–Plan Design Changes To Contain Costs. (a) The parties will, as appropriate, research the existence, costs, benefits and services provided, outcomes and other relevant statistics of regional health maintenance organizations, and shall make participation in such of those organizations as the parties deem appropriate available as an option to individuals covered by the Plan.
(b) With respect to Plan participants and their beneficiaries who live in an area where they may choose between CHCB and MMCP coverage, the percentage of Eligible Expenses payable by the Plan with respect to an individual covered under the CHCB will be 75% until the Out-of-Pocket Maximum is reached, but only 60% if a required notice to Care Coordination/Patient Management is not given or if Care Coordination/Patient Management determines that the service or supply involved, although a Covered Health Service, is not Medically Appropriate.
(c) The annual deductibles for Individual and Family under the Plan's CHCB will be increased to $200 and $400, respectively. The Annual Out-of-Pocket Maximum under the Plan's CHCB will be increased to $2,000 per individual and $4,000 per family.
(d) The annual deductibles for Individual and Family Out-of-Network services under the Plan's MMCP will be increased to $300 and $900, respectively. The Annual Out-of-Pocket Maximum under the Plan's MMCP for out of network services will be increased to $2,000 per individual and $4,000 per family.
(e) Under the MMCP:
(i) the Office Visit Co-Payment for In-Network Services shall be increased to $20.00 for each office visit to a provider in general practice or who specializes in pediatrics, obstetrics-gynecology, family practice or internal medicine.
(ii) The co-payment on behalf of a participant or beneficiary for each visit to an Urgent Care Center is $25.00
(iii) The co-payment on behalf of a participant or beneficiary for each visit to a Specialist or any other provider shall be $35.
(f) Under the MMCP, the co-payment on behalf of a participant or beneficiary with respect to any visit to a hospital emergency room shall be $50. Note: Where the participant or beneficiary is admitted to the hospital, such co-pay is waived.
(g) For purposes of the Plan, the term “children” as used in connection with eligibility for benefits is defined as follows: “Children include: • natural children, • stepchildren, • adopted children (including children placed with you for adoption), and • your grandchildren, provided they have their legal residence with you and are de...
–Plan Design Changes To Contain Costs. (a) The Plan’s Prescription Drug Card Program and Mail Order Prescription Drug Program shall be revised to include the PBM’s full utilization management rules package for specialty drugs and four additional non-specialty therapeutic classifications (anti-infective agents, central nervous system, gastroenterology and ophthalmology).
(b) The Plan shall implement improper billing detection and mitigation programs where available with the Plan’s medical vendors.
(c) The Plan shall implement out-of-network referenced-based pricing programs where available with the Plan’s medical vendors.
(d) The monthly payment for employees who elect to opt-out of coverage under the Plan will be increased from $100 to $200. The plan design changes contained in this Section shall become effective January 1, 2025, or as soon thereafter as practicable thereafter.
–Plan Design Changes To Contain Costs. (a) The parties will promptly solicit bids from interested companies to provide those services to the Plan involving the Managed Medical Care Program (“MMCP”) that are currently provided by Aetna U.S. Healthcare. The parties will evaluate the bids received and the capabilities of the companies making those bids and will accept such of them (or enter into negotiations with the bidding company or companies) as the parties deem appropriate.
(b) The parties will promptly research the existence, costs, benefits and services provided, outcomes and other relevant statistics of regional health maintenance organizations, and shall make participation in such of those organizations as the parties deem appropriate available as an option to individuals covered by the Plan.
(c) With respect to geographic areas where the Plan’s MMCP is not currently available but where companies capable of administering the MMCP provide such services, the parties will solicit proposals from such companies to administer the MMCP, and will evaluate the proposals they receive and accept such of them (or enter into negotiations with the proposing company or companies) as the parties deem appropriate.
(d) The parties will solicit proposals from pharmacy benefit managers who specialize in filling prescriptions for injectable medications and will accept one or more of such proposals (or enter into negotiations with the proposing company or companies) as the parties deem appropriate.
(e) With respect to Plan participants and their beneficiaries who live in an area where they may choose between CHCB and MMCP coverage, such Plan’s participants and their beneficiaries shall no longer have a choice but shall be enrolled in the MMCP.
(f) With respect to geographic areas where the Plan’s MMCP is not currently available, but Aetna U.S. Healthcare or United HealthCare is capable of administering the Plan’s MMCP on a cost-neutral or better basis, the Plan’s MMCP benefits shall be provided.
(g) The Individual and Family Out-of-Network Deductibles under the Plan’s MMCP will be increased to $200 and $600, respectively.
(h) During the prescribed election period preceding June 1, 2004 and preceding each January 1 thereafter, employees may certify to the Plan or its designee in writing that they have health care coverage (which includes medical, prescription drug, and mental health/substance abuse benefits) under another group health plan or health insurance policy that they identify by name and, where applica...
–Plan Design Changes To Contain Costs. The payment on behalf of a participant or beneficiary with respect to any visit to a hospital emergency room shall be $75. Note: Where the participant or beneficiary is admitted to the hospital, such payment is waived.
