Common use of –Plan Design Changes To Contain Costs Clause in Contracts

–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 dependent for care and support mainly upon you and wholly, in the aggregate, upon themselves, you, your spouse, scholarships and the like, and governmental disability benefits and the like.” The definition of the term “children”, as used in connection with determinations of “Eligible Dependents” under the terms of the Dental Plan and the Vision Plan, respectively, shall be revised as provided as above. (h) The Plan design changes contained in this Section shall become effective on May 1, 2008.