enhanced preferred provider insurance …...enhanced ppo 100 90/70 plan – 1e in-network...

COMPREHENSIVE COVERAGE

PREVENTIVE AND WELLNESS BENEFITS

LABORATORY BENEFITS LabOne

PPO SAVINGS

FREEDOM OF CHOICE

MULTIPLE PLAN DESIGNS

COST CONTAINMENT FEATURES

E N H A N C E D P R E F E R R E D P R O V I D E R I N S U R A N C E P L A N S

1 E – 7 E 9 0 / 7 0

PAY L E S S F O R M O R E

No one can be absolutely certain about the future of health care in America. However, one thing is clear, engineering firms and their employees are demanding greater flexibility in their health insurance options.

To meet this demand, the ACEC Life/Health Trust has developed the Enhanced Preferred Provider Plans –– a balance of cost savings and flexibility, along with exceptional access to care. These plans are an attractive choice for any firm wishing to offer cost sharing options of deductibles and coinsurance combined with the convenience of self-directed referral to a network of qualified medical professionals.

The Enhanced Preferred Provider Plans cover basic medical expenses, including wellness, preventive and recovery care. The plan also helps protect insureds against hospital and physician costs resulting from catastrophic illness or injury.

F R E E D O M O F C H O I C E

Insureds may choose any physician or hospital. Of course, there is an advantage for insureds to stay in-network because benefits will be paid at their highest level.

M U LT I P L E P L A N D E S I G N S

Participating firms may choose from a range of Enhanced Preferred Provider Plans. The plans vary by coinsurance, deductibles and out-of-pocket maximums. Refer to the Plan Comparison chart on the following pages for more information. This chart saves you time by organizing essential information about available benefits and choices.

F O U R L E V E L S O F C O V E R A G E

Each Enhanced Preferred Provider Plan includes a choice of four levels of coverage: Employee Only; Employee Plus Spouse; Employee Plus Child(ren); Employee plus Spouse and Child(ren).

P R OT E C T YO U R B OT TO M L I N E

Today, medical coverage is one of the most valued employee benefits. Enhanced Preferred Provider Plans offer various levels of coverage to help protect engineering firm employees from serious financial hardship. But that’s not all. The cost containment provisions, such as Preadmission Hospital Certification, Case Management, Continued Stay Review, Wellness and Preventive programs, offer employers a solid line of defense against rising health care costs. These features are designed to protect your bottom line while at the same time providing comprehensive medical care for insureds.

C O M P R E H E N S I V E C O V E R A G E

The following coverage is included with the Enhanced Preferred Provider Plans:*

Vision benefits provided through Vision Service Plan

Wellness Benefits

Prescription Drug Card

Laboratory benefits through LabOne

*6E does not include Vision or Prescription Drug Card.

ENHANCED PPO 100 90/70 PLAN – 1E

IN-NETWORK OUT-OF-NETWORK

ANNUAL DEDUCTIBLE —If you have employee Only coverage: —Total if you have Spouse, Children or Family coverage:

$100$200

OUT-OF-POCKET ANNUAL MAXIMUM (Includes deductible) —If you have employee Only coverage: —Total if you have Spouse, Children or Family coverage:

$750$1,500

$2,100$4,200

COINSURANCE (Up to out-of-pocket maximum then 100%) 90% 70%

DOCTOR’S ENCOUNTER FEE Deductible then 90% Deductible then 70%

PREVENTIVE CARE Pap smears, prostate cancer screening and mammography screening (Age and frequency limitations apply)

100%—No deductible

ROUTINE PHYSICALS STANDARD - One every calendar year, ages two and older up to $500 maximum—not subject to deductible, paid at 100%OPTIONAL - $250 every 5 years, age 2-44; $500 every 2 years, age 45-55; or $750 every year, age 56 and above—not

subject to deductible, paid at 100%

OUTPATIENT LAB TESTS THROUGH LABONE 100% —No deductible for covered testing processed at LabOne. (Provider collection and handling fees may apply and are subject to health benefit plan provisions.)

PRESCRIPTION DRUGS Please refer to separate prescription drug benefit brochure for available options

HOSPITALIZATION Semi-Private Private Room Limit

Deductible then 90%of Semi-Private room rate

Deductible then 70% of Semi-Private room rate

PHYSICIAN SERVICES Inpatient Surgery Outpatient/Ambulatory Surgery

Deductible then 90% Deductible then 70%

WELL BABY UP TO AGE 2 Deductible then 90% Deductible then 70%

MATERNITY Prenatal care Delivery and inpatient well baby care


SUPPLEMENTAL ACCIDENT BENEFIT First $500 paid at 100%, then deductible and coinsurance apply

TRANSPLANTS —100% for transplant performed at a designated Center of Excellence facility, no deductible. —$300,000 Lifetime Maximum for transplant services performed at a facility other than a Center of Excellence,

out-of-network deductible and coinsurance apply..

HOSPICE CARE 100% —No deductible

OTHER COVERED MEDICAL EXPENSES Deductible then 90% Deductible then 70%

PLAN MAXIMUMS

HOME HEALTH CARE Limited to 50 visits per Calendar Year

EXTENDED CARE FACILITY Limited to 60 days per Calendar Year

HEARING BENEFITS Hearing examination - up to $25 per 60 consecutive month period. Hearing aid including services and supplies – up to $300 per 60 consecutive month period. Hearing aid repair – all expenses up to $50 per Calendar Year

MENTAL HEALTH/CHEMICAL ABUSE BENEFITS Lifetime Maximum of 40 days Inpatient treatment. Lifetime Maximum of 120 Outpatient Visits at 50%

SPINAL MANIPULATION $1,000 per Calendar Year

OTHER COVERED EXPENSES Unlimited Lifetime Maximum for covered expenses, except as otherwise indicated in the Certificate

Benefits may vary based on state mandates.

MEDICAL EXPENSES





$300$600


$1,500$3,000

$4,000$8,000


















TRANSPLANTS —100% for transplant performed at a designated Center of Excellence facility, no deductible. —$300,000 Lifetime Maximum for transplant services performed at a facility other than a Center of Excellence, out-of-

network deductible and coinsurance apply..



PLAN MAXIMUMS







MEDICAL EXPENSES




$500$1,000


$2,000$4,000

$5,000$10,000





ROUTINE PHYSICALS STANDARD - One every calendar year, ages two and older up to $500 maximum—not subject to deductible, paid at 100%OPTIONAL - $250 every 5 years, age 2-44; $500 every 2 years, age 45-55; or $750 every year, age 56 and

above—not subject to deductible, paid at 100%














HOSPICE CARE 100%—No deductible


PLAN MAXIMUMS







MEDICAL EXPENSES





$300$600


$1,500$3,000

$4,000$8,000






















PLAN MAXIMUMS








MEDICAL EXPENSES




$1,000$2,000


$2,500$5,000

$5,500$11,000





ROUTINE PHYSICALS STANDARD - One every calendar year, ages two and older up to $500 maximum—not subject to deductible, paid at 100%OPTIONAL - $250 every 5 years, age 2-44; $500 every 2 years, age 45-55; or $750 every year, age 56 and

above—not subject to deductible, paid at 100%
















PLAN MAXIMUMS







MEDICAL EXPENSES





$1,500$3,000


$3,000$6,000

$6,000$12,000





ROUTINE PHYSICALS STANDARD - One every calendar year, ages two and older up to $500 maximum—not subject to deductible, paid at 100%OPTIONAL - $250 every 5 years, age 2-44; $500 every 2 years, age 45-55; or $750 every year, age 56 and above—

not subject to deductible, paid at 100%
















PLAN MAXIMUMS







MEDICAL EXPENSES





$2,000$4,000


$6,000$12,000

$14,000$28,000





ROUTINE PHYSICALS $250 every 5 years, age 2-44; $500 every 2 years, age 45-55; or $750 every year, age 56 and above— plan coinsurance and deductible apply











SUPPLEMENTAL ACCIDENT BENEFIT Deductible then 90% Deductible then 70%.


out-of-network deductible and coinsurance apply.

HOSPICE CARE Deductible then 90% Deductible then 70%


PLAN MAXIMUMS







MEDICAL EXPENSES


ENHANCED PPO 2000 CV 90/70 PLAN – 7E



$2,000$4,000


$3,500$7,000

$6,500$13,000





ROUTINE PHYSICALS $250 every 5 years, age 2-44; $500 every 2 years, age 45-55; or $750 every year, age 56 and above— plan coinsurance and deductible apply











SUPPLEMENTAL ACCIDENT BENEFIT Deductible then 90% Deductible then 70%.


out-of-network deductible and coinsurance apply.

HOSPICE CARE Deductible then 90% Deductible then 70%


PLAN MAXIMUMS







MEDICAL EXPENSES


MEDICAL EXCLUSIONS/LIMITATIONS

M E D I C A L E X C L U S I O N S / L I M I T A T I O N SEXCLUSIONS

Benefits will not be paid for expenses arising from or in connection with:• Charges in excess of the Prevailing Fee.• Treatment, services or supplies which are: - not Medically Necessary; - experimental, investigational, educational or primarily for the purpose of medical or other research; - not prescribed by a Physician as necessary to treat a Sickness or Injury; - received without charge or legal obligation to pay; - supplies or treatment that would not routinely be paid in the absence of insurance; - furnished by an employer-maintained health department or clinic, by a labor union or other similar person or

group; or - performed or received when coverage provided herein is not in effect.• War, declared or undeclared, acts of war, or while in the military service of any country.• Participating in a riot, civil disturbance or illegal occupation; or commission of, or attempt to commit, a felony or

crime which would be a felony if prosecuted.• Loss due to intentionally self-inflicted sickness or injury, if the sickness or injury is not a result of a medical

condition.• Loss due to suicide, if the suicide is not a result of a medical condition.• Services provided due to a court order.• Expenses incurred for Prescription Drugs, except if received while an inpatient.• Service or supply furnished by a member of the Immediate Family or person who usually resides in Your home.• Physician fees for any treatment when the Physician is not physically present or fees for missed appointments.• Dental care or treatment, except as specifically stated in Covered Charges.• Dental implantology.• Eye refractions; eyeglasses; contact lenses or the fitting of contact lenses (unless necessary after surgery) or

examinations for their prescription or fitting; eye exercises; or services or supplies related to the treatment of refractive error.

• Cosmetic surgery, except as specifically stated in Covered Charges.• Sex transformations or services related to sexual dysfunction.• Artificial insemination; surrogate pregnancy; in vitro fertilization and embryo transfer; and reversal of vasectomy or

tubal ligation.• Expenses incurred in connection with the pregnancy of a Dependent child, except for Complications of Pregnancy.• Behavior modification or psychological counseling in connection with smoking cessation and weight control,

including, but not limited to: vitamins, diet supplements and health club memberships.• Treatment of exogenous obesity.• Vitamins; minerals or nutritional substances; or supplements.• Sickness or Injury covered by any Workers' Compensation Act or similar law, except if You are not eligible for

Workers' Compensation or similar coverage.• Hearing aid batteries.• Services of any educational institution.

LIMITATIONS

Pre-existing Condition LimitationExpenses that result from care or treatment of a Pre-existing Condition will not be considered as Covered Charges. This limit will not apply to:• a Covered Person, after the first 12 months following the date he became covered or the first day of the

waiting period if earlier; or• a Late Enrollee, after the first 18 months following the date he became covered or the first day of the waiting period

if earlier;• a newborn for the first 30 days after birth; or• a child, if enrolled under this plan or any Qualifying Coverage within the first 31 days of birth, and continuously

covered with no break in coverage of more than 63 days; or• a child adopted prior to age 18, if enrolled under this plan or any Qualifying Coverage within the first 30 days

of the adoption or placement for adoption, and continuously covered with no break in coverage of more than 63 days.

This limitation period will be reduced for the time the Covered Person was covered under Qualifying Coverage if such coverage was continuous to a date not more than 63 days prior to the effective date of this coverage, excluding any waiting period.

Exclusions and limitations may vary based on state mandates.

The information contained in this brochure is a general description of features, benefits, requirements and restrictions of Trustmark Policy number AXX/K. Please refer to the Certificate of Insurance for more details, or contact your sales representative.

HealthPlan Services • 3501 E. Frontage Road • Tampa, FL 33607Trustmark Life Insurance Company and Trustmark Insurance Company • 400 Field Drive • Lake Forest, IL 60045

14858ENH90/701E-7E 6/05

enhanced preferred provider insurance …...enhanced ppo 100 90/70 plan – 1e in-network...

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