2016 Medical Plan Comparison Chart

Transcription

1 2016 Medical Plan Comparison Chart WellStar Health System is committed to helping you control healthcare costs while providing more choices and personal control over your healthcare coverage through the following plan options. The plan premiums are withheld on a pre-tax basis, which is a tax advantage for you. All our plan options are self-insured ERISA plans administered by Aetna. This information is not intended or designed to replace or serve as an evidence of coverage or the Summary Plan Description (SPD). If you have specific questions regarding benefits structure, limitation or exclusions, refer to the Member Handbook and Summary Plan Booklet (combined create the SPD). There are no pre-existing condition exclusions under the plan. The SPD is the official document of the medical plan. SUMMARY OF BENEFITS Health Savings Acount 1 or Health Reimbursement Account 2 Funded by WellStar $500 Team Member $750 Team Member + 1 $1,000 Family $500 Team Member $750 Team Member + 1 $1,000 Family In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network OUT-OF-POCKET (OOP) EXPENSES Annual Deductible 3, 4 - a fixed dollar amount for the plan year that you are required to pay before the plan starts making payments for covered medical services, prescriptions and supplies. $1,300 Team Member $2,600 Team Member + 1 $2,600 Family $2,500 Team Member $3,750 Team Member + 1 $5,000 Family $1,750 Team Member $2,625 Team Member + 1 $3,500 Family $3,500 Team Member $5,250 Team Member + 1 $7,000 Family $2,000 Team Member $3,000 Team Member + 1 $4,000 Family $4,000 Team Member $6,000 Team Member + 1 $8,000 Family Annual Coinsurance Maximum 3, 4 - after the annual deductible has been satisfied, you are required to pay a percentage of covered medical services, prescriptions and supplies. The plan pays the remaining percentage. Annual coinsurance payments are capped according to your elected coverage level. $1,750 Team Member $2,000 Team Member + 1 $3,500 Family $3,500 Team Member $5,250 Team Member + 1 $7,000 Family $2,750 Team Member $4,125 Team Member + 1 $5,500 Family $5,500 Team Member $8,250 Team Member + 1 $11,000 Family $3,000 Team Member $4,500 Team Member + 1 $6,000 Family $8,000 Team Member $12,000 Team Member + 1 $16,000 Family Annual Out-of-Pocket Maximum 4 - this is the total of your annual deductible and annual coinsurance amounts you are responsible for paying. Lifetime Benefits- some specific benefits have limitations. PREVENTIVE HEALTH SERVICES 5 Routine Physical Exam 8 - including well baby, well child, adult exam and certain immunizations and pathology. OBGYN Exam 8 Health Education & Promotion - prescribed by a physician. Manual Breast Pump OR $50 Credit Towards an Electronic Breast Pump - first 12 months following birth. Other Services Covered under Healthcare Reform Guidelines PHYSICIAN SERVICES 9 $3,050 Team Member $4,600 Team Member + 1 $6,100 Family Unlimited $6,000 Team Member $9,000 Team Member + 1 $12,000 Family $4,500 Team Member $6,750 Team Member + 1 $9, Family Unlimited $9,000 Team Member $13,500 Team Member + 1 $18,000 Family $5,000 Team Member $7, Team Member + 1 $10, Family $10,000 Team Member $15,000 Team Member + 1 $20,000 Family No Charge, 7 No Charge, 7 No Charge 50% 6, 7 Unlimited Primary Care Physician (PCP) Office Visit 0% 0%

2 Specialist (SP) Office Visit - including allergy treatment (shots, serum and testing). Radiology Pathology EMERGENCY SERVICES 10 Emergency Room Services - includes all physician, anesthesia, pathology, radiology and facility fees. Ambulance Services- air and ground. 50% 6 50% 6 Urgent Care Facilities HOSPITAL SERVICES Inpatient Surgery & Services 11 - including semiprivate room and board, operating room, intensive care units, physician and assistant physician services, general nursing care, extended hospital care, rehabilitation, hospice care, pre-testing, anesthesiology, radiology, medications, injections, oxygen, blood and blood plasma. Outpatient Surgery 11 & Some Procedures - including physician and assistant physician services, general nursing care, facility charges, pretesting, anesthesiology, radiology, medications, injections, oxygen, blood and blood plasma. Cardiac Rehabilitation, Chemotherapy, Radiation, Dialysis, Hemodialysis, Infusion Therapy - including necessary supplies. 50% 6 Respiratory Therapy 11 - including necessary supplies. Physical, Occupational & Speech Therapy 11 - including necessary supplies. Combined limit of 60 visits Applied Behavior Analysis (ABA) Therapy 11 - including necessary supplies. Limit of 60 visits Pathology Mammography, Colonoscopy, Sigmoidoscopy, Proctosigmoidoscopy and Prostate-Specific Antigen (PSA) 0% 0% 0% SPECIALTY FACILITIES SERVICES

3 Inpatient Skilled Nursing Facility & Rehabilitation Services 11 - including semiprivate room and board, operating room, intensive care units, physician and assistant physician services, general nursing care, extended hospital care, rehabilitation, hospice care, pre-testing, anesthesiology, radiology, medications, injections, oxygen, blood and blood plasma. Skilled Nursing limit of 100 days Outpatient Surgery 11 & Some Procedures - including physician and assistant physician services, general nursing care, facility charges, pretesting, anesthesiology, radiology, medications, injections, oxygen, blood and blood plasma. Cardiac Rehabilitation, Chemotherapy, Radiation, Dialysis, Hemodialysis, Infusion Therapy - including necessary supplies. 50% 6 Respiratory Therapy 11 - including necessary supplies. Physical, Occupational & Speech Therapy 11 - including necessary supplies. Combined limit of 60 visits Applied Behavior Analysis (ABA) Therapy 11 - including necessary supplies. Limit of 60 days Pathology Mammography, Colonoscopy, Sigmoidoscopy, Proctosigmoidoscopy and Prostate-Specific Antigen (PSA) 0% 0% 0% FAMILY PLANNING Family Planning, Counseling & Medical Devices 5 Contraception Methods & Counseling 5 No Charge No Charge No Charge Infertility & In-Vitro Fertilization - $10,000 annual limit with combination medical services and medications (through Rx plan). 50% 6 Vasectomy - does not include reversals. 13, 16 PREGNANCY AND MATERNITY CARE

4 Prenatal & Postnatal Office Visits & Delivery - all necessary inpatient hospital services for normal delivery, cesarean section, professional fees and complications of pregnancy. Midwife services preformed under the direct supervision of a participating Obstetrician. 50% 6 MENTAL HEALTH AND CHEMICAL DEPENDENCY Institutional & Professional Inpatient Care (Alcohol, Substance Abuse & Behavioral Health) 11 - includes residential treatment, ancillaries and detox. Institutional & Professional Outpatient Care (Alcohol, Substance Abuse & Behavioral Health)- including intensive outpatient therapy and partial hospitalization. Half way housing is not covered. 0% 0% 50% 6 HOME HEALTH CARE Home Visits - by a physician, nurse, physical therapist, speech therapist or respiratory therapist for a single illness or injury. Home Healthcare limit of 100 visits 50% 6 Home IV Therapy SHORT-TERM REHABILITATIVE THERAPY - Outpatient Rehabilitative Therapy Visits 11 - by a Physical, Occupational, Speech or Respiratory therapist for a single illness or injury. Physical, Occupational and Speech Therapy combined limit of 60 visits 11, 14 BARIATRIC SERVICES 50% 6 Surgery & Visits - limited to team members and spouses. Services must be rendered at a WellStar hospital. (WellStar Facilities & Lab Only) NA (WellStar Facilities & Lab Only) NA (WellStar Facilities & Lab Only) NA 10, 11 RECONSTRUCTIVE SURGERY Inpatient & Outpatient - surgery to repair or alleviate bodily damage caused by illness or injury and reconstructive surgery incidental to a mastectomy. TRANSPLANT SERVICES 10,11 Evaluation Services - to determine candidacy for transplantation. Organ & Bone Marrow Transplants - including search fees. 50% 6 NA

5 Travel & Lodging - organ transplants only. $10,000 per transplant. TREATMENT OF THE TEETH, GUMS, JAW, JOINTS OR JAWBONE 15 ER Hospital & Professional Services - treatment for tumors, gums and injuries to sound natural teeth incurred while you are covered under the WellStar Employee Medical Plan. Oral Surgery 11 - for infection, disease and injuries of the jaw joints or jawbones, including adjacent tissues, TMJ as specifically stated and orthogenetic surgery for skeletal deformity. 50% 6 MICELANEOUS SERVICES Diabetic Supplies Durable Medical Equipment (Purchase or Rental) 11 - including hearing aids. 100% coverage for manual breast pump OR $50 credit towards an electronic breast pump for mothers of infants during their first year. Vision Hardware - lens and contacts covered following cataract surgery only. Prosthesis 10 - one each, per member per lifetime unless determined to be medically necessary due to physiological changes of the member replacement prosthetics must be preauthorized. 10, 11 Orthotics Hospice Care (including at home) - a practitioner must certify member as terminally ill with a life expectancy of 6 months or less. Chiropractic - Preauthorization required for dependents under 13 years old. Limit 20 visits Wigs - in cases of cancer, alopecia, diabetes related hairloss, and any other disease that may result in the need for a wig. 50% 6 PRECRIPTION COVERAGE - Subject to Annual Deductible WellStar Pharmacy Network Select Preventive Rx No Charge No Charge No Charge Generic 10% ($125 max. per Rx) 10% ($125 max. per Rx) 40% ($175 max. per Rx) after Brand Formulary Deductible

6 Brand Non-Formulary 30% ($150 max. per Rx) 30% ($150 max. per Rx) 60% ($200 max. per Rx) after Deductible Retail Generic 30% 30% Brand Formulary Brand Non-Formulary 50% 50% 60% Mail Order Generic Brand Formulary Brand Non-Formulary 0% Specialty Specialty 11 10% ($150 max. per Rx) 10% ($150 max. per Rx) 10% ($150 max. per Rx) 1 Open enrollee employer contribution to an opened HSA will be available in full 1/1/2016. New hires and status changes prorated employer contribution to an opened HSA will be available in the month which coverage is effective. Members have until 4/17/2017 to open their accounts and receive the 2016 WellStar employer contribution. 2 HRA option is only for team members not eligible for an HSA based on IRS eligibility rules. Open enrollees employer contributon to the HRA will be available in full 1/1/2016. New hire and status changes prorated employer contribution to the HRA will be available on the first day coverage is effective. 3 The deductible and coinsurance are aggregate. For deductible this means that the entire deductible must be met before coinsurance is applied for any covered individual family member. For coinsurance this means that the entire coinsurance maximun must be satisfied before the plan pays 100% for any covered individual family member. 4 In-network and out-of-network are separate. 5 For a list of specific covered services refer to the 2015 Covered Preventive Service List. Preventive services are defined by the Affordable Care Act (ACA) and include all US Preventive Service Task Force A & B Recommendations, CDC Immunization Schedules and preventive care/screenings per recommendation by the Health Resources and Services Administration. 6 Since there are no contractual arrangements with OON providers or facilities, they can charge any fee for their services. WellStar's medical plan administrator processes claims for OON providers and facilities based on industry standard OON rates (125% Medicare rates). You will be responsible for a deductible, coinsurance and any charges over the OON rate. 7 OON preventive care services limited to routine exams, well child care and immunizations. 8 Only one well-visit will be paid 100%. Female members must choose to have all preventive services done with either an OBGYN or PCP - not both; otherwise, there will be a charge for one of the visits. 9 No referral required to see a specialist. 10 Medical necessity or medical emergency only. 11 Precertification/Preauthorization of services may be required in order for benefits to be payable. 12 All visit/day limits are combined In and Out-of-Network unless otherwise noted. 13 Claims processing is withheld by physician offices until birth. 14 Available to team members and 15 Treatment must begin within 90 days of injury to be covered by the plan; 16 Home births are not a covered benefit under the Plan. spouses 18 and older. Not available treatment must be completed within 12 months after the dental injury to be to dependents. covered by the plan. Initial extraction, replacement or other dental services of sound natural teeth due to injury. Benefits will be paid only for expenses incurred for the least expensive service. 17 Out-of-pocket maximum has a $6,850 embedded individual limit.