Health Reimbursement Account and Health Savings Account
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- Esther Corey Palmer
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1 Plan Design & Benefits 1 EFFECTIVE JANUARY 1, 2011 Health Reimbursement Account and Health Savings Account Employee: $1,000 Employee + spouse: $1,500 Employee + children: $1,500 Family: $2,000 Non- Employee: $1,000 Employee + spouse: $1,500 Employee + children: $1,500 Family: $2,000 Plan Deductible per plan year Employee: $1000 Employee + spouse: $1,500 Employee + children: $1,500 Family: $2,000 Employee: $1000 Employee + spouse: $1,500 Employee + children: $1,500 Family: $2,000 Deductible Carryover None, not applicable None, not applicable Co-insurance Maximum $1,500 per person $2,500 per family $3,000 per person $5,000 per family Lifetime Maximum Physician Services (except Mental Health/Alc/Drug) Office Visits to PCP Specialists (office visits) Unlimited except where otherwise indicated. Unlimited except where otherwise indicated.
2 Plan Design & Benefits 2 Non- 100% Preventive Care Maximum None Routine Physicals/Immunizations Children: 6 exams in first 12 months of life, 2 exams in the 13 th 24 th months of life, 1 exam every 12 months of life thereafter up to age 18, 1 exam every 24 months for children age 18 and older. Includes coverage for immunizations. Adults: 1 exam every 12 months age 18 and older. Includes coverage for immunizations. 100% not subject to or the fund. Hearing Aid Ded/coins- $3000 per year max Ded/Coins- $3000 per year max Routine Ob/Gyn Exam (1 routine exam per plan year; including 1 pap smear and related fees) 100% not subject to or fund. Related routine fees testing, covered at 100% when performed in conjunction with routine care Routine Vision Routine Mammography One mammogram per plan year for covered females age 35 and above. visit, ded waived. No routine vision under medical plan. See separate vendor for vision exam coverage. 100% not subject to or fund, related fees, testing covered at 100% when performed in conjunction with routine care visit. No routine vision under medical plan, see separate vendor for vision exam coverage
3 Plan Design & Benefits 3 Non- Routine Annual Digital Rectal Exam (DRE) and Prostate Antigen Test (PSA) for covered males age 35 and over Routine Hearing Exam 1 x 24 months Surgery Physician In-Hospital Services Allergy Testing Allergy Injections Hospital Services Inpatient coverage Outpatient coverage 100% not subject to or fund Related fees, testing covered at 100% when performed in conjunction with routine care visit. 100% not subject to or fund. Related fees, testing covered at 100% when performed in conjunction with routine care visit. Emergency Room 20% after 20% after Non-emergency use of the Emergency Room (routine care) Urgent Care Non urgent use of Urgent care (routine care) Diagnostic X-ray & Laboratory Convalescent Facility (Maximum benefit of 90 days per plan year. Confinement must start within 14 days of hospital discharge. Hospital stay must be at least 3 days.) Not covered 20% after Not covered Not covered 20% after Not covered for Non urgent use
4 Plan Design & Benefits 4 Non- Home Health Care 1 (Includes visiting nursing care and private duty nursing care. Maximum benefit of 120 visits per plan year.) Hospice Care - Inpatient coverage Outpatient coverage Short-Term Rehabilitation (Limited to 60 visits per plan year. Coverage s included are as follows: Physical therapy Occupational therapy Speech therapy Spinal Manipulations- 20 visit max, per plan year Ambulance Durable Medical Equipment 1 Each visiting nurse care or private duty nursing care shift of 4 hours or less counts as one home health visit. Each such shift of over 4 hours and up to 8 hours counts as two home health care visits.
5 Plan Design & Benefits 5 Non- Mouth, Jaws and Teeth (oral surgery procedures, whether medical or dental in nature) TMJ Coverage for TMJ services including appliances & splints up to $5000 life time maximum on all TMJ care. Contraceptive Drugs and Devices Not obtainable at a pharmacy -- also includes coverage for contraceptive associated office visits.
6 Plan Design & Benefits 6 Prescription Drug Under the HRA/HSA Balance plans, your must first be satisfied before the prescription drug plan co-pay applies NOTE: The is waived and co-pays will apply for chronic and/or preventive medicines as authorized by the Aetna plan formularies for HSA and HRA. 3 Tier Tier 1 - Generic Drugs Tier 2 - Formulary Brand Name Drugs Tier 3 - Non-Formulary Drugs No Mandatory Generic Member is responsible to pay the applicable copay only after your has been met. Step Therapy per formulary guidelines Pre-cert required per formulary guidelines Additional coverages: Contraceptive drugs and devices obtainable from a pharmacy Diabetic Supplies 3 Tier Retail 3 Tier Mail Order 100% after combined Medical/RX plan and after a $10 copay for generic drugs, $30 co-pay for formulary brand-name drugs, $90 co-pay for non-formulary drugs up to a 30 day supply at participating pharmacies. 100% after combined Medical/RX plan and after $20 copay for generic drugs, $60 co-pay for formulary brand-name drugs, and $180 co-pay for nonformulary brand-name drugs up to a day supply at participating pharmacies.. Non- (Out-Of-Network) 100% after combined Medical/RX plan and after a $10 copay for generic drugs, $30 co-pay for formulary brand-name drugs, $90 co-pay for non-formulary drugs up to a 30 day supply at participating pharmacies. Not Applicable Non-Preferred
7 Plan Design & Benefits 7 Benefits (Out-Of-Network) Maternity (Coverage includes voluntary sterilization and voluntary abortion.) Basic Infertility Services Diagnosis and treatment of the underlying medical condition Comprehensive Services including ART Lifetime max $5000 Mental Health Services Inpatient coverage Outpatient coverage Alcohol/Drug Abuse Inpatient coverage Outpatient coverage Inpatient precertification and concurrent review Penalty to employee for failure to precertify (Applies to inpatient hospital, treatment facility, convalescent facility, home health, hospice & private duty nursing care.) Payable as any other covered expense Payable as any other expense Provider initiated None Payable as any other covered expense Payable as any other expense 40% after the applicable 40% after the applicable 40% after the applicable 40% after the applicable Member initiated $400 penalty. Applies per occurrence
8 Plan Design & Benefits 8 Non- Outpatient Procedures and Services Ambulatory Procedure Review Provider initiated Member initiated Penalty to employee for failure to precertify Applies to Allergy Immunotherapy, Bunionectomy, Carpal Tunnel Surgery, Colonoscopy, Coronary Angiography, CT Scan spine, Dilation & Curettage (D&C), Hemorrhoidectomy, Knee Arthroscopy, Laparoscopy (Pelvic), MRI knee, MRI spine, Septoplasty, Tympanostomy Tube, UGI Endoscopy None $400 penalty. Applies per occurrence. Claim Submission Provider initiated Member initiated
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Optional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and
Optional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived 30% after deductible
PLAN FEATURES NON- Deductible (per calendar year) $500 Individual $750 Individual $1,500 Family $2,250 Family All covered expenses, excluding prescription drugs, accumulate toward both the preferred and
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$10 copay. $10 copay. $10 copay $5 copay $10 copay $5 copay. $10 copay. No charge. No charge. No charge
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