Plan Design Changes Sample Clauses

Plan Design Changes. (a) Effective January 1, 2023, the Plan’s Managed Medical Care Program (“MMCP”) and its Comprehensive Health Care Benefit (“CHCB”) shall be modified with respect to hearing benefits to increase the maximum annual payment for tests and examinations, including those by an audiologist or hearing aid dispenser, to diagnose and determine the cause of a hearing loss, and for a hearing aid necessary to restore lost, or help impaired, hearing, to $2,000. (b) Effective January 1, 2023, the MMCP, CHCB, and Mental Health and Substance Abuse programs, as applicable, shall be modified to add coverage for the diagnosis and treatment of Autism Spectrum Disorder, without application of age or dollar limitations (other than generally applicable cost-sharing requirements under the terms of the Plan). Coverage for the treatment of Autism Spectrum Disorder shall include speech, occupational and physical therapies, Applied Behavior Analysis, and other medically appropriate intensive behavioral therapies; provided that any such coverage shall be subject to medical management processes (such as prior authorization or treatment plan requirements) applied by the company administering the member’s benefits. (c) Effective January 1, 2023, the MMCP, CHCB, and Mental Health and Substance Abuse programs, as applicable, shall be modified to remove the age restriction on speech therapy as part of a treatment for developmental delay, cerebral palsy, hearing impairment or major congenital anomalies that affect speech such as, but not limited to, cleft lip and cleft palate. Medical management processes will continue to apply to such coverage.

Plan Design Changes. The Plan’s Managed Care Program “(MMCP”) and the Comprehensive Health Care Benefit (CHCB) shall both be revised as follows: (a) Plan coverage for surviving dependents will be extended through the end of the sixth (6th) month following the month in which the employee dies. (b) Plan benefits will include male sterilization procedures (i.e., vasectomy), not including reversals. The plan design changes contained in this Section shall become effective January 1, 2025, or as soon thereafter as practicable.

Plan Design Changes. (a) Emergency Room Co-pay shall be increased to $100 effective 1/1/19, and to $125 effective 1/1/21 (waived if admitted). (b) Clinical Management and Quality of Care Initiatives no earlier than 7/1/18. 1. Telemedicine option- Same co-pay as primary care physician 2. Aetna's High Performance Network- If an identified High Performance Specialist is used, the primary care co-pay will apply. 3. Opioid Control program covering quantity, duration, and pharmacy management- hard stop letter for multiple pharmacies out of network, and implementing CDC and FDA quantity and duration limits. 4. CVS Value-Based Formulary- generic prescriptions where available subject to continued medical necessity exception standard. Current prescriptions will be grandfathered until the point in time the prescription ceases to be renewed. 5. Advanced Control Specialty Prescriptions Formulary where multiple specialty drugs are available will be managed in accordance with clinical, price and efficiency standards. 6. Mandatory Maintenance Prescription Choice- (90 day, at CVS/mail). 7. Effective 1/1/19 Amtrak couples will participate in AmPlan I as non-Amtrak couples, subject to all plan conditions, provided however, that only one employee contribution will be paid. 8. Medical plan coverage, inclusive of dependent coverage, for employees who cease to render compensated service after the date of this agreement as a result of disability due to illness or injury; or who become disabled before coverage as a furloughed, dismissed or suspended employee ends; shall be changed to end on the earlier of the following: the date the disability ends or at the end of the twenty-four (24) month period following the month in which the employee last rendered compensated service. 9. Out-of-Network (OON) Cost 1/1/19- Share for employees who have network coverage and choose OON services -Deductible- $500 -Coinsurance- 75% -Out-of-pocket maximum- $3,000 (c) New Hire Plan (See Addendum 1 subject to below) 1. An Amtrak New Hire Plan is established for employees hired on or after 1/1/19. New hires electing health insurance coverage shall be required to participate in the New Hire Plan during the first 5 years of employment (through the end of the fifth calendar year). After 5 years of participation, the employee will have an annual choice during open enrollment to continue in the New Hire Plan or elect to participate in any other Plan(s) applicable to other active employees. All continuous service with Amtrak wil...

Plan Design Changes. The parties commit to implementing Medical Plan Design changes that will result in estimated savings of at least $3 million (as calculated with respect to the Coalition Unions) by 2020. The parties will work through the LMCC to identify changes that will result in the required savings. If, prior to January 1, 2020, the par- ties have not reached agreement upon the proposed changes, each party will submit its offer of proposed changes and the amount proposed to be reduced, including the methodology for estimating the value of the proposed changes, to a mutually agreed upon arbitrator, who will be limited to selecting either the City’s or the Coalition Unions’ offer. The offer selected by the ar- bitrator will be binding on the parties and on the LMCC.

Plan Design Changes. (a) The Plans’ Managed Medical Care Program (“MMCP”) shall be modified as follows: (1) The Annual Deductible for In-Network Services for which a fixed-dollar co-payment does not apply shall be $325 per individual and $650 per family, respectively, in 2018 and $350 and $700, respectively, in 2019 and thereafter. (2) The Individual and Family In-Network Out-of-Pocket Maximums shall be $1,800 and $3,600, respectively, in 2018 and $2,000 and $4,000, respectively, in 2019 and thereafter. (3) The Emergency Room fixed-dollar co-payment for In-Network and Out-of-Network Services shall be $100, for each visit, but shall not apply if the visit results in admission to the hospital. (4) The fixed-dollar co-payment for each visit to an In-Network Provider that is an Urgent Care Center, or who is in general practice, specializes in pediatrics, obstetrics/gynecology, family practice or internal medicine, or who is a Nurse Practitioner, Physician Assistant, Physical Therapist or Chiropractor, shall be $25. The fixed-dollar co-payment for each visit to any other In-Network Provider that is not a Convenient Care Clinic shall be $40. The fixed-dollar co-payment for each visit to a Convenient Care Clinic shall be $10. (5) Eligible Expenses for In-Network Services, other than ACA Preventive Health Services, shall be paid at 90% after any applicable deductible is satisfied and at 100% following payment of an applicable fixed-dollar co-payment or after the In-Network Out-of-Pocket Maximum is met. (6) The Annual Deductible for Out-of-Network Services shall be $650 per individual and $1,300 per family, respectively, in 2018, and $700 per individual and $1,400 per family, respectively, in 2019 and thereafter. (7) The Individual and Family Out-of-Network Out-of-Pocket Maximums shall be $3,600 and $7,200, respectively, in 2018 and $4,000 and $8,000, respectively, in 2019 and thereafter. (8) Eligible Expenses for Out-of-Network Services shall be paid at 70% after any applicable deductible is satisfied and at 100% after the Out-of-Pocket Maximum is met, in each case subject to a 20% reduction in benefits for failure to give any notice required by the Plans or if the company administering the member’s benefits determines that the service or supply is not Medically Appropriate. (b) The Plans’ Comprehensive Health Care Benefit (“CHCB”) shall be modified as follows: (1) The Annual Deductible shall be $325 per individual and $650 per family, respectively, in 2018 and $350 and $700, respecti...

Plan Design Changes. The parties further agree to meet during 2007 to develop additional plan design changes for Kaiser and Cigna for plan years 2008 and 2009. If the parties cannot reach agreement by July 1, 2007, for plan 2008, or July 1, 2008, for plan year 2009, default minimum plan design changes equivalent to other represented County-sponsored health plans shall be implemented for 2008 and 2009. The Coalition of County Unions and the County adopts and incorporates by reference herein the Cost Mitigation Goals and Objectives dated December 14, 2006. EBAC shall use the Cost Mitigation Goals and Objectives as a guideline in the development and design of benefit plans.