Transcript Monterey Bay Public Employees Trust Regional Hospitals of

Overview of
Medical Benefits -
Managed Care Plan
Effective 4/01/2015
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Annual Deductible
• $650.00 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Annual Out-of-Pocket Limit
• In-P.H.A.-network:
$3,150.00 per individual
$9,450.00 per family
The calendar year deductibles are included in the out-of-pocket limits
• Out-of-P.H.A.-network: $10,000.00 per individual.
•Note: The prescription Drug Program has a separate individual out-of-pocket limit of $3,400.00 and a family
limit of $3,750.00
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Lifetime Maximum
•Lifetime Maximum: Lifetime per person maximum zero.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Life Insurance
Life Insurance:
participants only.
$25,000.00 term life insurance for active
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.)
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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 preapproved inpatient facilities for specialized procedures/treatments).
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Hospital Services (slide 3 of 4)
• Non-network Hospitals: 60% of U.C.R. charges.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Hospital Services (slide 4 of 4)
• Non-Contracting Hospitals: 60% of U.C.R. charges.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
X-Ray and Laboratory Services
• In-P.H.A.-network:
does not apply.
80% of contracted rates (deductible
• Out-of-P.H.A.-network: 60% of U.C.R. covered charges.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Vasectomy
• In-P.H.A.-network: Covered as any other medical condition.
• Out-of-P.H.A.-network:
condition.
Covered as any other medical
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Emergency Room
• In-P.H.A.-network: 80% of contracted rates after a $200.00
co-payment.
•90% of contracted rates
$200.00 co-payment.
in Hospitals of Distinction after a
• Out-of-P.H.A.-network:
$200.00 co-payment.
60% of U.C.R. charges, after a
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Durable Medical Equipment / Prosthetics
• In-P.H.A.-network:
authorization required.)
80% of contracted rates.
• Out-of-P.H.A.-network: None.
(Pre-
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Prescription Drugs - Mail Order (slide 3 of 3)
• Generic:
supply;
$20.00 co-payment for up to a ninety (90) day
• 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.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Rates for active employees (effective 4/01/2014)
• Single: $1,215.45 per month.
• Two-Party: $1,746.50 per month.
• Family: $2,469.95 per month.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed Care Plan
Rates for retirees under 65
(effective 4/01/2014)
• Single: $1,215.45 per month.
• Two-Party: $1,746.50 per month.
• Family: $2,469.95 per month.
Monterey Bay Public Employees Trust
Overview
of
Medical
Benefits
Managed Care Plan
Rates for retirees 65 and older
(effective 4/01/2014)
• Single: $654.49 per month.
• Two-Party: $964.05 per month.
• Family: $1,172.47 per month.
Monterey Bay Public Employees Trust
Overview of Medical Benefits
Managed 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).