Restrictions. The following cost sharing plan and cost coverage restrictions shall be effective for all employees: (a) There shall be a five hundred dollar ($500.00) annual per person maximum on chiropractic care and a one thousand three hundred dollar ($1,300.00) annual per person maximum on physical therapy, both subject to the major medical deductible ($100/individual) and co-insurance (80%/20%). (b) Major medical benefits shall be paid to a lifetime maximum of one million dollars ($1,000,000.00) per person; provided that coverage for nervous and mental, drug and alcoholism treatment is limited per Section 2, paragraph C. (c) There shall be a two hundred dollar $200.00 co-pay for all emergency room (ER) visits, which shall be waived if the individual is admitted. For an employee who is referred to the ER by his or her primary care physician, or by an urgent care facility, or by a tele-medicine service, that employee may appeal the payment of one-half (1/2) of the ER co-pay. Any appeal must include written documentation of the referral from the primary care physician, urgent care facility, or tele-medicine service. Any appeal will be reviewed by the City’s third-party administrator for health care. Any further subsequent appeal by the employee will be reviewed by the members of the Health Care Cost Containment Committee, whose decision shall be by consensus and shall be final, with no further appeal by the employee. (d) There shall be a monthly co-premium payment amount for each employee. Single employees receiving coverage under this section shall pay a monthly premium of ninety-four dollars ($94) per month; a single employee with one (1) dependent shall pay a monthly premium of one hundred sixty dollars ($160) per month; an employee with more than one dependent (e.g., family coverage) shall pay a monthly premium of one hundred sixty six dollars ($166) per month. The co-premium payments will be made by payroll deduction on a pre-tax basis. Part time employees’ premiums will be pro-rated.. Spouses who are both employed by the Clerk or the City of Toledo will only pay one co-premium payment based on the level of coverage selected. The “Birthday Rule” and the spousal exclusion language in Section (1) (a) continue to apply to coverage options.
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Cost Sharing Plan and Cost Coverage Restrictions. The following cost sharing plan and cost coverage restrictions shall be effective for all employees: (a) There shall be a five hundred dollar ($500.00) annual per person maximum on chiropractic care and a one thousand three hundred dollar ($1,300.00) annual per person maximum on physical therapy, both subject to the major medical deductible ($100/individual) and co-insurance (80%/20%). (b) Major medical benefits shall be paid to a lifetime maximum of one million dollars ($1,000,000.00) per person; provided that coverage for nervous and mental, drug and alcoholism treatment is limited per Section 2, paragraph C. (c) There shall be one hundred dollar ($100.00) co-pay for all emergency room visits, which shall be waived if the individual is admitted or if the visit is between the hours of 8:00 p.m. and 9:00 a.m., or on a Saturday after 12:00 Noon, or on a Sunday. (d) There shall be a monthly co-premium payment amount for each employee. Employees will pay $25.00, $40.00 or $55.00 per month depending on the level of coverage selected. Coverage selections include the following: Single coverage (employee only) will be $25.00 per month; Single plus one (1) coverage (employee plus spouse or one (1) dependent) will be $40.00 per month; or Family coverage (employee plus two or more dependents) will be $55.00 per month. As a condition of continued coverage under the terms of this section, covered employees shall, beginning the first full pay period in July, 2013, be responsible for premium payments in accordance with the following schedule: Single employees receiving coverage under this section shall pay a monthly premium of forty-eight dollars ($48) per month; a single employee with one (1) dependent (e.g., “single + 1” coverage) shall pay a monthly premium of eighty dollars ($80) per month; an employee with more than one dependent (e.g., family coverage) shall pay a monthly premium of ninety-two dollars ($92) per month. Any employee eligible to receive coverage may waive such coverage. Effective the first full pay period in July, 2014 the monthly premiums will be increased as follows: Single employees receiving coverage under this section shall pay a monthly premium of seventy-one dollars ($71) per month; a single employee with one (1) dependent shall pay a monthly premium of one hundred twenty dollars ($120) per month; an employee with more than one dependent (e.g., family coverage) shall pay a monthly premium of one hundred twenty-nine dollars ($129) per month. Ef...
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Related to Cost Sharing Plan and Cost Coverage Restrictions

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