overview of medical benefits - managed care plan effective 4/01/2014
DESCRIPTION
Overview of Medical Benefits - Managed Care Plan Effective 4/01/2014. Monterey Bay Public Employees Trust Overview of Medical Benefits Managed Care Plan. Annual Deductible $650.00 per person; maximum of three deductibles per family. - PowerPoint PPT PresentationTRANSCRIPT
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Overview of Medical Benefits -
Managed Care PlanManaged Care PlanEffective 4/01/2016
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Annual Deductible• $800.00 per person; maximum of three deductibles per family.• After annual deductible has been met, the Plan pays the percentage of covered charges as shown. When the annual out-of-pocket amount has been met, the Plan will pay 100% of covered charges for that calendar year.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Lifetime Maximum•Lifetime Maximum: Lifetime per person maximum
zero.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Life Insurance Life Insurance: $25,000.00 term life insurance for active participants only.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Physician (Surgery, Home, Office, Hospital)
• In-P.H.A.-network: 80% of contracted rates for surgeon/anesthetist. 70% for hospital visits and home visits. $25.00 co-payment for office visits (deductible does not apply).
• Out-of-P.H.A.-network: 60% of U.C.R. charges.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Specialty Referral Process• In-P.H.A.-network: Referral to a specialist must be made by a Primary Care Physician and approved by Network Manager – not required for Ophthalmology, OB/GYN, or Podiatry.• Out-of-P.H.A.-network: 60% of U.C.R. charges. (Same referral process as for in-network.)
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Anesthesia• In-P.H.A.-network: 80% of contracted rates.
• Out-of-P.H.A.-network: 80% of U.C.R. covered charges.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Hospital Services (slide 1 of 4)• M.B.P.E.T. Hospitals of Distinction
• 90% of contracted rates. (Natividad Medical Center, George L. Mee Memorial Hospital, Hazel Hawkins Memorial Hospital, Salinas Valley Memorial Hospital, Watsonville Community Hospital and Community Hospital of the Monterey Peninsula.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Hospital Services (slide 2 of 4)• M.B.P.E.T. Centers of Excellence: 100% of contracted rates; $250.00 daily per diem for family expenses for each day of in-patient medically necessary care (must be pre-approved by Executive Director). (Stanford Medical Center and other pre-approved inpatient facilities for specialized procedures/treatments).
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Hospital Services (slide 3 of 4) • Non-network Hospitals: 60% of U.C.R. charges.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Hospital Services (slide 4 of 4)
• Non-Contracting Hospitals: 60% of U.C.R. charges.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Skilled Nursing Facility• In-P.H.A.-network: 80% of contracted rates up to 365 days per lifetime. (Must be pre-authorized.)
• Out-of-P.H.A.-network: None.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
X-Ray and Laboratory Services• In-P.H.A.-network: 80% of contracted rates (deductible does not apply.
• Out-of-P.H.A.-network: 60% of U.C.R. covered charges.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Maternity and Interrupted Pregnancy• In-P.H.A.-network: Covered as any other medical condition.• Out-of-P.H.A.-network: Covered as any other medical condition.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Vasectomy• In-P.H.A.-network: Covered as any other medical condition.• Out-of-P.H.A.-network: Covered as any other medical condition.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Emergency Room• In-P.H.A.-network: 80% of contracted rates after a $200.00 co-payment.•90% of contracted rates in Hospitals of Distinction after a $200.00 co-payment.• Out-of-P.H.A.-network: 60% of U.C.R. charges, after a $200.00 co-payment.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Wellness / Well Baby• In-P.H.A.-network: 100% of contracted rates for exams and immunizations as listed under the Affordable Care Act. There is no deductible or coinsurance.
• Out-of-P.H.A.-network: None.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Flu Immunizations• In-P.H.A.-network: 100% of covered charges as listed under the Affordable Health Care Protection Act. There is no deductible or coinsurance.
• Out-of-P.H.A.-network: None.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Physical Exams and Mammograms• In-P.H.A.-network: 100% of contracted rates for mammograms. For routine physicals as listed under the Affordable Health Care Protection Act. There is no deductible or coinsurance.
• Out-of-P.H.A.-network: None.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Allergy Testing / Administration of Serum
• In-P.H.A.-network: 80% of contracted rates for testing, and 100% of covered charges for administration of serum.• Out-of-P.H.A.-network: 70% of U.C.R. charges for testing, and 100% of covered charges for administration of serum.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Home Health Care• In-P.H.A.-network: 80% of contracted rates up to 120 days per disability, when home care plan is prescribed by your physician. (Pre-authorization required.)
• Out-of-P.H.A.-network: None.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Hospice Care• In-P.H.A.-network: 80% of contracted rates up to $15,000.00 lifetime maximum. Pre-certification required; otherwise, penalties apply.
• Out-of-P.H.A.-network: None.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Durable Medical Equipment / Prosthetics
• In-P.H.A.-network: 80% of contracted rates. (Pre-authorization required.)
• Out-of-P.H.A.-network: None.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Acupuncture• In-P.H.A.-network: 80% of contracted rates to a maximum allowance of $50.00 per visit for up to eighteen (18) visits per calendar year.
• Out-of-P.H.A.-network: None.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Hearing Services•In-P.H.A.-network: Payable under office visit benefits and/or physician benefits. No hearing aid coverage except if required because of surgery.
• Out-of-P.H.A.-network: None.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Podiatry• In-P.H.A.-network: Payable under office visit benefits and/or physician benefits.• Out-of-P.H.A.-network: 60% of U.C.R. charges.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Chiropractic Care• In-C.H.P.C.-network: $10.00 co-payment per visit up to forty-five (45) visits per calendar year.
• Out-of-C.H.P.C.-network: None.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Prescription Drugs – Retail Store (slide 1 of 3)
• Generic: $10.00 co-payment for up to a thirty (30) day supply (co-payment waived only at CVS Pharmacy Stores);• Formulary Brand: $30.00 co-payment for up to a thirty (30) day supply;• Non-Formulary Brand: $50.00 co-payment for up to a thirty (30) day supply.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Prescription Drugs – CVS Pharmacy Stores (slide 2 of 3)
• Generic: $0.00 co-payment for up to a thirty (30) day supply;• Formulary Brand: $30.00 co-payment for up to a thirty (30) day supply;• Non-Formulary Brand: $50.00 co-payment for up to a thirty (30) day supply.
Note: Ninety (90) day supply solely at CVS Pharmacy Stores at same co-payments as the prescription mail
order program except there is a zero co-pay for generics.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Prescription Drugs - Mail Order (slide 3 of 3)
• Generic: $20.00 co-payment for up to a ninety (90) day supply;• Formulary Brand: $60.00 co-payment for up to a ninety (90) day supply;• Non-Formulary Brand: $100.00 co-payment for up to a ninety (90) day supply.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Rates for active employees (effective 4/01/2016)
• Single: $1,324.84 per month.• Two-Party: $1,903.69 per month.
• Family: $2,692.25 per month.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Rates for retirees under 65 (effective 4/01/2016)
• Single: $1,324.84 per month.• Two-Party: $1,903.69 per month.
• Family: $2,692.25 per month.
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Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Rates for retirees 65 and older (effective 4/01/2016)
• Single: $654.49 per month.• Two-Party: $964.05 per month.
• Family: $1,172.47 per month.
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Monterey Bay Public Employees Trust
Overview of Medical BenefitsManaged Care PlanManaged Care Plan
Disclaimer• This presentation provides only a general overview of
the Medical benefits for the Managed Care Plan;• For complete information, consult your copy of the Summary Plan Description or call Health Services &
Benefit Administrators(1-831-757-1711 or 1-888-742-3380).