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Your Summary of Benefits <br />City of South Bend — HRA Plan <br />Lumenos Health Reimbursement Accounts <br />Effective January, 1.. 2019 <br />Employer Health Reimbursement Account <br />Contribution: <br />Single: $500 Family: $1,000 <br />Deductible (Embedded) <br />Single: $2,500 <br />The single deductible does apply to family covera_11111ge <br />.. . <br />Family: $5,000 <br />Employee Bridge Amount* <br />Single: $2,000 <br />........... _-.. <br />Family: $4,000 <br />— <br />Out -of -Pocket Limit <br />Single: $5,000 <br />Family $10 000 <br />Physician Home and Office Services <br />20% <br />o Including Office Surgeries, allergy serum, <br />allergy injections and allergy testing <br />Preventive Care Services <br />NCS <br />o Routine medical exams, Mammograms, Pelvic <br />Exams, Pap testing, PSA tests, Immunizations, <br />Annual diabetic eye exam, Hearing screenings <br />and Vision screenings which are limited to <br />Screening tests (i.e. Snellen eye chart) and <br />Ocular Photo screening <br />Emergency and Urgent Care <br />o Emergency Room Services @ Hospital 20% <br />(facility/other covered services) <br />(copayment waived if admitted) <br />o Urgent Care Center Services 20% <br />Inpatient and Outpatient Professional Services 20% <br />Include but are not limited to: <br />o Medical Care visits (1 per day), Intensive <br />Medical Care, Concurrent Care, Consultations, <br />Surgery and administration of general <br />anesthesia and Newborn exams <br />Inpatient Facility Services (Network/Non-Network 20% <br />combined) Unlimited days except for: <br />0 60 days for physical medicine/rehab <br />(limit includes Day Rehabilitation Therapy <br />Services on an outpatient basis) <br />0 100 days for skilled nursing facility <br />Blue 11.0 <br />An e;, <br />B1ueCross BlueShield m <br />Single: $5,000 <br />Family: $10,000 <br />Single: $10,000 <br />Family $20 000 <br />50% <br />50% <br />20% <br />50% <br />50% <br />50% <br />Outpatient Surgery Hospital/Alternative Care Facility 20% 50% <br />o Surgery and administration of <br />_ general anesthesia <br />Anftm Blue Cumes and MOM M01 Be the Mode nAnis of An07em 9newH'a wo CoamsptaMa%, Inc, lode,pamlebut <br />tioensee. aup dto fNPWe Cows wullNot'u SMIa1d As�ax'd'vNtwr., � Ak�kf Hk'MX hn e aagpltdwead tiawlamomlu' al AnMhwnu <br />tnsurwtie Wavain1mi Inc Th.0@ue Cress and Ob. Shl@W mmtee vd symlrploereratitatored ma to of Nis Blue <br />rm. <br />City or South Band 11.0 LHRA SOB National FodooA- National Cm and Sbe �hdp�NAasoatdtodr. <br />