Medicare Retirees - County Of Sonoma New Medical Plan Options Comparison Chart for 2008/2009 (With Consumer Driven Health Plan)

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Everett Phillips
5 years ago
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1 DEDUCTIBLE $1,000 individual $3,000 family $500 individual $1,500 family None None HRA AMOUNT $500 individual (does not apply towards Out of Pocket Maximum) $1,500 family (does not apply towards Out of Pocket Maximum) DEDUCTIBLE GAP $500 individual $1,500 family DEPENDENT ELIGIBILITY Legal spouse or domestic Legal spouse or domestic partner Legal spouse or domestic partner Legal spouse or domestic partner partner and unmarried and unmarried dependent children and unmarried dependent children and unmarried dependent dependent children are are eligible if you are eligible are eligible if you are eligible children are eligible if you are Dependent Age Limit: eligible if you are eligible eligible Non-Student up to 19 up to 19 Full Time Student up to 23 up to 23 Disabled LIFETIME MAXIMUM PER INDIVIDUAL $3,000,000 $3,000,000 Unlimited Unlimited Page 1

2 OUT-OF-POCKET MAXIMUM (covered expenses, including deductible, apply) Per Individual/Year Per Family/Year $4,000 $8,000 $5,000 $10,000 Unlimited $1,500 $3,000 SERVICE AREA Nationwide Online provider listing at Nationwide Online provider listing at Statewide No coverage in Alpine, Amador, Butte, Glenn, Humboldt, Lake, Mariposa, Mendocino, Napa and Sutter Counties Statewide Live within a geographical area within a 30-mile radius of any Kaiser Permanente Medical Facility CARE OUTSIDE SERVICE AREA co-insurance Only if you cannot access the PPO network because your permanent residence is more than 30 miles from a PPO primary care physician co-insurance Only if you cannot access the PPO network because your permanent residence is more than 30 miles from a PPO primary care physician Outpatient: Covered after $50 co-pay, waived if hospitalized Inpatient: Covered if plan notified within 24 hours of admission Outpatient: Covered after $50 co-pay, waived if hospitalized Inpatient: Covered if medically necessary; contact Kaiser immediately if admitted to a non-kaiser facility ACUPUNCTURE Physician referral required; intractable pain only Physician referral required; intractable pain only Emergency Care: Covered if meets plan's definition of emergency Not covered Emergency Care: Covered if meets plan s definition of emergency Must be medically necessary and prescribed by a plan physician Page 2

3 CHIROPRACTIC SERVICES 12-visits per year maximum; Covered if Medicare approved treatment Not covered EMERGENCY (Emergency ambulance services paid at ) (Emergency ambulance services paid at ) $50 co-pay (No charge if admitted to hospital) $50 co-pay (No charge if admitted to hospital) HOSPITAL & PHYSICIAN SERVICES Pre-authorization required for inpatient Pre-authorization required for inpatient $150 per admission co-pay + $250 per admission co-pay + if directed by a plan physician if directed by a plan physician MATERNITY & PREGNANCY CARE Services cover subscriber, spouse or domestic partner Services cover subscriber, spouse or domestic partner $5 co-pay Page 3

4 INPATIENT Max days/year: 20 days Max days/lifetime: 10 days Max days/lifetime: 190 days (Combined with inpatient substance abuse) Max days/year: 45 days OUTPATIENT Max visits/year: 24 visits (Provider must be MFT or LCSW; Marriage counseling excluded) Max visits/year: 24 visits (Provider must be MFT or LCSW; Marriage counseling excluded) - 50% after 10 visits - 50% after 10 visits for individual therapy $5 co-pay for group therapy SUBSTANCE ABUSE INPATIENT Max days/year: 20 days Max: None Max days/lifetime: 190 days (Combined with inpatient mental health) Hospitalization for detox only SUBSTANCE ABUSE OUTPATIENT Max visits/year: 24 visits Max lifetime: $1,000/individual for individual therapy $5 co-pay for group therapy Page 4

5 OFFICE VISITS Specialist visits authorized by primary care physician only $30 co-pay () co-insurance OPTICAL Not Covered Not Covered $75 allowance toward price of eyeglass lenses, frame or contact lenses every 24 months $150 allowance toward price of eyeglass lenses, frame or contact lenses every 24 months per eye exam per eye exam PHYSICAL THERAPY Short term treatment only Medically necessary treatment only PRESCRIPTION DRUGS Supply Mail Order Generic Brand Name Formulary Non-Formulary 34-days or 100-unit doses 3 months supply/1 co-pay $10 $20 $45 34-days or 100-unit doses 3 months supply/1 co-pay $10 $20 $45 30-days 3 months supply/2 co-pays $5 $15 $ days $5 $10 n/a Page 5

6 PREVENTIVE CARE Adult Routine Care (Male & Female - ages 20 & older) Max: $75 per Individual/year 100% 50% 50% PREVENTIVE CARE Well Baby to Age 2 Routine physical exams: 8 visits, Immunizations given in accordance with American Pediatric Guidelines 100% Routine physical exams: 8 visits, Immunizations given in accordance with American Pediatric Guidelines Not covered PREVENTIVE CARE Women 18 & Older Annual routine pelvic exam, pap smear, breast exam Annual routine pelvic exam, pap smear, breast exam 100% X-RAY & LAB SERVICES when authorized by primary care physician Page 6

EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan

2018 EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan Summary Table of Benefits Select Medicare Supplement Plan PLAN REIMBURSEMENT METHOD DEDUCTIBLE - Individual Medicare