Schedule of Benefits A. Hospital Care
Loss of Benefits Employees who are separated from the service by a discharge under other than honorable conditions, bad conduct, or dishonorable discharge shall not be entitled to any of the benefits of Section 3 through Section 9 of the Article (relating to military leaves without pay) except such vested rights as they may have acquired thereto by virtue of payments made into their retirement accounts.
Description of Benefits The benefits available under this Plan will be as defined in Item F(5) of the Adoption Agreement.
Summary of Benefits Plan Feature Employee Co-pay - Network Only Preventive and Diagnostic Services • Examination • Cleaning • x-rays $0 $0 $0 Minor Restorative • Fillings and extractions • Oral surgery • Endodontic services1 • Periodontal services1 $0 $40-$196 based on specific service $45-$310 based on specific service $25-$145 based on specific service 1 Additional employee co-pay if approved specialist performs services. Major Restorative • Crowns • Bridges • Complete Dentures $92-$190 based on specific service $115-$291 based on specific service $249-$264 based on specific service Complete Orthodontics $1,850 co-pay D PPO “Buy Up” Option (Voluntary) Summary of Benefits Plan Feature In Network/Out of Network Class I (Preventative) 100%/100% Class II (Basic/Restorative) 80%/80% Class III (Major) 60%/60% Class IV (Orthodontia - adult ortho is included) 50%/50% Annual Deductible per Member (does not apply to Class I services) $50/$50 Orthodontia Lifetime Max $1,500/$1,500
Benefits for Part-Time Employees (a) A part-time employee including a casual employee, and a temporary employee shall receive in lieu of all fringe benefits (being those benefits to an employee, paid in whole or part by the Hospital, as part of direct compensation or otherwise, including holiday pay, save and except salary, vacation pay, standby pay, call back pay, reporting pay, responsibility allowance, jury and witness duty, bereavement pay, and maternity supplemental unemployment benefits) an amount equal to 14% of his/her regular straight time hourly rate for all straight time hours paid.
Coordination of Benefits The coordination of benefits (COB) provision applies when a Member has health care coverage under more than one plan. Plan is defined below. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. If the Member is covered by more than one health benefit plan, and the Member does not know which is the primary plan, the Member or the Member’s provider should contact any one of the health plans to verify which plan is primary. The health plan the Member contacts is responsible for working with the other plan to determine which is primary and will let the Member know within 30 calendar days. All health plans have timely claim filing requirements. If the Member or the Member’s provider fails to submit the Member’s claim to a secondary health plan within that plan’s claim filing time limit, the plan can deny the claim. If the Member experiences delays in the processing of the claim by the primary health plan, the Member or the Member’s provider will need to submit the claim to the secondary health plan within its claim filing time limit to prevent a denial of the claim. If the Member is covered by more than one health benefit plan, the Member or the Member’s provider should file all the Member’s claims with each plan at the same time. If Medicare is the Member’s primary plan, Medicare may submit the Member’s claims to the Member’s secondary carrier.
Predetermination of Benefits If charges for a planned course of treatment by a licensed dentist would exceed $300.00, proposed details and x-rays should be submitted to the Plan Administrator for approval. Failure to do so may result in a payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist.
Coordination of Benefits and Subrogation IPA and HMO shall establish and implement a system for coordination of benefits and subrogation, in accordance with those rules established under the HMO's policies and procedures and applicable federal and state laws. If known to IPA, IPA shall identify and inform HMO of Members for whom coordination of benefits and subrogation opportunities exist. HMO hereby authorizes IPA to seek payment, on a fee-for service basis or otherwise, from any insurance carrier, organization, or government agency which is primarily responsible for the payment or provision of medical services provided by IPA under this Agreement which can be recovered by reason of coordination of benefits, motor vehicle injury, worker's compensation, temporary disability, occupational disease, or similar exclusionary or limiting provisions, to the extent authorized by the applicable and not otherwise prohibited by law.
Explanation of Benefits Contractor shall send each Enrollee an Explanation of Benefits to Enrollees in Plans that issue Explanation of Benefits or similar documents as required by Federal and State laws, rules, and regulations. The Explanation of Benefits and other documents shall be in a form that is consistent with industry standards.
Duration of Benefits Eligibility for Income Protection benefits will cease upon the earliest of the following dates:
