HomeMy WebLinkAboutProfessional Services Agreement - Gibson Insurance - Medical Service and Prescription Services for Employees through Anthem BCBSY
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Your Summary of Benefits anthem. = W.
City of South Bend - PPO Plan
Blue Access@ (PPO)
Effective January 1, 2018
Deductible Sin le/Fami€
$1,0001$3,000
$2,0001$6,000
Out -of -Pocket Limit Sin le/Famil
$4,0001$8,000
$7,5001$16,500
Physician Rome and Office Services (PCPISCP)
$301$60
40%
Primary Care Physician (PCP)l
Specialty Care Physician (SCP)
Including Office Surgeries and allergy serum:
o allergy injections (PCP and SCP)
$5
40%
o allergy testing
20%
40%
o MRAs, MRIs, PETS, C-Scans, Nuclear
20%
40%
Cardiology Imaging Studies,
non -maternity related Ultrasounds, and
pharmaceutical products
Preventive Care Services
Services include but are not limited to:
Routine Exams, Mammograms, Pelvic Exams, Pap
testing, PSA tests, Immunizations', Annual diabetic eye
exam, Vision and Hearing screenings
o Physician Home and Office Visits (PCPISCP)
NCS
40%
o Other Outpatient Services @
NCS
40%
Hospital/Alternative Care Facility_
Emergency and Urgent Care
Emergency Room Services
$200120%
$200120%
o facil€tylother covered services
(copayment waived if admitted)
Urgent Care Center Services
$75
40%
o MRAs, MRls, PETS, C-Scans, Nuclear
20%
40%
Cardiology Imaging Studies,
non -maternity related Ultrasounds, and
pharmaceutical products
o Allergy injections
$5
40%
o Allergy testing
20%
40%
Inpatient and Outpatient Professional Services
20%- -
40%
Include, but are not limited to:
o Medical Care visits (1 per day), Intensive
Medical Care, Concurrent Care, Consultations,
Surgery and administration of general
anesthesia and Newborn exams
Blue 8.0 — --
Anthem Blue Cross and Blue Shield Is the Irado name of Anthem Insurance Companies, Ina Independent licen sea
of the Blue Goss and Blua Shfekf Association. ®ANTHEM Is regishrodirademark of Anthem Insane
Companies, Inc, The Me Cross and Bhre Shiekl names and symholsate registered marks of the Blue Cross and
City of South Bend BA PPO Nallonal PormAoc- Naboat Blue ShfeN Association,
Your Summary of Benefits
Inpatient Facility Services (Network/Non-Network
20%
40%
combined) Unlimited days except for:
a 60 days Network/Non-Network combined
for physical medicine/rehab (limit includes
Day Rehabilitation Therapy Services on an
outpatient basis)
0 90 da s for skilled nursing facility _
Outpatient Surgery HospitallAlternative Care Facility
20%
40%
0 Surgery and administration of general anesthesia
Other Outpatient Services (including but not limited to):
20%
40%
o Non Surgical Outpatient Services
For example: MRIs, C-Scans,
Chemotherapy, Ultrasounds and
other diagnostic outpatient services.
o Home Care Services
(Network/Non-Network combined)
90 visits (excludes IV Therapy)
o Durable Medical Equipment and Orthotics
o Prosthetic Devices
a Prosthetic Limbs
o Physical Medicine Therapy Day
Rehabilitation programs
o Hospice Care
NCS
NCS
o Ambulance Services
20%
20%
Outpatient Therapy Services
(Combined Network & Non -Network limits apply)
o Physician Home and Office Visits (PCPISCP)
$301$60
40%
o Other Outpatient Services @ Hospital/Alternative
20%
40%
Care Facility
Limits apply to:
a Physical therapy: 60 visits
a Occupational therapy: 60 visits
o Manipulation therapy: 12 visits
o Speech therapy: 40 visits
o Cardiac Rehabilitation: Unlimited
o Pulmonary Rehabilitation: Unlimited
Accidental Dental: $3,000 limit per occurrence
CopaymentslCoinsurance
40%
(Network and Non -network combined)
based on setting where
covered services are
received
Your Summary of Benefits
Behavioral Health Services
Mental Illness and Substance Abuser:
40%
o Inpatient Facility Services
20%
o Inpatient Professional Services
20%
o Physician Home and Office Visits (PCPISCP)
$30$30
o Other Outpatient Services, Outpatient Facility
20%
@ Hospital/Alternative Care Facility,
Outpatient Professional
Human Organ and Tissue Transplants3
NCS
50%
o Acquisition and transplant procedures,
harvest and storage
Prescription Drug Options:
Anthem National Drug list
Network Tier structure equals 11213
(and 4, if applicable)
Tier 1: 20%
50%, min $604
o Network Retail Pharmacies:
Tier 2: 30%
(30-day supply)
Tier 3: 40%
Includes diabetic test strip
All Tiers: $250 maximum per
prescription
o Home Delivery Service:
Tier 1: 20%
Not covered
(90-day supply)
Tier 2: 30%
Includes diabetic test strip
Tier 3: 40%
All Tiers: $750 maximum per
prescription
$2,6001$5,200
$5,2001$10,400
o Calendar Year Out of Pocket Maximum:
Member may be responsible for additional cost when not
selecting the available generic drug.
Medicare Rx • Wrap
Lifetime Maximum
Medical
Unlimited
Unlimited
Surgical Treatment of Morbid Obesity
Not covered
Not covered
notes:
o All medical and prescription drug deductibles, copsyments and coinsurance apply toward the out-of-pocket maximum (excluding Non -Network
Human Organ and Tissue Transplant (HOTT) Services)
o Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance, including 0%. However, the deductible does not apply
to Emergency Room Services where a copayment and coinsurance applies and may not apply to some Behavioral Health services where
coinsurance applies.
o Dependent Age: to end of the month which the child attains age 26
0 Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OBIGYNs and Geriatrics or any other
Network Provider as allowed by the plan.
o When allergy injections are rendered with a Physicians Home and Office Visit, only the Office Visit cost share applies. When the Office Visit cost
share is a %coinsurance, deductible and coinsurance apply to allergy Injections.
Your Summary of Benefits
o NCS (No Cost Share) means no deductiblelcopaymenticoinsurance up to the maximum allowable amount.
o PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics,
obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan.
o SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
o Certain diabetic and asthmatic supplies have no deductiblelcopaymenUcoinsurance up to the maximum allowable amount at network pharmacies
except diabetic test strips,
a Benefit period = calendar year
o Prosthetic limbs are unlimited and do not apply to the Plan Lifetime Maximum.
o Mammograms (Diagnostic) are no copaymenUcoinsurance in Network office and outpatient facility settings.
o Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity.
o Preventive Care Services that meet the requirements of federal and state law, Including certain screenings, immunizations and physician
visits are covered.
o Private Duty Nursing -- limited to 82 vlsilslCalendar Year and 164 visitsliifetime.
o Elective abortions not covered unless otherwise noted in your Certificate of Coverage
o Live Health Online (LHO) is covered at the PCP costshare
f These covered services are not subject to the deductibielwpaymenl if you have a fiat dollar copayment and if rendered without an office visit.
2 We encourage you to review the Schedule of Benefits for limitations.
3 Kidney and Cornea are treated the same as any other illness and subject to the medical benefits.
4 Rx non -network diabeticlasthmatic supplies not covered except diabetic test strips.
Precertiftcation:
Members are encouraged to always obtain prior approval when using non -network providers. Precertification will help the member know if the services are considered not
medically necessary.
Pre-existing Exclusion Period: none
This summary of benefits has been updated to comply with federal and stale requirements, including applicable provisions of the recently enacted federal health care reform
laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor
and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
This benefit overview is for illustrative purposes and some content may be pendfng Indiana Department of Insurance approval.
This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and
Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.
By signing this Summary of Benefits, I agree to the benefits for the product selected as of the effective date indicated.
Authorized group signature (if applicable)
v --YD ( Ur
Date
I ladsrktin4 signature (if applicable)
Date
Your Summary of Benefits
City of South Bend — HRA Plan
Lumenos. Health Reimbursement Accounts
Effective January 1, 2018
.em. D®®
(W
B1ucCross BlueShield e
Employer Health Reimbursement Account
Contribution:
Single: $600 Family., $1,000
Deductible (Embedded)
Single: $2,500
Single: $5,000
The single deductible does apply to family coverage.
Family: $5,000
Family: $10,000
Employee Bridge Amount*
Single: $2,000
Famii : $4,000
Out -of -Pocket Limit
Single: $5,000
Single: $10,000
Family: $10,000
family: $20,000
Physician Home and Office Services
20%
50%
o Including Office Surgeries, allergy serum,
__ allergy injections and allergy testing
Preventive Care Services
NCS
50%
o Routine medical exams, Mammograms, Pelvic
Exams, Pap testing, PSA tests, Immunizations,
Annual diabetic eye exam, Hearing screenings
and Vision screenings which are limited to
Screening tests (i.e. Snellen eye chart) and
Ocular Photo screening
Emergency and Urgent Care
o Emergency Room Services Q Hospital
20%
20%
(facilitylother covered services)
(copayment waived if admitted)
o Urgent Care Center Services
20%
50%
Inpatient and Outpatient Professional Services
20%
50%
Include but are not limited to:
o Medical Care visits (1 per day), Intensive
Medical Care, Concurrent Care, Consultations,
Surgery and administration of general
anesthesia and Newborn exams
Inpatient Facility Services (Network/Non-Network
20%
50%
combined) Unlimited days except for:
0 60 days for physical medicine/rehab
(limit includes Day Rehabilitation Therapy
Services on an outpatient basis)
0 100 days for skilled nursing facility
Blue 8.0
Outpatient Surgery Hospital/Alternative Care Facility
20%�
500
o Surgery and administration of
general anesthesia
Anthem Blue Cross and Blue Shield N the bade name of Abihem insursno Companies, far, Independent
Ifcansee of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered kadamarkof Antham
Insuranoo Companies, Inc. The Brae Cross and Blue Shield names and symbols amtegistered marks of the Was
Oily of South Bend 8.0 LHRA SOB National Form.docKM National Class and Bkto Shield Association.
Your Summary of Benefits
Other Outpatient Services
20%
50%
including but not limited to:
o Non Surgical Outpatient Services
For example: MRIs, C-Scans,
Chemotherapy, Ultrasounds and
other diagnostic outpatient services.
o Home Care Services 90 visits
(excludes IV Therapy) (Network/Non-network
combined)
o Durable Medical Equipment, Orthotics
and Prosthetics
o Physical Medicine Therapy Day
Rehabilitation programs
o Hospice Care
20%
20%
o Ambulance Services
20%
20%
Accidental Dental Services $3,000 per accident
20%
50%
(Network and Non -network combined
Outpatient Therapy Services
(Combined Network & Non -Network limits apply)
o Physician Home and Office Visits
20%
50%
o Other Outpatient Services @ Hospital/Alternative
20%
50%
Care Facility
Limits apply to:
o Cardiac Rehabilitation: Unlimited
o Pulmonary Rehabilitation: Unlimited
o Physical therapy: 60 visits
o Occupational therapy: 60 visits
o Manipulation therapy: 12 visits
_ o_ Speech therapy:40 visits
Behavioral Health Services:
Benefits provided in
50°/0
Mental Illness and Substance Abuse'
accordance with Federal
o Inpatient Facility Services
Mental Health Parity
o Physician Home and Office Visits
o Other Outpatient Services @ Hospital/Alternative
Care Facility
Human Organ and Tissue Transplants
o Acquisition and transplant procedures,
20%
50%
harvest and storage.
Your Summary of Benefits
Prescription Drugs: Anthem National Drug List
o Network Retail Pharmacies: 20% 50%2
(30-day supply)
Includes diabetic test strip
o Home Delivery Service: 20% Not covered
(90-day supply)
Includes diabetic test strip
- Specialty medications are limited up to a 30 day supply
regardless of whether they are retail or mail service
- Member may be responsible for additional cost when
not selecting the available generic drug
Medicare Rx • Wrap
Notes:
o All medical and drug cost shares, deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding Nan -Network
Human Organ and Tissue Transplant (HOTT) Services.
o Deduclible(s) apply to covered services listed with a percentage (%) coinsurance, including 0%.
o Deductible applies to all prescription drug expenses for Rx plans except HRA with copay plans. Once the deductible is met the appropriate
copaymentl coinsurance applies. Copaymentslcolnsurance accumulate to the Medical OOP max. Once the Medical OOP max is met, no
additional cost share appl€es.
o Once the family deductible is satisfied by either one member or all members collectively, then the additional percentage coinsurance will be
required before the family out-of-pocket is satisfied. does not apply to embedded deductible plans.
0 Network and Non -network Deductible, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward
each other.
0 Dependent Age: to end of the month which the child attains age 26
0 0% means no coinsurance up to the maximum allowable amount. However, when choosing a Nan -network provider, the member is responsible
for any balance due after the plan payment.
0 Benefit period = calendar year
0 The maximum allowable H R A rollover contribution amount will be either three times your employer health account contribution or unlimited.
o For employers that select calendar year benefits and have an effective date other than January t, the Employees H R A Employer Contribution
will be pro rated based upon the number of months enrolled in the plan.
0 Behavioral Health Services; Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity.
o Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits
are covered.
0 No Cost Share (NCS): No deductiblelcopaymentleoinsurance up to the maximum allowable amount.
0 Private Duty Nursing — limited to 82 visitslCalendar Year and 164 visitsllifelime
o Wigs: limit f (one) maximum for wigs due to cancer diagnosis per benefit
o Elective abortions not covered unless otherwise noted in your Certificate of Coverage
o Live Health Online (LHO) is covered at the PCP costshare
i We encourage you to refer to the Schedule of Benefits for limllatiens.
2 Rx non -network disbelidasthmatic supplies not covered except diabetic test strips.
4 Meets Indiana state mandated effective 7tV08.
;"41h Tier per script 30 day supply.
'Bridge is not an insurance term and does not appear in the Certificate, HRA funds can be used for covered services under the benefit plan. Bridge amounts may be reduced
if Incentives are earned end by Contribution Rollover amounts in subsequent years, Employer must fund in order to be considered a Health Reimbursement Account.
Employer must continue to fund for the entire year at the HRA level indicated.
Precertiffcation:
Members are encouraged to always obtain prior approval when using non -network providers. Precertificafion will help the member know if the services are considered not
medically necessary.
Pre-existing Exclusion Period: None
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform
laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor
and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
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