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Overview of Medical Benefits - Medical Choice Plan Effective 04/01/2014

Explore the detailed breakdown of the Monterey Bay Public Employees Trust Medical Choice Plan effective 04/01/2014, including deductibles, coverage percentages, lifetime limits, specialist access, and hospital services. Learn about the plan's benefits for various medical services.

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Overview of Medical Benefits - Medical Choice Plan Effective 04/01/2014

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  1. Overview of Medical Benefits - Medical Choice Plan Effective 04/01/2014

  2. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Annual Deductible • $750.00 per person; maximum of $2,250.00 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 for network providers has been met, the Plan will pay 100% of covered charges for that calendar year. There is no out-of-pocket maximum for non-network providers.

  3. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Annual Out-of-Pocket Limit • In-P.H.A.-network: $3,000.00 per individual, $9,000.00 per family. • Out-of-P.H.A.-network: None.

  4. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan None • Lifetime Maximum • Lifetime Maximum: No Lifetime maximum per person.

  5. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Life Insurance • Life Insurance: $25,000.00 term life insurance for active participants only.

  6. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Physician (Surgery, Home, Office, Hospital) • In-P.H.A.-network: 70% of contracted rates for surgeon/anesthetist. 70% for hospital visits and home visits. $20.00 co-payment for office visits (deductible does not apply). • Out-of-P.H.A.-network: 50% of U.C.R. charges.

  7. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Access to Specialists • In-P.H.A.-network: 70% of contracted rates for specialists. (Direct access to specialists allowed.) • Out-of-P.H.A.-network: 50% of U.C.R. charges. (Direct access to specialists allowed.)

  8. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Anesthesia • In-P.H.A.-network: 70% of contracted rates. • Out-of-P.H.A.-network: 50% of U.C.R. charges.

  9. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice 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.

  10. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice 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 facilities for specialized procedures or treatments).

  11. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Hospital Services(slide 3 of 4) • Network Hospitals: 80% of contracted rates. • Non-Network Hospitals- 60% of U.C.R. covered expenses.

  12. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Hospital Services(slide 4 of 4) • Non-Network Hospitals: 60% of U.C.R. charges

  13. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Skilled Nursing Facility • In-P.H.A.-network: 70% of contracted rates for the first ten (10) days and 60% of contracted rates for the next ninety (90) days - annual maximum of one-hundred (100) days. Pre-certification required; otherwise, penalties applied. • Out-of-P.H.A.-network: None.

  14. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • X-Ray and Laboratory Services • In-P.H.A.-network: 70% of contracted rates. • Out-of-P.H.A.-network: 50% of U.C.R. charges.

  15. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice 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.

  16. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice 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.

  17. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Emergency Room • In-P.H.A.-network: 70% 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: 50% of U.C.R. charges after a $200.00 co-payment.

  18. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Wellness / Well Baby • In-P.H.A.-network: 100% of contracted rates. Well Baby Care is listed under the Affordable Care Act. There is no deductible or coinsurance. • Out-of-P.H.A.-network: No coverage.

  19. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Immunizations • In-P.H.A.-network: 100% of contracted rates as listed by the Affordable Care Act. There is no deductible or coinsurance. • Out-of-P.H.A.-network: No coverage.

  20. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Physical Exams and Mammograms • In-P.H.A.-network: 100% of contracted rates for routine gynecological exams and routine health exams as listed under the Affordable Care Act. There is no deductible or coinsurance. • Out-of-P.H.A.-network: No coverage.

  21. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Allergy Testing / Administration of Serum • In-P.H.A.-network: 70% of contracted rates for testing/treatment with allowance of up to $400.00 per year for allergy serum. • Out-of-P.H.A.-network: 50% of U.C.R. charges for testing/ treatment with allowance of up to $400.00 per year for allergy serum.

  22. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Home Health Care • In-P.H.A.-network: 70% of contracted rates up to $6,000.00 annual maximum. Pre-certification required for more than ten (10) visits. • Out-of-P.H.A.-network: 50% of U.C.R. charges up to $6,000.00 annual maximum. Pre-certification required for more than ten (10) visits.

  23. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Hospice Care • In-P.H.A.-network: 70% of contracted rates up to $7,500.00 lifetime maximum. Two (2) visits for bereavement counseling. Pre-certification required; otherwise, penalties apply. • Out-of-P.H.A.-network: None.

  24. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Durable Medical Equipment / Prosthetics • In-P.H.A.-network: 70% of contracted rates. • Out-of-P.H.A.-network: 50% of U.C.R. charges.

  25. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Hearing Services / Hearing Aids • In-P.H.A.-network: 80% of contracted rates. Hearing Aid benefit up to $1,000.00 annual maximum provided once every thirty-six (36) months. • Out-of-P.H.A.-network: 60% of U.C.R. charges. Hearing Aid benefit up to $1,000.00 annual maximum provided once every thirty-six (36) months.

  26. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Acupuncture • In-P.H.A.-network: 70% of contracted rates to a maximum allowance of $50.00 per visit for up to fifteen (15) visits per calendar year. • Out-of-P.H.A.-network: 70% of U.C.R. charges to a maximum allowance of $50.00 per visit for up to fifteen (15) visits per calendar year.

  27. Monterey Bay Public Employees Trust Overview of Medical BenefitsMedical Choice Plan • Chiropractic Care • In-C.H.P.C.-network: $10.00 co-payment per visit up to forty-five (45) annual visits per calendar year. • Out-of-C.H.P.C.-network: None.

  28. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Prescription Drugs – Retail Store (slide 1 of 3) • Generic: $10.00 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.

  29. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice 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.

  30. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Prescription Drugs - Mail Order(slide 2 of 2) • Generic: $20.00 co-payment for up to a ninety (90) day supply; • Formulary Brand: $60.00 co-payment for up a to ninety (90) day supply; • Non-Formulary Brand: $100.00 co-payment for up to a ninety (90) day supply.

  31. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Rates for active employees(effective 4/01/2014) • Single: $879.58 per month. • Two-Party: $1,285.26 per month. • Family: $1,837.91 per month.

  32. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Rates for retirees under 65(effective 4/01/2014) • Single: $879.58 per month. • Two-Party: $1,285.25 per month. • Family: $1,837.91 per month.

  33. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Rates for retirees 65 and older(effective 4/01/2014) • Single: $456.86 per month. • Two-Party: $693.31 per month. • Family: $853.75 per month.

  34. Monterey Bay Public Employees TrustOverview of Medical BenefitsMedical Choice Plan • Disclaimer • This presentation provides only a general overview of the Medical benefits for the Medical Choice Plan; • For complete information, consult your copy of theSummary Plan Description or callHealth Services & Benefit Administrators (1-831-757-1711 or 1-888-742-3380).

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