SCHEDULE OF BENEFITS

(Effective 04-01-2016)

 

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

 

Medical Choice Plan

 

Managed Care Plan

(closed to new participants effective

April 1, 2016

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.

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.

Dependent Coverage

Spouses and domestic partners; children up to age 26.

 

 

 

Spouses and domestic partners; children up to age 26. 

 

Spouses and domestic partners:  children up to age 26. 

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.  Please see note (2) for an exception.

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

$400 deductible per individual per calendar year; $1,200 deductible per family.  For contract providers, the annual out-of-pocket limit is $1,400 per individual, $4,200 per family.   The deductible is included in out-of-pocket amount.

 

 

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.

$750.00 deductible per individual, per calendar year; maximum of $2,250 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 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 $3,750 per member and $11,250 per family.  The maximum annual out-of-pocket limit applies only to network providers and for services that are received from a contract provider.  The deductible is included in out-of–pocket amount. 

$800.00 deductible per individual, per calendar year; maximum of 3 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 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 $3,150.00 per individual and $9,450 per family.  For non-contact providers, the annual out-of-pocket limit is $20,000.00 per person.  The deductible is included in out-of-pocket amount.

 

Physician:

  Surgery

  Office

  Hospital

  Home

 

 

 

 

 

 

 

 

 

 

 

 

 

Pre-authorization

 

Effective 4/01/2014, after a $20.00 copayment is subtracted, the plan will pay 100% of a network provider’s fee for an office visit.  You pay $20.00.

 

For surgery & hospital and home

visits, 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.

 

Contract Providers: The plan pays 70% for surgery.  Co-payment of $20 (1) hospital visits and office visits.  Non-contract Providers: The plan pays 50% of UCR covered charges for surgery, hospital visits and office visits.

 

 

 

 

 

 

 

 

 

 

 

Pre-authorization must be obtained prior to a scheduled surgery and certain medical procedures.

Contract Providers: The plan pays 80% for surgeon/anesthetist; 70% for hospital visits and home visits.  You pay only $25 (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.

Anesthesia

The plan pays 80% of contracted rates or 80% of UCR covered charges at contracted facilities after deductible is satisfied.

 

Contract Providers: 70%. Non-contract Providers: 50% of UCR covered charges.

 

Contract Providers: 80%.  Non-Contract Providers: 80% of UCR covered charges.

Hospital Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maximum Allowable

Charge (MAC) Procedures

 

Effective April 1, 2013 the Plan will pay 100% of facility charges for certain procedures at certain

Premier Providers.  If the procedure is performed at a non-Premier Provider, the plan will pay its usual

benefits up to the Premier Provider maximum.

Hospital services must be received at one of the following

Monterey Bay Area Contract Hospitals ( payable at 90% (1) until the out-of pocket maximum is met):

 

Natividad Medical Center & G.L.Mee Memorial & Hazel Hawkins & Salinas Valley Memorial Hospital & Watsonville Community Hospital & Community Hospital of the Monterey Peninsula.

 

Out of area referral network and hospitals (by referral and pre-approval 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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attached is a listing of approved Premier Providers for the Maximum Allowable Charge (MAC) procedures.  The listing includes the dollar maximum benefit payment for each procedure.

 

The following is a listing of MAC

Procedures:

 

Gastric surgery and other weight

Loss surgeries.

 

Hip replacement surgery.

 

Knee replacement surgery.

 

Colonoscopies.

 

Sleep Apnea studies.

 

Arthroscopic Surgeries

Hospitals of Distinction are paid at 90% (1).  Network Hospitals charges are paid at 80%.   Non-Network Hospital reimbursement is limited to 60% of UCR covered charges.

 

The following is a listing of the

Hospitals of Distinction (charges payable at 90% until the out-of pocket maximum is met and then 100%):

 

Natividad Medical Center & G.L. Mee Memorial Hospital & Hazel Hawkins & Salinas Valley Memorial Hospital &Watsonville Community Hospital & Community Hospital of the Monterey Peninsula.

 

 

Centers of Excellence - (1) for inpatient stays: Centers of  Excellence include Stanford Hospital (Inpatient: 100% reimbursement; Outpatient: 90%; Other services: 70%), UCSF Hospital (90% reimbursement) and other specialty hospitals designated by the network manager on a case by case basis.

 

 

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.

 

(2) See important note concerning

hospital Coordination of Benefits on the last page.

 

 

 

 

 

 

 

 

 

 

Attached is a listing of approved Premier Providers for the Maximum

Allowable Charge (MAC) procedures.  The listing includes the dollar maximum benefit payment for each procedure.

 

The following is a listing of MAC

Procedures:

 

Gastric surgery and other weight loss surgeries.

 

Hip replacement surgery.

 

Knee replacement surgery

 

Colonoscopies.

 

Sleep Apnea studies.

 

Arthroscopic Surgery

Charges from Hospitals of Distinction are paid at 90%(1).  Out of Area Network Hospitals are paid at 80%. Non-

Network Providers are paid at 60%.

 

 

The following is a listing of the Hospitals of Distinction (charges paid at 90% until the out-of pocket maximum is reached and then 100%):

 

Natividad Medical Center & G.L. Mee Memorial Hospital & Hazel Hawkins, Salinas Valley Memorial Hospital & Watsonville Community &

Community Hospital of the Monterey

Peninsula.

 

 

Centers of Excellence- (1) for inpatient stays: Centers of Excellence include Stanford University Hospital (Inpatient: 100% reimbursement; Outpatient: 90%: other services: 80%), UCSF Hospital (90% reimbursement) and other specialty hospitals as designated by the network manager on a case by case basis.

 

 

(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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attached is a listing of approved Premier Providers for the Maximum Allowable Charge (MAC) procedures.  The listing includes the dollar maximum benefit payment for each procedure.

 

The following is a listing of MAC Procedures:

 

Gastric surgery and other weight loss

surgeries.

 

Hip replacement surgery.

 

Knee replacement surgery.

 

Colonoscopies.

 

Sleep Apnea Studies.

 

Arthroscopic Surgeries

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 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.

The plan will pay 80% of covered charges up to 365 days per lifetime

X-Ray and Lab

(all MRI’s and cat-scans require prior

authorization)

Contract Providers Only,

The plan pays 80% of contracted rates after deductible is satisfied.

 

The plan will pay 70% of covered charges for services received in a contract facility; 50% of UCR for covered services by a non-contract provider. 

 

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.

 

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.

Ambulance

      80% after deductible

        80% after the deductible

              80% after deductible

Emergency Room

The plan pays 80% of contracted rates or 80% of UCR for non-contract facilities after deductible is satisfied.   A $200.00 co-payment

applies to all emergency room billings.

 

90% of Covered Charges payable at HOSPITALS of distinction.  A $200.00 co-payment applies to all emergency room billings.

The plan will pay 70% of contracted rates or 70% of UCR for non-contract facilities after deductible satisfied.  A $200.00 co-payment applies to all emergency room billings.

 

 

90% OF COVERED CHARGES PAYABLE AT HOSPITALS OF DISTINCTION.  A $200 CO-PAYMENT APPLIES TO ALL EMERGENCY ROOM BILLINGS

 

 

The plan will pay 80% of covered charges in a contract facility and 80% of UCR covered charges in a non-contract facility.  A $200.00 co-payment applies to all emergency room billings.

 

 

90% OF COVERED CHARGES PAYABLE AT HOSPITALS OF DISTINCTION. A $200.00 CO-PAYMENT APPLIES TO ALL EMERGENCY ROOM BILLINGS.

Urgent Care Center

$20 copayment

$20 copayment

$25 copayment

Wellness

 Well Baby

Contract Providers Only,

The plan pays 100% for well baby care services and immunizations covered under the Affordable Care Act.* There is no deductible or coinsurance. 

 Non-network provider services are not covered.

 

Contracted Network Provider Only:

The Plan pays 100% for well baby care services and immunizations covered under the Affordable Care Act.* There is no deductible or coinsurance

Non-network provider services are not covered.

 

 

 

Contracted Network Providers Only:

The plan pays 100% for well baby care services and immunizations covered under the Affordable Care Act.* There is no deductible or coinsurance. 

 

Non-network provider services are not covered.

Immunizations

Contract Providers Only:

Immunizations listed under the Affordable Care Act* are covered at 100% with no deductible or co-insurance.  Also, coverage for influenza vaccinations offered by the Trust in conjunction with the health faire.

Non –network provider services are not covered

 Contract Network Providers Only:

Immunizations listed under the Affordable Care Act* are covered at 100% with no deductible or co-insurance.  Also, coverage for influenza vaccinations offered by the trust in conjunction with the Health Faire. 

Non-network provider services are not covered.

Contract Network Providers Only:
Immunizations listed under the Affordable

 Care Act* are covered at 100% with no deductible and co-insurance.  Also, coverage for influenza vaccinations offered by the trust in conjunction with the Health Faire.

 

Non-network provider services are not covered.

Physical Exams

Contract Providers Only,

The plan will pay 100% of fees for

routine physical examinations and

screenings as listed under the Affordable Care Act.*  

 

Non-network provider services are not covered

Contract Network Providers Only;

The plan will pay 100% of fees for

routine physical exams and screenings as listed under the Affordable Care Act* with no deductible or coinsurance.

Non-network provider services are not covered.

Contract Network Providers Only:

The plan will pay 100% of fees for routine

physical exams and screenings as listed under the Affordable Care Act * with no deductible or co-insurance.

 

 Non-network provider services are not covered.

Allergy Testing and

Administration of

Allergy Serum

Contract Providers Only,

The plan pays 80% of contracted rates (1).

The plan will pay 70% of 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.

The plan will pay 80% of covered charges rendered by a contract provider and 60% of UCR covered charges rendered by a non- contract provider.  No charge to you for administration of allergy serum.

Home Health Care

Contract Providers Only,

The plan pays 80% of contracted rates after deductible is satisfied.

The plan will pay 70% of covered charges from a contract provider, 50% from a non-contract provider.  Pre-certification required for more than 10 visits per calendar year; otherwise, penalties will apply.

 

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.

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 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.

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.

Mental Health -

Treated as any other

illness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Benefits are provided through Claremont Behavioral Services.  First 5 visits at no charge to you when a Claremont provider is used.

Subsequent visits are paid under

the normal office benefit structure

of the plan.  Under the EPO

Plan, participants must use network

providers and authorization by

Claremont is required.

 

Inpatient benefits are provided through Claremont Behavioral Services only. There

are no frequency limitations or

lifetime maximums, but authorization by Claremont is required.

 

Benefits are provided through Claremont Behavioral Services.  First 5 visits at no charge to you when a Claremont provider is used. Subsequent visits are paid under the normal office visit provisions of the Plan.  In network and out of network copayment and coinsurance provisions apply to all mental health services.

 

Inpatient benefits are provided through Claremont Behavioral Services only.  There are no frequency limitations or lifetime maximums, but authorization by Claremont is required.

 

Benefit schedules for network and

non- network inpatient care apply

 

Benefits are provided through Claremont Behavioral Services.  First 5 visits at no charge to you when a Claremont provider is

used.  Subsequent visits are paid under the

normal office visit provisions of the plan.

In network and out of network copayment

and coinsurance provisions apply to all mental health services.

 

 

 

Inpatient benefits are provided through Claremont Behavioral Services only. There are no frequency limitations or lifetime maximums, but authorization by Claremont is required.

 

Benefit schedules for network and non-

network inpatient care apply.

 

Substance Abuse Treatment

Benefits provided through Claremont Behavioral Services only.  The plan will pay 100% of covered charges for detoxification in a contract hospital.  There is a maximum of 2 programs per lifetime.  No benefits payable at non-contract facilities

 

 

 

Benefits provided through Claremont Behavioral Services only.  The plan will pay 100% of covered charges for detoxification in a contract hospital.  There is a maximum of 2 programs per lifetime.  No benefits payable at non-contract facilities.

 

 

Benefits provided through Claremont Behavioral Services only.  The plan will pay 100% of covered charges for detoxification in a contract hospital.  

There is a maximum of 2 programs per lifetime.  No benefits payable at non-contract facilities.

Durable Medical

Equipment & Prosthetic Devices

Contract Providers Only,

The plan pays 80% of contracted rates after deductible is satisfied.

 

Pre-authorization is required

The plan will pay 70% of covered charges from a contract provider and 50% from a non-contract provider

 

Pre-authorization is required

 

 

The plan will pay 80% of covered charges.

 

 

 

Pre-authorization required

 

Hearing Aid Services

 Audio-Logical Exam

 

 

 Hearing Aids

 

Contract Providers Only,

The plan pays 80% of contracted rates after the deductible satisfied.

 

Not covered

80% of covered charges from a contract provider, 60% from a non-contract provider.

 

80% of covered charges to a $1,000 max.  per member, once every 36 months, from a contract provider; 60% of covered charges to $1,000 max. per member, once every 36 months, from a non-contract provider.

 

 

Covered under office visit benefit.

 

 

 

Not Covered, except when required because of surgery

Acupuncture

Not covered

70% of covered charges to a maximum allowance of $50 per visit, 15 visits per calendar year.

 

 

80% of covered charges to a maximum allowance of $50 per visit, 18 visits per calendar year.

Podiatry

Contract Providers Only,

The Plan pays 80% of contracted rates after deductible is satisfied.

 

 

The plan will pay 70% of covered charges from a contract provider and 50% from a non-contract provider

 

 

Payable under Physician Benefit.

Chiropractic Care

$10 copayment per visit (1), maximum of 45 visits per calendar year.  BENEFITS AVAILABLE ONLY THROUGH “CHIROPRACTIC HEALTH PLAN OF CALIF.” CONTRACT PROVIDERS.

 

 

$10 copayment per visit (1), maximum of 45 visits per calendar year.  BENEFITS AVAILABLE ONLY THROUGH “CHIROPRACTIC HEALTH PLAN OF CALIF.” CONTRACT PROVIDERS.

$10 copayment per visit (1), maximum of 45 visits per calendar year.  BENEFITS AVAILABLE ONLY THROUGH “CHIROPRACTIC HEALTH PLAN OF CALIF.” CONTRACT PROVIDERS.

Physical Therapy

 

The Plan pay 80% of contracted rates after deductible is satisfied. Contract Providers Only

 

 

Pre-authorization Required

The plan pays 70% of contracted rates and 50% of UCR for covered services by a non-contract provider after deductible is satisfied.

 

No Authorization Required

The plan pays 80% of contracted rates and 60% of UCR for covered services by a non-contract provider after deductible is satisfied.

 

Pre-authorization Required

 

 

 

 

 

 

 

 

 

 

 

 

Prescription Drugs

$10 co-payment per prescription for generic drugs, $30 copayment for brand name drugs, $50 copayment non-formulary, from a contract walk-in pharmacy per 30-day supply and $20 generic drugs, $60  formulary brand name and  $100  non formulary brand name per 90 day supply from the mail order program (first fill must be through a walk-in contract pharmacy). Zero co-pay on generic drugs purchased at CVS Pharmacy.

 

You may obtain a 90 day supply

at a CVS Pharmacy as an

alternative to using the mail order program. The zero co-pay on generics will apply on 90 day supplies obtained at CVS pharmacies

 

The prescription drug program has a out-of-pocket maximum of $5,200 per individual and $9,000 family for covered prescription drug coinsurances and copayments.

 

Prescriptions filled at Rite Aid and Walgreen’s are not covered

 

 

$10 copayment per prescription for generic drugs, $30 copayment for formulary brand name drugs, $50 copayment non-formulary from a contract walk-in pharmacy per 30-day supply and $20 generic, $60

Formulary brand name and $100 non-formulary brand name

per 90 day supply from the mail order program (first fill must be through a walk-in contract pharmacy). Zero co-pay for generic drugs purchased at CVS Pharmacy.

 

 You may obtain a 90 day supply at a CVS Pharmacy as an alternative to

Using the mail order program.

 

The zero co-pay on generics will apply on 90 day supplies obtain at CVS Pharmacies.

 

The prescription drug program has a out-of-pocket individual and family maximum of $1,950 for covered prescription drug coinsurances and copayments.

 

Prescriptions filled at Rite Aid and Walgreen’s are not covered.

 

$10 co-payment per prescription for generic drugs, $30 copayment for formulary brand name drugs, $50 copayment non-formulary, from a contract walk-in pharmacy per 30 day supply and $20.00 generic drugs, $60 formulary drugs and $100 non formulary drugs per 90 day supply from the mail order program (first fill must be through a walk in contract pharmacy).  Zero co-pay on generic drugs purchased at CVS Pharmacy.

 

You may obtain a 90 day supply at a CVS Pharmacy as an alternative to using the

mail order program.

 

The zero co-pay on generics will apply on

90 day supplies obtained at CVS Pharmacies.

 

The prescription drug program has a out-of-pocket maximum of $3,450 per individual and $3,750 family for covered prescription drug coinsurances and copayments.

 

 

 

 

 

Prescriptions filled at Rite Aid and Walgreen’s are not covered.

 

Lifetime Maximum

No Limit

No Limit

No Limit

 

* See Routine Physical Exam, Well Baby care and Immunization/Vaccination, etc. benefits required to be reimbursed at 100% under  the Affordable  Care Act at http://www.healthcare.gov/what-are-my-preventive-care-benefits

 

(1) Deductible waived.

 

(2) Important note:  Hospital Coordination of Benefits Under Managed Care and Medical Choice Plans –

If a member is covered as a dependent under another group health plan, inpatient hospital benefits under this plan will be paid at 50%

of covered charges, so that the benefits payable under the other plan, combined with this plan, should cover eligible hospital charges

in full.

 

Premier Provider and MAC procedure listing is attached.

 

 

Claims for services received from providers outside of the United States are covered.