Health Plan Changes

1.   Co-pays, Deductible, and Co-Insurance Limit Changes

• Office Visit Co-pay             $20
• Deductible                        $200 individual / $400 family
• Co-Insurance                   *90% paid by plan;  10% paid by employee
• Co-Insurance Limit             $1,000 individual / $2,000 family
• Emergency Room Co-pay     $50
• Lifetime Maximum               $3,000,000
  

*For most expenses. See the health plan chart for details.

The following is a brief description of each change.  For more details regarding plan coverage levels please view the 2009 PPO Coverage Chart Highlights.

Office Visit Co-pay:  The Office Visit Co-pay is charged to the employee for all office visits, including but not limited to office visits for family physicians, pediatricians, specialists, osteopathic manipulation, physical therapy, speech therapy, mental health counseling, and etc.  Most physicians require the $20 co-pay be paid at the time of the office visit.  The Office Visit Co-pay must be paid regardless of whether an employee or family member has satisfied the annual deductible or co-insurance limit.

Deductible:  The deductible is the dollar amount the employee is responsible for paying before the insurance plan will begin to pay for health care expenses.  For the PPO plan, the Tier 1 deductible is $200 for an individual and $400 for a family.  The employee is responsible for paying the first $200 (or $400) of health care expenses in a year.  Once health care expenses reach the $200 (or $400) deductible level, the health plan will begin to pay expenses via the co-insurance.

Co-Insurance:  After the deductible level has been reached, the health plan will pay a portion of health care expenses, with the employee paying the rest.  This is called co-insurance.  For the PPO plan, the Tier 1 co-insurance ratio is 90% paid by the health plan and 10% paid by the employee.

Co-Insurance Limit:  The co-insurance limit is the amount the employee must pay in co-insurance before the insurance plan will begin to pay for all health care expenses.  For the PPO plan, the Tier 1 co-insurance limit is $1,000 for an individual and $2,000 for a family.  For the PPO plan, the employee co-insurance is 10% for most expenses.  After the deductible is met, employees will pay 10% of expenses until the 10% paid throughout the year reaches the $1,000 (or $2,000) co-insurance limit.  After the co-insurance limit is met, the health plan will pay 100% of charges for most health care expenses.

The following are not subject to the deductible and co-insurance limit:

• Office Visits (co-pay is required)
• Prescription Drugs (co-pay is required)
• Preventive Care examinations, procedures, vaccines, and etc.
• Items with specific benefit limits, such as TMJ, Hearing benefits, and etc.

Emergency Room co-pay:  The emergency room co-pay will be charged to the employee for all emergency room visits, unless the employee is admitted to a hospital for a period of 24 hours or more.  The employee may also be charged the deductible and co-insurance for any care received during the emergency room visit, including but not limited to facility charges and charges for diagnostic procedures such as x-ray, MRI, lab tests, and etc.

Lifetime Maximum:  The lifetime maximum is the maximum amount the health plan will pay for health care expenses per family member covered by the health plan.    Unless otherwise specified in the health plan certificate, the plan will pay for up to $3 million in health care expenses per lifetime per family members.  This is one of the 12 improvements to the health plan that will be implemented July 1, 2009.

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