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Overview of Medical Benefits - Managed Care Plan Effective 4/01/2014

Overview of Medical Benefits - Managed Care Plan Effective 4/01/2014. Monterey Bay Public Employees Trust Overview of Medical Benefits Managed Care Plan. Annual Deductible $650.00 per person; maximum of three deductibles per family.

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Overview of Medical Benefits - Managed Care Plan Effective 4/01/2014

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  1. Overview of Medical Benefits - Managed Care Plan Effective 4/01/2014

  2. Monterey Bay Public Employees TrustOverview of Medical BenefitsManaged 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.

  3. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged Care Plan • Annual Out-of-Pocket Limit • In-P.H.A.-network: $2,500.00 per individual. • Out-of-P.H.A.-network: $10,000.00 per individual.

  4. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged Care Plan NONE • Lifetime Maximum • Lifetime Maximum: Lifetime per person maximum zero.

  5. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged Care Plan Life Insurance Life Insurance: $25,000.00 term life insurance for active participants only.

  6. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  7. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.)

  8. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  9. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  10. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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 pre-approved inpatient facilities for specialized procedures/treatments).

  11. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged Care Plan • Hospital Services(slide 3 of 4) • Non-network Hospitals: 60% of U.C.R. charges.

  12. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged Care Plan • Hospital Services(slide 4 of 4) • Non-Contracting Hospitals: 60% of U.C.R. charges.

  13. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  14. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged Care Plan • X-Ray and Laboratory Services • In-P.H.A.-network: 80% of contracted rates (deductible does not apply. • Out-of-P.H.A.-network: 60% of U.C.R. covered charges.

  15. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  16. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged Care 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 Trust Overview of Medical BenefitsManaged Care Plan • Emergency Room • In-P.H.A.-network: 80% 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: 60% of U.C.R. charges, after a $200.00 co-payment.

  18. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  19. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  20. Monterey Bay Public Employees TrustOverview of Medical BenefitsManaged 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.

  21. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  22. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  23. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  24. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged Care Plan • Durable Medical Equipment / Prosthetics • In-P.H.A.-network: 80% of contracted rates. (Pre-authorization required.) • Out-of-P.H.A.-network: None.

  25. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  26. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  27. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  28. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  29. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  30. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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 CVSPharmacy Stores at same co-payments as the prescription mail order program except there is a zero co-pay for generics.

  31. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged Care Plan • Prescription Drugs - Mail Order(slide 3 of 3) • Generic: $20.00 co-payment for up to a ninety (90) day supply; • 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.

  32. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  33. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  34. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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.

  35. Monterey Bay Public Employees Trust Overview of Medical BenefitsManaged 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 theSummary Plan Description or callHealth Services & Benefit Administrators(1-831-757-1711 or 1-888-742-3380).

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