SCHEDULE OF BENEFITS
(Effective 01/01/08)
MONTEREY BAY PUBLIC EMPLOYEES TRUST
Comparison of Medical Plan Benefits
The following is a brief summary of the medical benefits provided through the Trust. Exact benefits are paid according to the terms, exclusions and conditions of the applicable contract or plan booklet.
IMPORTANT NOTE: For contract providers, the plan pays the percentage shown of covered
charges of a negotiated rate. For
non-contract providers, the plan pays the percentage shown of usual, customary
and reasonable (UCR) covered charges.
|
|
EPO Plan |
Managed Care Plan |
Medical Choice Plan |
|
Choice of Physicians See Provider directories at
school sites and district office. |
Exclusive Providers Only; must choose a primary care physician; all
referrals must go through PCP, see provider directory. No non-network coverage except for
emergency room treatment for life-threatening illnesses and injuries. |
Choice of contract or
non-contract physicians. Contract
physician services are reimbursed at a higher level than benefits paid for
services rendered by a non-contract physician. Members
must contact a primary care physician for medical care in order to receive
maximum benefits. Please refer to
Physician Benefit below. |
Choice
of contract or non-contract physicians. Contract physician services are
reimbursed at a higher level than benefits paid for services rendered by a
non-contract physician. |
|
Dependent Coverage |
Spouse and unmarried
children to age 19, or 25 if full-time student or financially dependent. |
Spouse and unmarried
children to age 19, or 25 if full-time student or financially dependent. |
Spouse and unmarried
children to age 19, or 25 if full-time student or financially dependent. |
|
Non-duplication of benefits
& coordination of benefits |
Normal coordination of
benefits applies to this plan. |
Normal coordination of
benefits applies to this plan. Please see note (2) for an exception. |
Normal
coordination of benefits applies to this plan. |
|
Claim Forms |
Claim
forms are not required when contract providers are used. |
Claim forms are not
required when contract providers are used. |
Claim
forms are not required when contract providers are used. |
|
Deductibles/ Coinsurance |
$100 deductible per
individual per calendar year; $200 deductible per family. For contract providers, the annual
out-of-pocket limit (which includes the deductible and covered coinsurance is
$500 per individual, $1,000 per family. No coverage for non-network providers
except for emergency room treatment for life-threatening illnesses or
injuries. In emergency non-network
situations, amounts in excess of UCR are not included in the out-of-pocket
limit. |
$150 deductible per
individual, per calendar year; maximum of 2 deductibles per family. After the calendar year deductible has been
met, the Plan pays the percentage of covered charges as shown below. When the annual out-of-pocket limit (which
includes the deductible and covered coinsurance but not amounts in excess of
UCR) has been reached, the plan will pay 100% of covered charges incurred
during the remainder of the calendar year.
For contract providers, the annual out-of-pocket limit is $750 per
individual. For non-contract
providers, the annual out-of-pocket limit is $2,500 per person. The $1,000.00 hospital
admission copayment for Monterey Bay area non primary contracting and
non-contracting hospitals does not apply to the out-of-pocket limit. Expenses incurred for
Mental/Nervous and Substance Abuse disorders do not apply to the
out-of-pocket maximum. |
$250
deductible per individual, per calendar year; maximum of $500 per
family. After the calendar year
deductible has been met, the plan pays the percentage of covered charges as
shown below. When the annual
out-of-pocket limit (which includes the deductible and covered coinsurance
but not amounts in excess of UCR) has been reached, the Plan will pay 100% of
covered charges incurred during the remainder of the calendar year. The maximum annual out-of-pocket limit is
$3,000 per member and $6,000 per family. The maximum
annual out-of-pocket limit applies only if services are received from a
contract provider, or if you live and receive covered services outside of a
contract provider area. The $1,000.00 copayment for Monterey Bay
area non-primary contracting and non-contracting hospitals does not apply to
the out-of-pocket limit. |
|
Physician: Surgery Office Hospital Home Pre-authorization
Second Surgical Opinion |
The plan pays 80% of contracted rates after
deductible is satisfied. (The plan
does not pay anything for non-contract providers.) Pre-authorization must be obtained prior to a scheduled surgery and certain medical
procedures. Failure to obtain
pre-authorization will result in an additional 25% copayment of eligible
expenses. No second surgical opinion
is required under this Plan. |
Contract Providers: The
plan pays 80% for
surgeon/anesthetist; 70% for
hospital visits and home visits. You
pay only $15(1) for office visits. Referral
to a specialist must be made by a Primary Care Physician, (PCP) and approved
by Network Manager. PCP referral
is not required for ophthalmology, OB/GYN or Podiatry. Non- contract- the
plan pays 60% of UCR fees. Pre-authorization must be obtained prior to
a scheduled surgery and certain medical procedures. You must obtain a second surgical opinion
for certain procedures; failure to obtain a required 2nd surgical opinion
will result in an additional 20% copayment on eligible expenses. |
Contract
Providers: The plan pays 70% for
surgery. Co-payment of $10(1) hospital visits and office
visits. Non-contract Providers: The
plan pays 50% of UCR covered
charges for surgery, hospital and office visits. Pre-authorization must be obtained prior to
a scheduled surgery and certain medical procedures. You must obtain a second surgical opinion
for certain procedures; failure to obtain a required 2nd opinion
will result in an additional 25% copayment on eligible expenses. |
|
Anesthesia |
The plan pays 80% of contracted rates or 80% of UCR covered charges at contracted facilities after
deductible is satisfied. |
Contract Providers: 80%.
Non-Contract Providers: 80%
of UCR covered charges. |
Contract
Providers: 70%. Non-contract
Providers: 50% of UCR covered
charges. |
|
Hospital Services |
Hospital services must be received at one of the following Monterey Bay Area Contract Hospitals ( payable
at 100%): Natividad Medical Center G.L. Mee Memorial Hazel Hawkins Watsonville Community Dominican Santa Cruz. Must have authorization from Pacific Health Alliance Out of area referral
network hospitals (by referral only): The plan pays 80% of
contracted rates after the deductible is
satisfied. Pre-authorization must be
obtained prior to any hospital admission (except in life-threatening
emergencies). Failure to comply will
result in an additional 25% copayment |
Hospitals of Distinction and Centers of Excellence charges are paid at 100%.
Primary Network Hospitals
are paid at 90%. Out of Area Network Hospitals
are paid at 80%. Non-Network Providers are paid at 60%. Area
Non-Network Hospitals have a $1,000.00 per admission deductible (except
for life threatening emergencies). The
$1,000.00 copayment does not apply to the out-of-pocket limit. Hospitals of Distinction The following is a listing of the Hospitals of Distinction (charges
paid at $100%) Natividad Medical Center G.L.
Mee Memorial Hospital Hazel
Hawkins, Watsonville
Community Dominican
Santa Cruz Centers of Excellence Charges
paid @ 100% Stanford
University Hospital UCSF
Medical Center Hospital Sequoia
Hospital O’Conner
Hospital (2) See important note concerning hospital Coordination of Benefits on
the last page. Pre-authorization must be
obtained prior to any hospital admission (except in life-threatening
emergencies). Failure to comply will
result in an additional $500 hospital deductible. |
Hospitals of Distinction are paid at 100%.
Network Hospitals charges
are paid at 80%. Non-Network Hospital reimbursement is limited
to 60% of UCR covered charges.
Non-primary network hospitals and non-network hospitals have a $1,000.00 per admission
copayment, (except for life threatening emergencies). The copayment does not apply to the annual
out-of-pocket limit. Hospitals of Distinction Charges payable at 100% Natividad Medical Center G.L.Mee Memorial Hospital Hazel
Hawkins Watsonville
Community Dominican Santa Cruz. Centers of Excellence Charges payable at 100% Stanford
Hospital UCSF
Medical Center Hospital Sequoia
Hospital O’Conner
Hospital (2) See important note concerning hospital Coordination of Benefits on
the last page. Pre-authorization
must be obtained prior to any hospital admission (except in life-threatening
emergencies). Failure to comply will
result in an additional 10% hospital copayment. Failure to obtain a second opinion for
certain hospital admissions will result in an additional 25% copayment. |
|
Skilled Nursing Facility |
Contract Providers Only, The plan pays 80% of contracted rates after
deductible is satisfied. There is a
maximum of 100 days each calendar year.
Pre-certification required; otherwise penalties will apply. |
The plan will pay 80% of covered charges up to 365 days
per lifetime |
The
plan will pay 70% for the first 10
days and 60% the next 90
days. There is a maximum of 100 days
each calendar year. Pre-certification
required; otherwise penalties will apply. |
|
X-Ray and Lab |
Contract Providers Only, The plan pays 80% of contracted rates after
deductible is satisfied. Lab One Services covered at
100% |
The plan will pay 80% of covered charges for services
received in a contract facility (1); 60% of UCR for covered
services by a non-contract provider. Lab
One Services covered at 100%. |
The plan will pay 70% of covered charges for services received in a contract
facility; 50% of UCR for covered
at non-contract provider. Lab One Services covered at 100% |
|
Maternity |
Covered as any other
illness. |
Covered as any other
illness. |
Covered as any other
illness. |
|
Interrupted Pregnancy |
Covered as any other
illness. |
Covered as any other
illness. |
Covered as any other
illness. |
|
Tubal Ligation |
Covered as any other
illness. |
Covered as any other
illness. |
Covered as any other
illness. |
|
Vasectomy |
Covered as any other
illness. |
Covered as any other
illness. |
Covered as any other
illness. |
|
Emergency Room or Urgent
Care Center |
The plan pays 80% of contracted rates or 80% of UCR for non-contract
facilities after deductible is satisfied.
A $50.00 co-payment applies to all emergency room
billings. Emergency Room Continued 100% of Covered Charges payable at Natividad
under this Plan) for emergency room sevices. |
The plan will pay 80% of covered charges in a contract
facility and 60% of UCR covered
charges in a non-contract facility. A $50.00
co-payment applies to all emergency room billings. Emergency Room Continued 100% OF COVERED CHARGES PAYABLE AT NATIVIDAD MEDICAL CENTER FOR
EMERGENCY ROOM SERVICES. |
The
plan will pay 70% of covered
charges in a contract facility and 50%
of UCR charges in a non-contract facility.
A $50.00 co-payment applies to all emergency room billings. Emergency Room Continued 100% OF COVERED CHARGES
PAYABLE AT NATIVIDAD MEDICAL CENTER FOR EMERGENCY ROOM SERVICES. |
|
Wellness Well Baby |
Contract Providers Only, The plan pays 90% of contracted rates after
deductible is satisfied for dependent children through age 17. Includes only exams and immunizations as
recommended by the American Pediatric Association's guidelines. |
After
a $15 office visit copayment, the
plan will pay 100% of covered charges by contract physicians for dependent
children through age 17. Includes only
exams and immunizations as recommended by the American Pediatric Association's
guidelines. Charges by non-contract
physicians are not covered. |
The
plan will pay 100% of covered
charges by contract physicians; 60%
for non-contract physicians. Includes
exams and immunizations as recommended by the American Pediatric
Association's guidelines |
|
Immunizations |
Contract Providers Only, The plan pays 80% of contracted rates after
deductible is satisfied |
Not
covered, except as indicated in Well Baby Care Benefit and for annual flu
shots under a program offered by the Trust.
No coverage for flu shots received from an entity other than as
arranged by the Trust. |
The
plan will pay 100% of covered
charges for immunization received in a contract facility; 60% from a non-contract
facility. |
|
Physical
Exams |
Contract Providers Only, The
plan pays 90% of contracted rates
after deductible is satisfied. |
The
plan will pay 100% of covered charges for mammograms and up to $200 per exam
for routine physicals (see page 38) when performed by contract providers (1). Physicals and mammograms are covered
through contract providers only. |
The
plan will pay 100% of covered
charges for gynecological exams and routine health exams, received in a
contract facility; 60% from a non-contract facility. Services provided on an age-based schedule.
(See page 38) |
|
Allergy Testing and Administration
of Allergy
Serum |
Contract Providers Only, The plan pays 80% of contracted rates (1). |
The plan will pay 80% of covered charges rendered by a
contract provider and 70% of UCR
covered charges rendered by a non- contract provider. No charge to you for administration of
allergy serum. |
The plan will pay 70% off covered charges for testing/treatment by a contract
provider; 50% from a non-contract
provider. The plan pays up to $400 per
calendar year for antigens. |
|
Home Health Care |
Contract Providers Only, The plan pays 80% of contracted rates after
deductible is satisfied, with a $6,000 calendar year maximum. |
The plan pays 80% of covered charges up to 120 days
per disability. A home health care treatment plan must have prior approval by
your physician. |
The plan will pay 70% of covered charges from a contract provider, with a $6,000
calendar year maximum; 50% from a
non-contract provider, with a $6,000 calendar year maximum. Pre-certification required for more than 10
visits per calendar year; otherwise, penalties will apply. |
|
Hospice Care |
The plan pays 80% of covered charges after
deductible is satisfied up to a $7,500 lifetime maximum; 2 visits bereavement
counseling. Pre-certification required
for all hospice care; otherwise, penalties will apply. |
The plan will pay 80% of covered charges up to $15,000
lifetime maximum. Pre-certification required for all hospice care; otherwise,
penalties will apply. |
The
plan will pay 70% of covered
charges up to a $7,500 lifetime maximum; 2 visits bereavement
counseling. Pre-certification required
for all hospice care; otherwise, penalties will apply. |
|
Mental Health Mental Health (Continued) |
Benefits are provided
through Claremont Behavioral Health. First 5 visits at no charge to you when a Claremont
Behavioral Health provider used, then the plan pays 80% of covered charges for visits
6-20 and 50% of covered charges
for visits 21-52. Maximum of 52 visits
per calendar year. If a non-CBH
provider is used, the plan pays 80%
of UCR covered charges for the first 15 visits and 50% of UCR covered charges for the next 32 visits; maximum of 47
visits per calendar year. Inpatient benefits are
provided through CBH only. Inpatient: 30 days per calendar year.
Lifetime Max: 90 Days .No inpatient benefits payable at non- contract
facilities. |
Benefits are provided
through Claremont Behavioral Health . First 5 visits at no charge to you when a
United Behavioral Health provider used, then the plan pays 80% of covered charges for visits
6-20 and 50% of covered charges
for visits 21-52. Maximum of 52 visits
per calendar year. If a non-CBH
provider is used, the plan pays 80%
of UCR covered charges for the first 15 visits and 50% of UCR covered charges for the next 32 visits; maximum of 47
visits per calendar year. Inpatient
benefits are provided through CBH only. Inpatient: 30 days per
calendar year. Lifetime Max: 90 Days.
No inpatient benefits payable at non- contract facilities. |
Benefits are provided through Claremont Behavioral Health. First 5 visits at no charge to you when a Claremont Behavioral Health provider used, then plan pays |