Summary of Benefits. Medicare Part A helps pay for health care in hospitals, skilled nursing facilities, hospice care, and some home health care services. The table below shows how much Medicare, this plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan Select G. Hospitalization (*) Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 $1,556 (Part A deductible) $0 Days 61 thru 90 All but $389 per day $389 per day $0 Days 91 and after while using 60 lifetime reserve days All but $778 per day $778 per day $0 Once lifetime reserve days are used, an additional 365 days $0 100% of Medicare eligible expenses (**) $0(**) Beyond the additional 365 days $0 $0 100% Skilled Nursing Facility (SNF) Care (*) You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 Days 21 thru 100 All but $194.50 per day Up to $194.50 per day $0 Days 101 and after $0 $0 100% Blood (inpatient) First 3 pints $0 100% $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment or coinsurance for outpatient drugs and inpatient respite care Medicare copayment or coinsurance for outpatient drugs and inpatient respite care $0 (*) A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. (**) When your Medicare Part A hospital benefits are exhausted, BCBSRI stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. Medicare Part B helps pay for doctors’ services, outpatient hospital care, certain medically necessary home health care services and other medical services that Part A does not cover, such as physical and speech therapy. The table below shows how much Medicare, your plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Suppleme...
Summary of Benefits. This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California plan. It is only a summary and it is part of the contract for health care coverage, called the Evi- dence of Coverage (EOC). Please read both documents carefully for details. ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE First $250 each Calendar Year $250 Remainder of charges 20% plus 100% of additional charges over the $50,000 lifetime maximum BASIC GYM ACCESS THROUGH SILVERSNEAKERS® FITNESS $0 HEARING AID SERVICES – Your hearing aid services benefits are provided by EPIC Hearing Healthcare (EPIC). This benefit is designed for you to use EPIC network providers. EPIC Participating Providers are listed at xxxxxxxxxxxx.xxx/XxxxxxxXxxx. If you choose to use out-of-network providers, those services will not be covered. This benefit is separate from diagnostic hearing examinations and related charges as covered by Medi- care. Hearing aid benefits every year include: • One routine hearing exam • Hearing aid instrument o Choice of private-labeled Silver (mid-level) or Gold (premium level) tech- nology hearing aid models o Up to two hearing aids in the following styles: in-the-ear; in-the-canal; completely-in-canal; behind-the-ear; or receiver-in-the-ear. o All technology levels include: one consultation; two-year supply of batteries per hearing aid; and three-year extended warranty. o Silver technology level hearing aids include: one behind-the-ear hearing aid (non-ear mold model) delivered directly to your home; and up to three virtual follow-up visits by a participating provider for hearing aid fitting, consultation, device check, and adjustment for no additional cost. o Gold technology level hearing aids include: one hearing aid delivered in-person by a participating provider; up to three in-person follow-up visits for hearing aid fitting, con- sultation, device check, and adjustment for no additional cost; and standard ear molds & impressions. $0 Silver Technology Level: $449 per hearing aid Gold Technology Level: $699 per hearing aid ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE VISION SERVICES– Your vision benefits are provided by Vision Service Plan (VSP). This benefit offers one of the largest national network of independent doctors located in retail, neighborhood, medical and professional settings. You can lower any out-of-pocket costs by choosing network providers for covered services. VSP Participating Providers may...
Summary of Benefits. Such insurance shall provide employees with insurance protection while engaged in the maintenance of order and discipline and the protection of school personnel, students and property. Such insurance must include as a minimum, liability insurance covering injury to persons and property, and insurance protecting the employee from loss or damage of personal property while so engaged.
Summary of Benefits. Benefit Maximum Benefit Payable Medical Emergency Insurance $2,000,000 per Insured Person per Covered Trip.
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
Summary of Benefits. Health Plan shall submit an annual Summary of Benefits of Health Plan’s D-SNP benefits offered under the plan benefit packages, including Supplemental Benefits, for the counties identified in Attachment B, by January 1 each year, and within 15 calendar days of any update or modification.
Summary of Benefits. MTC Full-Time Regular Represented and Confidential Employee Positions (Except as otherwise noted and excluding executive employees)
Summary of Benefits. Eligibility A regular, full-time or part-time employee working at least 17.5 hours per week (at least 21 hours per week with respect to Long Term Disability benefits). $1,000 if not already a multiple thereof, subject to a maximum of $700,000. following your 75th birthday, or earlier retirement. next higher $1 if not already a multiple thereof, subject to a maximum of $3,500 per month. Benefits begin after 90 days of continuous disability. The maximum benefit period is to age 65, or earlier recovery. Deductible $50 Single per calendar year; or $50 Family per calendar year Coinsurance 100% of eligible expenses Maximum $15,000 per person per calendar year
Summary of Benefits. Crothall Employees
Summary of Benefits. MTC Full-Time Regular Represented and Confidential Employee Positions (Except as otherwise noted and excluding executive employees) Public Transit Option MTC provides a subsidy in accordance with IRS Fringe Benefit regulation for employees for legitimate and applicable transit ticket purchases. Purchases must be made through authorized MTC provided third-party transit administrator(s) only and must be for a monthly amount needed and used by each employee each month, per IRS regulation. Effective July 1, 2014, MTC’s monthly subsidy will increase to up to $214 per month. MTC will provide this subsidy tax-free per IRS fringe benefit allowances. As of January 2014, the allowable tax free level for fare purchase is $130, and for eligible parking is $250. As of January 2016, the allowable tax free level for fare purchase and parking is $255 monthly. Any subsidy above the IRS limits is taxable income. Six months after relocation to MTC’s new San Francisco office, MTC reviewed the transit subsidy level to determine if it was sufficient to serve the majority of employee transit costs. Based on this review and in consultation with employees, the transit subsidy level was increased to $255 monthly on December 21, 2016. Employer Provided Parking Option While MTC is still located at 000 0xx Xxxxxx, employees may select to contribute $18.50 per month pre-tax for parking in the MTC leased employee parking lot in lieu of receiving the monthly transit subsidy. This option is based on availability of parking spaces in the lot. After moving the office to San Francisco, this option will change as follows: (a) MTC will maintain rental of the Caltrans owned parking lot; (b) Parking spaces in this lot will be available to eligible employees to park at this lot and purchase transit to commute to San Francisco.
