city of baltimore you are still employed and enrolled in health benefits with the city of baltimore...
TRANSCRIPT
October 2016 Revised 9/26/2016
Rajesh Gulhar, Chief, Employee Benefits Division
Mary H. Talley Director & Chief Human Capital Officer
Note: This Comparison Is To Be Used As A Guide Only. Actual Benefits Will Be Governed by The Terms and conditions of the Master Contract.
City of Baltimore 2017
Active Employee Benefits Booklet
3
Table of Contents
Section Contents Page Cover Page Table of Contents Section 1 Important Information
Important Information About 2017 Benefits 4-5 Medicare Information for Active Employees 6
Flexible Spending Account 7 Family Status Change 8
Waiver Credit 9
Alex 10
Wellness Information 11 Section 2 Premium Deductions
Weekly Medical Premium
13 Bi-Weekly Medical Premium
14
21-Pay Medical Premium 15
Prescription Premiums 16
Dental Premiums 17 Section 3 Benefits Information
Prescription Drug Co-Pay Information 19 CareFirst Select Vision Schedule of Benefits 20
Delta Dental HMO Benefits Information 21-22 Delta Dental PPO Benefits Information 23
Life Insurance Information 24
Section 4 Medical Plan Comparison
Aetna PPO 26-28
UnitedHealthcare POS 29-31 CareFirst PPN 32-36 HMO Plan Comparisons (Aetna, UnitedHealthcare, Kaiser) 37-40 Contact Information 41
4
Section 1 Important Information
5
Information About Your 2017 Benefits
Please read the information provided in this Comparison Chart
Medicare Secondary Payer
(MSP)
Mandatory Reporting
You must notify your agency about your change of address, in writing.
Administrative Notices
Duplicate Coverage
Information
If you and your spouse/partner are both a City employee/retiree, you both
cannot enroll each other or the same eligible dependents on your City medical,
dental, vision and prescription plans during any coverage period. You will be
notified to adjust duplicate coverage, if applicable.
Summary Benefits and
Coverage (SBC)
The Patient Protection and Affordable Care Act (PPACA) requires health plans
and health insurance issuers to provide a Summary of Benefits and Coverage
(SBC) to applicants and enrollees. The SBC is a concise document providing
simple and consistent information about health plan benefits and coverage. Its
purpose is to help health plan consumers better understand the coverage they
have and to help them make easy comparisons of different options when
shopping for new coverage. The City of Baltimore will post this document on its
enrollment website: www.baltimorecity.essbenefits.com under its own drop
down menu labeled Summary of Benefits and Coverage.
Enrollment Website www.baltimorecity.essbenefits.com
Under the Medicare Secondary Payer (MSP) Mandatory Reporting Provision and
the Affordable Care Act (ACA) Individual Shared Responsibility Reporting
provision, the federal law requires the mandatory collection and reporting of
social security numbers of all covered participants, including employees, retirees
and their dependents through employer group health plans. Noncompliance
may be subject to a $50 penalty imposed by the IRS under Section 6723 of the
Internal Revenue Code.
Important Medicare
Information
The City requires all its members (including you and your dependents) to enroll
in Medicare Part B at the time you become eligible for Medicare Part A. Once
enrolled in Medicare part B, you must remain enrolled in order to continue
receiving the maximum possible benefit from the City's supplemental medical
plan. The CareFirst Medicare Supplemental offered by the City, will cover only
80% of your health claims not covered by Medicare up to the maximum
Medicare Allowed Amount, you will be responsible for any balance due.
Disability Retirees as
Determined
by Social Security
When you (or spouse/child) become disabled as determined by the SSA, you
must apply for Medicare Part B through SSA at the time you become eligible for
Medicare Part A and provide Employee Benefits with your Medicare information
immediately. If you decline your Medicare Part B, you will be responsible for all
Medicare Part B (Medical) claims that would ordinarily be covered by Medicare
B. The CareFirst Medicare Supplemental offered by the City, will cover only 80%
of your health claims not covered by Medicare up to the maximum Medicare
Allowed Amount, you will be responsible for any balance due.
Change of Address
6
Information About Your 2017 Benefits
FSA plans and Waiver Credits
Reminder; the Waiver Credit, Healthcare FSA and the Dependent Care FSA plans
do not roll over, they end on December 31st each year. You must re-enroll each
year during Open Enrollment.
Aetna Open Access HMO Plan
The Open Access Aetna Select (HMO).
- PCP (Primary Care Physician) selection not required
- Referrals will no longer be required
- Nationwide network access
United Healthcare Choice
(HMO) Plan
The UnitedHealthcare Choice (HMO).
- PCP (Primary Care Physician) selection not required
- Referrals will no longer be required
- Nationwide network access
Jelly Vision - Alex is back!
JellyVision is back for the 2017 Open Enrollment period as well as Ongoing
Enrollment starting October 21, 2016. Active employees and retirees without
Medicare will have an opportunity to interact online with Alex the virtual
benefits counselor. You can find Alex on the City's health Benefits Enrollment
System under the Main Menu. Alex will help you make smarter healthcare
decisions that may save you time and money by answering a series of health
related questions.
Plan Information
ID CardsNew ID cards will be mailed to members who change medical plans, enroll in
medical and or the FSA plans during open enrollment.
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Employee Benefits Division 201 E. Baltimore Street, Suite 500, Baltimore, MD 21202
IMPORTANT MEDICARE INFORMATION
Actively Employed with the City of Baltimore (COB) At Age 65 & Older
What should I do if I am still actively employed and enrolled in health benefits with the City of Baltimore when I turn age 65?
If you are still employed and enrolled in health benefits with the City of Baltimore (COB) as an active full-time employee when you (or your spouse) turn age 65, you should contact Social Security Administration (SSA) three months before you (or your spouse) turn age 65 to enroll in Medicare Part A and Part B. However, if you decide to remain employed as an active full-time employee with COB beyond age 65 and you (and your spouse) remain enrolled in COB group health benefits, you (or your spouse) may consider delaying your enrollment in Medicare Part B through SSA without a late-enrollment penalty. Your (and spouse’s) health plan coverage will remain primary until your employment or coverage ends, whichever occurs first. Three months before and 8 months after your current employment or group health plan coverage ends with the COB, whichever happens first, you must visit your local Social Security office to enroll in Medicare Part B during the Special Enrollment Period, which runs for 8 months from the date your employment and/or group health plan coverage ends. Prior to your Special Enrollment Period, you should obtain a Request For Employment Information form from SSA to be completed by the Employee Benefits Division. If you are an employee of BCPSS, this form must be completed by the BCPSS - Office of Benefits Management. This form verifies your employment and health benefits status with the Baltimore City or BCPSS at the time your employment ends. Return the completed form to your Social Security office in order to waive the late-enrollment penalty for enrollment in Medicare Part B. Note: If you wait until after you retire (within the 8-month special enrollment period) to enroll in Medicare Part B, your Medicare Part B start date will be delayed causing a lapse in coverage and out of pocket expenses.
Who do I contact if I have any questions?
If you have any questions regarding your Baltimore City medical plan coverage, please contact our office at 410-396-5830/TTY 711 (Maryland). Baltimore City retirees should select option 2 and BCPSS retirees should select option 3, and then choose option 1 to speak to a customer service representative. If you have any questions regarding the Baltimore City Medicare Part D Rx Plan, please call 410-396-1780. If you have any questions regarding Medicare enrollment in Part A and Part B, please contact the Social Security Administration at 1-800-772-1213. If you have any questions regarding Medicare benefits, please call 1-800-633-4227.
8
Flexible Spending Accounts (FSA) The City of Baltimore gives you the opportunity to save taxes on your eligible health and dependent care expenses by participating in one or both flexible spending accounts (FSAs):
Health Care Flexible Spending Account (FSA)
Dependent Care Flexible Spending Account (FSA) Participation in both types of flexible spending accounts is completely voluntary and currently administered by, Vantagen Baker Tilly. If you choose to enroll, simply decide how much to contribute each year to one or both accounts. Contributions to your account(s) are deducted from your paycheck before federal, state* income and Social Security taxes are withheld. This reduces your taxes and saves you money. When you have an eligible expense, you submit a claim for reimbursement to the City’s FSA Administrator, Vantagen. FSA Eligibility You can use your Health Care FSA to be reimbursed for eligible health care expenses incurred by you, your spouse, your qualifying child, or your qualifying relative. You may use your Dependent Care FSA to be reimbursed for eligible dependent care expenses for your child (under age 13) or other qualifying individual. Please see the Flexible Spending Account FAQs at www.myflexdollars.com for more information. You will need to register the first time you use the site Enrolling in an FSA If you are a new hire, you may enroll in one or both of the FSAs. Your FSA participation becomes effective with your first payroll deduction, as long as you enroll online within 45 days from your date of hire. Once enrolled, you may not change your election mid-year unless you have a Qualified Life Event (QLE), such as marriage or the birth of a child. (See the “General Information” section of the City’s Benefits Guide for more information on Qualified Life Events). Each year during the annual benefits Open Enrollment period, you may choose to enroll or re-enroll in one or both of the FSAs. Your participation starts on the January 1 following your enrollment. You must re-enroll each year during Open Enrollment if you wish to participate in one or both FSAs the following plan year. Your enrollment does not automatically carry over from year to year. If you do not actively enroll in an FSA during Open Enrollment, you will not participate in that FSA for the following year. Estimating Your Expenses If you are enrolling during the annual Open Enrollment period, your election will be in force for the full plan year (January 1 – December 31). Therefore, you should estimate your eligible expenses for the full twelve months. However, if you are a new hire, you should estimate only those expenses you will incur from the effective date of your enrollment to the end of the year, December 31. Estimate carefully to avoid forfeiting any money left in these FSA accounts. For more information about the FSA plans please visit the enrollment website at https://www.baltimorecity.essbenefits.com , located under “plan Information”. To receive information on the eligible health care expenses, and dependent care expenses, please call Vantagen at 1-800-307-0230. You may also visit www.myflexdollars.com .
9
10
Waiver Credit You have the option of opting out of certain City of Baltimore health benefits and electing the waiver credit. The City of Baltimore determines which waiver credit applies to you, based on your union affiliation. The Waiver Credit amount is provided in increments over the course of the full plan year if enrolling during Open Enrollment or based on the number of pay periods left in the year for a new employee. New employees have 45 days from their date of hire to enroll online for the waiver credit. If, after waiving coverage with the City of Baltimore, you (the employee) lose coverage due to divorce, loss of employment, or the death of your spouse or other person who is the source of coverage, you may enroll in health benefits through the City within 60 days of the qualifying life event. In this case, you will relinquish the waiver payment. $2,500 Waiver Credit AFSCME Local 558, 44, and 2202 If you are represented by the AFSCME Local 558, 44, or 2202 union, you may elect the $2,500 waiver credit. To receive the waiver credit, you must enroll online within 45 days of hire or during the Open Enrollment period each year. When you make this election, you are waiving medical, dental, prescription drug, and vision coverage with the understanding that you cannot enroll in any of these plans, as the policyholder or as a dependent, through the City of Baltimore for that plan year. You must re-enroll each year. $650 Waiver Credit (waives Medical only) CUB, MAPS, and Police If you are represented by the CUB, MAPS, or Police union, you may elect the $650 waiver credit. To receive this waiver credit you must enroll online within 45 days of hire or during the Open Enrollment period each year. If you waive medical coverage, you may still elect dental, prescription drug, and vision coverage. However, you may not elect dental, prescription drug, and vision coverage as the policyholder if you are already enrolled as a dependent under the City plans for that plan year. You must re-enroll each year. $650 Waiver Credit (waives Medical and Prescription Drug) Firefighters and Fire Officers If you are a firefighter or fire officer, you may elect the $650 waiver credit. To receive this waiver credit, you must enroll online within 45 days of hire or during the Open Enrollment period each year. If you waive medical and prescription drug coverage, you may still elect dental and vision coverage. However, you may not elect dental and vision coverage as the policyholder if you are already enrolled as a dependent under the City plans for that plan year. You must re-enroll each year. Each year during the annual benefits Open Enrollment period, you may choose to enroll or re-enroll in the waiver credit. Your participation starts on the January 1 following your enrollment. You must re-enroll each year during Open Enrollment if you wish to receive the waiver credit the following plan year. Your enrollment does not automatically carry over from year to year. If you do not actively enroll in the waiver credit during Open Enrollment, you will not receive the increments for the following benefit year. For more information about the Waiver credit plans please visit the enrollment website at https://www.baltimorecity.essbenefits.com and view the Benefit Guide located under “plan Information”.
11
12
Wellness Programs for Active Employees
Wellness Programs for Active Employees
13
Section 2
Premium Deductions
Medical Premium
14
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 158.63$ 114.78$ 43.85$ Participant Only 143.47$ 114.78$ 28.69$
Participant + Child 307.89$ 222.78$ 85.11$ Participant + Child 278.48$ 222.78$ 55.70$
Participant + Spouse 354.71$ 256.65$ 98.06$ Participant + Spouse 320.82$ 256.66$ 64.16$
Participant + Family 385.01$ 278.58$ 106.43$ Participant + Family 348.23$ 278.58$ 69.65$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 140.77$ 99.15$ 41.62$ Participant Only 123.93$ 99.14$ 24.79$
Participant + Child 267.45$ 188.44$ 79.01$ Participant + Child 235.56$ 188.45$ 47.11$
Participant + Spouse 295.63$ 208.30$ 87.33$ Participant + Spouse 260.37$ 208.30$ 52.07$
Participant + Family 422.30$ 297.55$ 124.75$ Participant + Family 371.94$ 297.55$ 74.39$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 117.44$ 82.09$ 35.35$ Participant Only 102.60$ 82.08$ 20.52$
Participant + Child 253.84$ 177.80$ 76.04$ Participant + Child 222.25$ 177.80$ 44.45$
Participant + Spouse 279.94$ 196.97$ 82.97$ Participant + Spouse 246.22$ 196.98$ 49.24$
Participant + Family 388.97$ 272.65$ 116.32$ Participant + Family 340.80$ 272.64$ 68.16$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 114.35 102.92 11.43 Participant Only 101.78$ 91.60$ 10.18$
Participant + Child 217.26 195.53 21.73 Participant + Child 193.39$ 174.05$ 19.34$
Participant + Spouse 240.13 216.12 24.01 Participant + Spouse 213.75$ 192.38$ 21.37$
Participant + Family 343.04 308.74 34.30 Participant + Family 305.35$ 274.81$ 30.54$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 105.17$ 94.65$ 10.52$
Participant + Child 212.33$ 191.10$ 21.23$
Participant + Spouse 232.94$ 209.65$ 23.29$
Participant + Family 254.13$ 228.72$ 25.41$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 28.95$ 22.16$ 6.79$ Participant Only 27.70$ 22.16$ 5.54$
Participant + Child 56.20$ 43.02$ 13.18$ Participant + Child 53.77$ 43.02$ 10.75$
Participant + Spouse 64.75$ 49.56$ 15.19$ Participant + Spouse 61.95$ 49.56$ 12.39$
Participant + Family 70.27$ 53.79$ 16.48$ Participant + Family 67.24$ 53.79$ 13.45$
High Option Medical Plan Standard Option Medical Plan
2017 Weekly Medical & Rx Plan Rates for Active Employees
CareFirst Preferred Provider Network (PPN)High Option Medical Plan Standard Option Medical Plan
UnitedHealthcare Point of Service (POS)
High Option Medical Plans => High Option Rx Plan
Aetna Choice POS IIHigh Option Medical Plan Standard Option Medical Plan
UnitedHealthcare Choice (HMO) Kaiser Permanente HMOOptimum Choice HMO Plan Kaiser Permanente HMO Plan
Open Access Aetna Select (HMO) Bundled Medical & Rx Election ChartAetna HMO Plan Bundled Medical & Rx Election Chart
Rx coverage is bundled with Medical plan election, but
with a separate payroll deduction.
Standard Option Medical Plans => Standard Option Rx Plan
HMO Medical Plans => High Option Rx Plan
Express Scripts (High & Standard Options)Express Scripts High Option Rx Plan Express Scripts Standard Option Rx Plan
15
Medical Premium
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 317.26$ 229.56$ 87.70$ Participant Only 286.94$ 229.55$ 57.39$
Participant + Child 615.78$ 445.56$ 170.22$ Participant + Child 556.95$ 445.56$ 111.39$
Participant + Spouse 709.42$ 513.31$ 196.11$ Participant + Spouse 641.63$ 513.30$ 128.33$
Participant + Family 770.03$ 557.16$ 212.87$ Participant + Family 696.45$ 557.16$ 139.29$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 281.54$ 198.30$ 83.24$ Participant Only 247.87$ 198.30$ 49.57$
Participant + Child 534.90$ 376.89$ 158.01$ Participant + Child 471.11$ 376.89$ 94.22$
Participant + Spouse 591.25$ 416.58$ 174.67$ Participant + Spouse 520.73$ 416.58$ 104.15$
Participant + Family 844.61$ 595.10$ 249.51$ Participant + Family 743.88$ 595.10$ 148.78$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 234.87$ 164.16$ 70.71$ Participant Only 205.20$ 164.16$ 41.04$
Participant + Child 507.68$ 355.61$ 152.07$ Participant + Child 444.51$ 355.61$ 88.90$
Participant + Spouse 559.88$ 393.94$ 165.94$ Participant + Spouse 492.43$ 393.94$ 98.49$
Participant + Family 777.93$ 545.29$ 232.64$ Participant + Family 681.61$ 545.29$ 136.32$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 228.69 205.82 22.87 Participant Only 203.57$ 183.21$ 20.36$
Participant + Child 434.52 391.07 43.45 Participant + Child 386.78$ 348.10$ 38.68$
Participant + Spouse 480.26 432.23 48.03 Participant + Spouse 427.49$ 384.74$ 42.75$
Participant + Family 686.08 617.47 68.61 Participant + Family 610.70$ 549.63$ 61.07$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 210.34$ 189.31$ 21.03$
Participant + Child 424.65$ 382.18$ 42.47$
Participant + Spouse 465.88$ 419.29$ 46.59$
Participant + Family 508.26$ 457.44$ 50.82$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 57.91$ 44.33$ 13.58$ Participant Only 55.41$ 44.33$ 11.08$
Participant + Child 112.40$ 86.04$ 26.36$ Participant + Child 107.54$ 86.03$ 21.51$
Participant + Spouse 129.49$ 99.12$ 30.37$ Participant + Spouse 123.90$ 99.12$ 24.78$
Participant + Family 140.54$ 107.58$ 32.96$ Participant + Family 134.47$ 107.58$ 26.89$
High Option Medical Plan Standard Option Medical Plan
Express Scripts High Option Rx Plan
2017 Biweekly Medical & Rx Plan Rates for Active Employees
High Option Medical Plan Standard Option Medical Plan
CareFirst Preferred Provider Network (PPN)
UnitedHealthcare Point of Service (POS)
Aetna Choice POS IIHigh Option Medical Plan Standard Option Medical Plan
Optimum Choice HMO Plan Kaiser Permanente HMO Plan
Aetna HMO Plan Bundled Medical & Rx Election Chart
UnitedHealthcare Choice (HMO) Kaiser Permanente HMO
Open Access Aetna Select (HMO) Bundled Medical & Rx Election Chart
Express Scripts Standard Option Rx Plan
Rx coverage is bundled with Medical plan election, but
with a separate payroll deduction.
High Option Medical Plans => High Option Rx Plan
Standard Option Medical Plans => Standard Option Rx Plan
HMO Medical Plans => High Option Rx Plan
Express Scripts (High & Standard Options)
16
Medical Premium
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 392.79$ 284.21$ 108.58$ Participant Only 355.26$ 284.21$ 71.05$
Participant + Child 762.40$ 551.65$ 210.75$ Participant + Child 689.56$ 551.65$ 137.91$
Participant + Spouse 878.33$ 635.52$ 242.81$ Participant + Spouse 794.40$ 635.52$ 158.88$
Participant + Family 953.37$ 689.82$ 263.55$ Participant + Family 862.27$ 689.81$ 172.46$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 348.57$ 245.51$ 103.06$ Participant Only 306.89$ 245.51$ 61.38$
Participant + Child 662.26$ 466.63$ 195.63$ Participant + Child 583.28$ 466.62$ 116.66$
Participant + Spouse 732.03$ 515.77$ 216.26$ Participant + Spouse 644.71$ 515.77$ 128.94$
Participant + Family 1,045.70$ 736.79$ 308.91$ Participant + Family 920.99$ 736.79$ 184.20$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 290.79$ 203.25$ 87.54$ Participant Only 254.06$ 203.25$ 50.81$
Participant + Child 628.55$ 440.27$ 188.28$ Participant + Child 550.34$ 440.27$ 110.07$
Participant + Spouse 693.19$ 487.74$ 205.45$ Participant + Spouse 609.68$ 487.74$ 121.94$
Participant + Family 963.15$ 675.12$ 288.03$ Participant + Family 843.90$ 675.12$ 168.78$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 283.14 254.83 28.31 Participant Only 252.03$ 226.82$ 25.21$
Participant + Child 537.98 484.18 53.80 Participant + Child 478.87$ 430.98$ 47.89$
Participant + Spouse 594.61 535.15 59.46 Participant + Spouse 529.27$ 476.34$ 52.93$
Participant + Family 849.43 764.49 84.94 Participant + Family 756.11$ 680.50$ 75.61$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 260.42$ 234.38$ 26.04$
Participant + Child 525.76$ 473.18$ 52.58$
Participant + Spouse 576.81$ 519.13$ 57.68$
Participant + Family 629.27$ 566.34$ 62.93$
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 71.70$ 54.88$ 16.82$ Participant Only 68.60$ 54.88$ 13.72$
Participant + Child 139.16$ 106.52$ 32.64$ Participant + Child 133.15$ 106.52$ 26.63$
Participant + Spouse 160.33$ 122.72$ 37.61$ Participant + Spouse 153.40$ 122.72$ 30.68$
Participant + Family 174.01$ 133.20$ 40.81$ Participant + Family 166.49$ 133.19$ 33.30$
High Option Medical Plan Standard Option Medical Plan
2017 21-Pay Medical & Rx Plan Rates for Active Employees
CareFirst Preferred Provider Network (PPN)High Option Medical Plan Standard Option Medical Plan
UnitedHealthcare Point of Service (POS)
High Option Medical Plans => High Option Rx Plan
Aetna Choice POS IIHigh Option Medical Plan Standard Option Medical Plan
UnitedHealthcare Choice (HMO) Kaiser Permanente HMOOptimum Choice HMO Plan Kaiser Permanente HMO Plan
Open Access Aetna Select (HMO) Bundled Medical & Rx Election ChartAetna HMO Plan Bundled Medical & Rx Election Chart
Rx coverage is bundled with Medical plan election, but
with a separate payroll deduction.
Standard Option Medical Plans => Standard Option Rx Plan
HMO Medical Plans => High Option Rx Plan
Express Scripts (High & Standard Options)Express Scripts High Option Rx Plan Express Scripts Standard Option Rx Plan
17
2017 Prescription Drug Premium
Weekly Prescription Premiums
Bi-Weekly Prescription Premiums
21-Pay Prescription Premiums
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 28.95$ 22.16$ 6.79$ Participant Only 27.70$ 22.16$ 5.54$
Participant + Child 56.20$ 43.02$ 13.18$ Participant + Child 53.77$ 43.02$ 10.75$
Participant + Spouse 64.75$ 49.56$ 15.19$ Participant + Spouse 61.95$ 49.56$ 12.39$
Participant + Family 70.27$ 53.79$ 16.48$ Participant + Family 67.24$ 53.79$ 13.45$
Express Scripts (High & Standard Options)Express Scripts High Option Rx Plan Express Scripts Standard Option Rx Plan
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 57.91$ 44.33$ 13.58$ Participant Only 55.41$ 44.33$ 11.08$
Participant + Child 112.40$ 86.04$ 26.36$ Participant + Child 107.54$ 86.03$ 21.51$
Participant + Spouse 129.49$ 99.12$ 30.37$ Participant + Spouse 123.90$ 99.12$ 24.78$
Participant + Family 140.54$ 107.58$ 32.96$ Participant + Family 134.47$ 107.58$ 26.89$
Express Scripts High Option Rx Plan Express Scripts Standard Option Rx Plan
Express Scripts (High & Standard Options)
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Coverage
Level
Total
Cost
City
Cost
Employee
Cost
Participant Only 71.70$ 54.88$ 16.82$ Participant Only 68.60$ 54.88$ 13.72$
Participant + Child 139.16$ 106.52$ 32.64$ Participant + Child 133.15$ 106.52$ 26.63$
Participant + Spouse 160.33$ 122.72$ 37.61$ Participant + Spouse 153.40$ 122.72$ 30.68$
Participant + Family 174.01$ 133.20$ 40.81$ Participant + Family 166.49$ 133.19$ 33.30$
Express Scripts (High & Standard Options)Express Scripts High Option Rx Plan Express Scripts Standard Option Rx Plan
18
Dental Premium
19
Section 3
Benefit Information (Rx, Vision, Dental & Life Insurance)
20
2017 Prescription Drug Copays
High Option Prescription Drug Plan
Generic Formulary
(Preferred Brand) Non-Formulary
(Non-Preferred Brand)
MAPS/Unrepresented
Retail (30 Day Supply) $15 $30 $40
Mail Order (90 Day Supply) $20 $40 $60
Represented
Retail (30 Day Supply) $10 $20 $30
Mail Order (90 Day Supply) $15 $25 $35
Standard Option Prescription Drug Plan Generic
Formulary (Preferred Brand)
Non-Formulary (Non-Preferred Brand)
Retail (30 Day Supply) $5 $30 $50
Mail Order (90 Day Supply) $10 $60 $100
The Standard Prescription Drug Plan requires that all plan participants meet a $50.00 deductible, per member, per calendar year. A deductible is the amount of covered expenses you must pay before your
insurance plan will pay benefits.
Prescription Out of Pocket Maximums
Medical Plan Enrollment
2017 Medical Out-of-Pocket Maximums
2017 Rx Out-of-Pocket
Maximums
2017 Total Out-of-Pocket
Maximums
In-Network
Family/Individual
Out-of-Network
Family/Individual
NOTE: Based on medical
plan enrollment (Combined Medical & Rx)
Active PPO Plans
High Option $1,000/$2,000 None $5,500/$9,600 $6,500/$11,200
Standard Option <$45,000 $1,000/$2,000 $2,000/$4,000 $5,100/$10,200 $6,100/$12,200
Standard Option >$44,999 $1,500/$3,000 $3,000/$6,000 $5,100/$10,200 $6,600/$13,200
Active HMO Plans
Kaiser $1,100/$3,600 $5,500/$9,600 $6,600/$13,200
UnitedHealthcare $1,100/$3,600 $5,500/$9,600 $6,600/$13,200
Aetna $1,100/$2,200 $5,500/$9,600 $6,600/$11,800
Out-of-Pocket Maximum Definition: The yearly out-of-pocket maximum is the highest or total amount your health plan requires you to pay towards the cost of your health care. Once you have met your out-of-pocket maximums you will not be required to pay towards the cost of services, you will still be required to pay your
premiums.
Out-of-Pocket expenses are what you pay for health-related services above and beyond your monthly premium, including: annual deductible, coinsurance and copayments.
21
CareFirst Select Vision‐ Schedule of Benefits If you go to a ....
Participating Provider Non‐Participating Provider
Covered Service (Note: Plan allows one pair of glasses or contacts, per member, in a 24 month period.)
Vision Exam Plan Pays 100% of Allowed Benefit.
Plan Pays 100% of allowed Benefit; you pay the balance.
Glassess
Plan pays up to: Plan pays up to: You Pay:
Single Vision $41.50 Single Vision $41.50 Balance
Bifocal $67.00 Bifocal $67.00 Balance
Trifocal $89.50 Trifocal $89.50 Balance
Double Bifocal $100.50 Double Bifocal $100.50 Balance
Cataract (Aphakic) $156.50 Cataract (Aphakic) $156.50 Balance Frames Per Pair
(If you select more expensive frames then you pay the Play pays up to $29.50; you pay the balance.
Contact Lenses**
Covered only if medically necessary or instead of glasses
Medically Required* Plan pays up to $221. Plan pays up to $221; you pay the balance.
Not Medically Required. Single Vision.**
Plan pays up to $71. Plan pays up to $71; you pay the balance.
Not Medically Required. Bifocal **
Plan pays up to $96.50. Plan pays up to $96.50; you pay the balance.
* Following cataract surgery or when visual acuity of at least 20/70 in the better eye is possible with the use of contact lenses. ** In place of glasses (frames and lenses)
22
CODE DESCRIPTION OF SERVICE ENROLLEE PAYS
D0120 Periodic oral evaluation – established patient $5.00
D0140 Limited oral evaluation - problem focused $5.00
D0150Comprehensive oral evaluation - new or established
patient$5.00
D0210 Intraoral - complete series of radiographic images $25.00
D0220 Intraoral - periapical first radiographic image $4.00
D0230 Intraoral - periapical each additional radiographic image $3.00
D0272 Bitewings - two radiographic images $5.00
D0274 Bitewings - four radiographic images $5.00
D0330 Panoramic radiographic image $20.00
CODE DESCRIPTION OF SERVICE ENROLLEE PAYS
D1110 Prophylaxis - adult $10.00
D1120 Prophylaxis - child $10.00
D1208Topical application of fluoride (prophylaxis excluded) -
through age 18 $5.00
D1351 Sealant - per tooth $5.00
COPAYMENTS FOR COMMON DENTAL SERVICES
D0100-D0999 I. Diagnostic
D1000-D0999 II. Preventive
CODE DESCRIPTION OF SERVICE ENROLLEE PAYS
D2140 Amalgam - one surface, primary or permanent $28.00
D2150 Amalgam - two surfaces, primary or permanent $35.00
D2160 Amalgam - three surfaces, primary or permanent $45.00
D2161Amalgam - four or more surfaces, primary or
permanent$55.00
D2330 Resin-based composite - one surface, anterior $35.00
D2331 Resin-based composite - two surfaces, anterior $45.00
D2332 Resin-based composite - three surfaces, anterior $55.00
D2335Resin-based composite - four or more surfaces or
involving incisal angle (anterior)$80.00
D2391 Resin-based composite - one surface, posterior $40.00
D2392 Resin-based composite - two surfaces, posterior $50.00
D2750 Crown - porcelain fused to high noble metal $390.00
D2752 Crown - porcelain fused to noble metal $380.00
D2790 Crown - full cast high noble metal $390.00
D2792 Crown - full cast noble metal $380.00
D2920 Recement crown $25.00
D2950 Core buildup, including any pins $60.00
D2954 Prefabricated post and core in addition to crown $70.00
D2000-D2999 III. Restorative
DeltaCare USA: Dental HMO
CODE DESCRIPTION OF SERVICE ENROLLEE PAYS
D3310Endodontic therapy, anterior tooth (excluding final
restoration)$200.00
D3320Endodontic therapy, bicuspid tooth (excluding final
restoration)$300.00
D3330 Endodontic therapy, molar (excluding final restoration) $425.00
CODE DESCRIPTION OF SERVICE ENROLLEE PAYS
D4341Periodontal scaling and root planing - four or more
teeth per quadrant$60.00
D4910 Periodontal maintenance $50.00
D7140Extraction, erupted tooth or exposed root (elevation
and/or forceps removal)$35.00
CODE DESCRIPTION OF SERVICE ENROLLEE PAYS
D7230 Removal of impacted tooth - partially bony $110.00
D7240 Removal of impacted tooth - completely bony $150.00
D9110Palliative (emergency) treatment of dental pain - minor
procedure$10.00
D9230 Deep sedation/general anesthesia - first 30 minutes $88.00
D7000-D7999 VI. Oral and Maxillofacial Surgery
NOTE: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN.
The Group Dental Service Contract must be consulted to determine the exact terms and conditions of coverage. An Evidence of Coverage will be sent to you upon enrollment.
D7210
Surgical removal of erupted tooth requiring removal of
bone and/or sectioning of tooth, and including elevation
of mucoperiosteal flap if indicated
$60.00
D3000-D3999 IV. Endodontics
D4000-D4999 V. Periodontics
23
24
Delta Dental PPO
25
Minnesota Life: Basic & Optional Life/AD&D Coverage
Minnesota Life Beneficiary Maintenance System
26
Section 4
Medical Plan Comparison
Comparing Medical Plan Benefits The following charts are a summary of generally available benefits and do not guarantee coverage. Check each carrier’s website to find out if your providers and the facilities in which your providers work are included in the various plan networks. To ensure coverage under your plan, contact the plan before receiving services or treatment to obtain more information on coverage limitations, exclusions, determinations of medical necessity, and preauthorization requirements.
27
Are Referrals Required? No No No No
Deductible$250 per individual
$500 per family
$500 per individual
$1000 per familyNone None
Out-of-Pocket Maximum
(Based on annual salary)
Employee Salary < $45,000:
$1,000
per individual/$2,000 per family
Employee Salary > $44,999:
$1,500
per individual/$3,000 per family
Employee Salary < $45,000:
$2,000
per individual/$4,000 per family
Employee Salary > $44,999:
$3,000
per individual/$6,000 per family
$1,000 per individual
$2,000 per family None
Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited
Routine Office Visit
(Annual physical) 100% 100% allowed benefit* covered in full 100% allowed benefit*
Well Baby/Child Care
(Age & frequency schedule
apply)
100% 100% allowed benefit* covered in full 100% allowed benefit*
Routine GYN Examination
(Limit-one per year) 100% 100% allowed benefit* covered in full 100% allowed benefit*
Screenings:
Mammography, Colorectal &
Prostate
100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% Allowed Benefit
Physician's Office Visit
(Sickness)$25 copay 80% $5 copay per visit
$5 copay per visit; 100 %
allowed benefit*
Specialist Office Visit $40 copay 80% $5 copay per visit$5 copay per visit; 100 %
allowed benefit*
Hearing Exams 90% 70% $5 copay per visit$5 copay per visit; 100 %
allowed benefit*
Ambulance Service
(based on medical necessity) 90% 90% covered in full 100% allowed benefit*
Emergency Room
(copay waived if admitted) 90% 90% $50 copay $50 copay
Urgent Care $25 Copay, 90% $25 Copay, 90% $5 copay per visit $5 copay per visit
Physician Office Visits (Non-Routine)
Emergency Room and Urgent Care Services
Aetna PPO 2017 Active Benefit Plan Comparison Charts
*All Out of Network benefits paid at Allowed Amount. Allowed Benefit is 50% of R & C
** any out-of-network provider can balance bill the difference between allowed amount and billed amount
Standard Option Plan
In-Network Out-of-Network**
High Option Plan
In-Network Out-of-Network**
Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.
Routine & Preventive Services
28
Anesthesia 90% 70% covered in full 100% allowed benefit*
Hospital Services, including
Room, Board & General
Nursing Services
90% 70% covered in full 100% allowed benefit*
Organ Transplant
(Pre-Auth Required) 90% 70% Covered in full no coverage
Diagnostic Lab Work & X-
rays90% 70% covered in full 100% allowed benefit*
Acute Inpatient Rehab 90% 70% covered in full 100% allowed benefit*
Medical Surgical Physician
Services90% 70% covered in full 100% allowed benefit*
Physical, Speech &
Occupational Therapy
90% (Combined 60 visits per
year)
70% (Combined 60 visits per
year)covered in full 100% allowed benefit*
Chemotherapy & Radiation 90% 70% $5 copay per visit$5 copay per visit, 100%
allowed benefit*
Renal Dialysis 90% 70% covered in full 100% allowed benefit *
Diagnostic Lab Work
& X-rays90% 70% covered in full 100% allowed benefit*
Cardiac Rehab $40 copay per visit 70% $5 copay per visit$5 copay per visit, 100%
allowed benefit*
Outpatient Surgery 90% 70% covered in full 100% allowed benefit*
Physical, Speech &
Occupational Therapy
90% (Combined 60 visits per
year)
70% (Combined 60 visits per
year)
$5 copay per visit
Call Plan for Visit l imits
$5 copay per visit, 100%
allowed benefit* Call
Plan for Visit l imits
Pre-Admission Testing 90% 70% covered in full 100% allowed benefit*
Allergy Testing 90% 70% $5 copay per visit $5 copay per visit, 100%
allowed benefit *
Allergy Serum 90%, Call Aetna for plan details 70%, Call Aetna for plan details $5 copay per visit $5 copay per visit, 100%
allowed benefit*
Pre/Post-Natal
(Physician Services)Covered in Full 80% covered in full 100% allowed benefit*
Fertil ity Testing &
Family Planning
Member cost sharing based on
type of service performed and
place of service where rendered
Member cost sharing based on
type of service performed and
place of service where rendered
Member cost sharing
based on type of service
performed and place of
service where rendered
100% allowed benefit*
member cost sharing
based on type of service
performed and place of
service where rendered
In-Vitro Fertil ization
90%; $100,000 Maximum
lifetime benefit; up to 3 attempts
per l ive birth combined with
ART, AI and AO
70%; $100,000 Maximum
lifetime benefit; up to 3 attempts
per l ive birth combined with Art,
AI and AO
Covered in full;
$100,000 Maximum
lifetime benefit; up to 3
attempts per l ive birth
combined with ART, AI &
AO
100% allowed benefit*
covered in full; $100,000
Maximum lifetime
benefit; up to 3 attempts
per l ive birth combined
with Art, AI & AO
*All Out of Network benefits paid at Allowed Amount. Allowed Benefit is 50% of R & C
** any out-of-network provider can balance bill the difference between allowed amount and billed amount
Standard Option Plan
In-Network Out-of-Network**
High Option Plan
In-Network Out-of-Network**
Fertility Testing & Family Planning
Hospital Inpatient Services
Outpatient Services
Maternity
Aetna PPO 2017 Active Benefit Plan Comparison Charts
29
Inpatient Mental Health &
Alcohol & Substance Abuse 90% 70% covered in full 100% allowed benefit*
Outpatient Mental Health &
Alcohol & Substance Abuse $25 copay 80% $5 copay per visit
$5 copay per visit
100% allowed benefit*
Nutrition Counseling 90% 70% $5 copay per visit, $5 copay per visit, 100%
allowed benefit*
Diabetic Supplies 90% 70% covered in full 100% allowed benefit*
Durable Medical Equipment 90% 70% covered in full 100% allowed benefit*
Private duty nursing
(pre-auth required)90% 70% covered in full 100% allowed benefit *
Hospice Care 90% 70% covered in full 100% allowed benefit *
Prosthetic Devices 90% 70% covered in full 100% allowed benefit *
Aetna PPO 2017 Active Benefit Plan Comparison Charts
*All Out of Network benefits paid at Allowed Amount. Allowed Benefit is 50% of R & C
** any out-of-network provider can balance bill the difference between allowed amount and billed amount
Standard Option Plan
In-Network Out-of-Network**
High Option Plan
In-Network Out-of-Network**
Mental Health & Substance Abuse Benefits
Miscellaneous Supplies & Services
Insulin & Syringes Covered by Rx Plan
30
Are Referrals Required? No No No No
Deductible$250 per individual
$500 per family
$500 per individual
$1000 per familyNone None
Out-of-Pocket Maximum
(Based on annual salary)
Employee Salary < $45,000:
$1,000 per individual/$2,000
per family
Employee Salary > $44,999:
$1,500 per individual/$3,000
per family
Employee Salary < $45,000:
$2,000 per
individual/$4,000
per family
Employee Salary > $44,999:
$3,000 per
individual/$6,000 per
family
$1,000 per
individual
$2,000 per family
None
Plan Lifetime Maximum
Benefit Unlimited Unlimited Unlimited Unlimited
Routine Office Visit
(Annual physical) 100% 100% Covered in full
$5 copay per visit,
100% allowed Benefit*
Well Baby/Child Care 100% 100% Covered in full $5 copay per visit;
100% allowed Benefit*
Routine GYN Examination 100% 100% Covered in full $5 copay per visit,
100% allowed Benefit*
Screenings:
Mammography, Colorectal
& Prostate
100% Allowed Benefit 100% Allowed Benefit Covered in full 100% allowed Beneft*
Physician's Office Visit
(Sickness) $25 copay per visit 80% $5 copay per visit
$5 copay per visit,
100% allowed Benefit*
Specialist Office Visit $40 copay per visit 80% $5 copay per visit$5 copay per visit,
100% allowed Benefit*
Hearing Exams 90% 70% $5 copay per visit $5 copay per visit
100% allowed benefit*
Ambulance Service
(based on medical
necessity)
90% 90%Covered in full for
emergency only
100 % allowed benefit
for emergency only
Emergency Room
(copay waived if admitted) 90% 90% $50 copay $50 copay
Urgent Care $25 Copay, 90% $25 Copay, 90% $5 copay per visit$5 copay per visit,
100% allowed Benefit*
Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital
status.
Physician Office Visits (Non-Routine)
Routine & Preventive Services
Emergency Room and Urgent Care Services
Standard Option Plan
In-Network Out-of-Network**
UnitedHealthcare POS 2017 Active Benefit Plan Comparison Charts
*Allowed Benefit is 50% of R & C
** any out-of-network provider can balance bill the difference between allowed amount & billed amount
High Option
In-Network Out-of-Network**
31
Anesthesia 90% 70% covered in full 100% allowed benefit*
Hospital Services, including
Room, Board & General Nursing
Services
90% 70% covered in full 100% allowed benefit*
Diagnostic Lab Work & X-rays 90% 70% covered in full 100% allowed benefit*
Medical Surgical Physician
Services90% 70% covered in full 100% allowed benefit*
Physical, Speech &
Occupational Therapy90% 70% covered in full 100% allowed benefit*
Organ Transplant
(Pre-Authorization Required)
90% for non-experimental
transplants70%
covered in full for non-
experimental
transplants
100% allowed benefit*
Acute Inpatient Rehab 90% 70% covered in full covered in full
Cardiac Rehab 90% 70% $5 copay per visit$5 copay per visit,
100% allowed benefit*
Chemotherapy & Radiation 90% 70% $5 copay per visit$5 copay per visit,
100% allowed benefit*
Renal Dialysis 90% 70% covered in full 100% allowed benefit*
Diagnostic Lab Work & X-rays 90% 70% covered in full 100% allowed benefit*
Outpatient Surgery 90% 70% covered in full 100% allowed benefit*
Physical, Speech & Occupational
Therapy
(60 visits combined per
therapy/type per year)
90% 70% $5 copay per visit; $5 copay per visit;
100% allowed benefit*
Pre-Admission Testing 90% 70%$5 copay per visit,
testing covered in full
$5 copay per visit,
100% allowed benefit*
Allergy Testing 90% 70% $5 copay per visit$5 copay per visit;
100% allowed benefit*
Allergy Serum 90% 70% Covered in Full 100% allowed benefit*
Standard Option Plan
In-Network Out-of-Network**
High Option
In-Network Out-of-Network**
Hospital Inpatient Services
Outpatient Services
Outpatient Services
UnitedHealthcare POS 2017 Active Benefit Plan Comparison Charts
*Allowed Benefit is 50% of R & C
** any out-of-network provider can balance bill the difference between allowed amount & billed amount
32
Pre and Post-Natal
(Physician Services)100% 80% Covered in Full
$5 copay for initial
visit to determine
pregnancy,
then 100% allowed
benefit*
Fertil ity Testing & Family
Planning 90% 70% $5 copay per visit
$5 copay per visit;
100% allowed benefit*
In-Vitro Fertil ization90 % allowable charges;
$100,000 maximum lifetime
70% allowed benefit*;
$100,000 maximum lifetime
100 % allowable
charges; $100,000
100% allowed
benefit*; $100,000
Inpatient Alcohol & Substance
Abuse/Mental Health 90% 70% covered in full 100% allowed benefit*
Outpatient Alcohol & Substance
Abuse/Mental Health $25 copay per visit 80% after deductible $5 copay per visit
$5 copay per visit;
100% allowed benefit*
Nutrition Counseling 90% 70% $5 copay per visit $5 copay per visit
Diabetic Supplies 90% 70%
covered in full ,
including lancets,
tests strips and
glucometers
100% allowed benefit,
including lancets, test
strips & glucometers
Durable Medical Equipment
(pre-authorization required)90%
70% (pre-authorization
required for over $1,000)covered in full;
100% allowed benefit;
(pre-authorization
required for over
$1,000)
Private duty nursing
(pre-authorization required)Contact plan for details Contact plan for details
covered in full for
skil led care based on
medical necessity
100% allowed benefit*
Hospice Care
(pre-authorization required)90% 70% covered in full;
100% allowed
benefit*;
Prosthetic Devices
(Such as artificial limbs)
(pre-authorization required)
90%70% (pre-authorization
required for over $1,000)covered in full
100% allowed benefit*
after prior plan
approval (pre-
authorization
required for over
$1,000)
UnitedHealthcare POS 2017 Active Benefit Plan Comparison Charts
*Allowed Benefit is 50% of R & C
** any out-of-network provider can balance bill the difference between allowed amount & billed amount
Standard Option Plan
In-Network Out-of-Network**
High Option
In-Network Out-of-Network**
Insulin & Syringes Covered by Rx Plan
Miscellaneous Supplies & Services
Maternity
Fertility Testing & Family Planning
Mental Health & Substance Abuse Benefits
33
Are Referrals Required? No No No No
Deductible$250 per individual
$500 per family
$500 per individual
$1,000 per family
Out-of-Pocket Maximum
(Based on annual salary)
Employee Salary < $45,000:
$1,000 individual/$2,000
family
Employee Salary > $44,999:
$1,500 individual/$3,000
family
Employee Salary < $45,000:
$2,000 individual/$4,000
family
Employee Salary > $44,999:
$3,000 individual/$6,000
family
$1,000 per individual
$2,000 per familyN/A
Plan Lifetime Maximum
Benefit Unlimited Unlimited Unlimited Unlimited
Routine Office Visit (Annual
physical) 100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% of Allowed Benefit
Well Baby/Child Care 100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% Allowed Benefit
Routine GYN Examination
(Limit-one per year) 100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% allowed benefit
Screenings:
Mammography, Colorectal &
Prostate
100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% Allowed Benefit
Physician's Office Visit
(Sickness)
(Maps & Unrepresented)
$25 Copay 80% Allowed Benefit$20 copay per visit
100% allowed benefit80% allowed benefit
Physician's Office Visit
(Sickness)
(Represented)
$25 Copay 80% Allowed Benefit$10 copay per visit
100% allowed benefit80% allowed benefit
Specialist Office Visit
(Maps & Unrepresented)$40 Copay 80% Allowed Benefit
$25 copay per visit
100% allowed benefit80% allowed benefit
Specialist Office Visit
(Represented)$40 Copay 80% Allowed Benefit
$15 copay per visit
100% allowed benefit80% allowed benefit
Hearing Exams- one exam
every 36 months (routine
exams excluded)
90% Allowed Benefit 70% Allowed Benefit
100% allowed benefit
with medical
diagnosis
80% allowed benefit
with medical
diagnosis
Ambulance Service
(Based on medical necessity)
(Ground Only)
90% Allowed Benefit 90% Allowed Benefit
major medical
subject to deductible
and coinsurance if
applicable
major medical subject
to deductible and
coinsurance if
applicable
Emergency Room
(copay waived if admitted) 90% Allowed Benefit 90% Allowed Benefit $50 copay $50 copay
Urgent Care$25 Copay, 90% Allowed
Benefit
$25 Copay, 90% Allowed
Benefit $10 copay per visit;
100% of allowed
benefit
Physician Office Visits (Not-Routine)
Emergency Room and Urgent Care Services
CareFirst PPN 2017 Active Benefit Plan Comparison Charts
** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount.
Standard Option Plan
In-Network Out-of-Network**
High Option Plan
In-Network Out-of-Network**
Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.
Routine & Preventive Services
34
Anesthesia 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Maps & Unrepresented
Hospital Services, including
Room, Board & General
Nursing Services
90% Allowed Benefit 70% Allowed Benefit
100% allowed benefit
preauthorization
required
$100 deductible per
admission, then plan
pays 70% up to $1,500
out of pocket
Represented Hospital
Services, including Room,
Board & General Nursing
Services pre-authorization
required
90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit
$100 deductible per
admission, then plan
pays 80% up to $1,500
out of pocket
maximum per
admission, then 100%
Medical Surgical Physician
Services90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Physical, Speech &
Occupational Therapy90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Organ Transplant
(Pre-Authorization Required) 90% Allowed Benefit
70% Allowed Benefit
($30,000 per transplant max)100% allowed benefit 100% allowed benefit
Acute Inpatient Rehab Not a covered benefit Not a covered benefit Not a covered benefit Not a covered benefit
** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount.
Standard Option Plan
In-Network Out-of-Network**
High Option Plan
In-Network Out-of-Network** Hospital Inpatient Services
CareFirst PPN 2017 Active Benefit Plan Comparison Charts
Anesthesia 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Maps & Unrepresented
Hospital Services, including
Room, Board & General
Nursing Services
90% Allowed Benefit 70% Allowed Benefit
100% allowed benefit
preauthorization
required
$100 deductible per
admission, then plan
pays 70% up to $1,500
out of pocket
Represented Hospital
Services, including Room,
Board & General Nursing
Services pre-authorization
required
90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit
$100 deductible per
admission, then plan
pays 80% up to $1,500
out of pocket
maximum per
admission, then 100%
Medical Surgical Physician
Services90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Physical, Speech &
Occupational Therapy90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Organ Transplant
(Pre-Authorization Required) 90% Allowed Benefit
70% Allowed Benefit
($30,000 per transplant max)100% allowed benefit 100% allowed benefit
Acute Inpatient Rehab Not a covered benefit Not a covered benefit Not a covered benefit Not a covered benefit
Cardiac Rehab 90% Allowed Benefit 70% Allowed Benefit 100% Allowed Benefit 80% Allowed Benefit
Chemotherapy & Radiation 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Renal Dialysis 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Diagnostic Lab Work & X-
rays90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Outpatient Surgery 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Physical, Speech &
Occupational Therapy
(Maps & Unrepresented)
90% Allowed Benefit - l imit
60 visits combined
70% Allowed Benefit - l imit
60 visits combined
100% allowed benefit -
precertification
required after 10th
lifetime visit - l imited
to 100 combined
visits per calendar
year
80% allowed benefit -
precertification
required after 10th
lifetime visit - l imited
to 100 combined visits
per calendar year
** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount.
Standard Option Plan
In-Network Out-of-Network**
High Option Plan
In-Network Out-of-Network**
Outpatient Services
Hospital Inpatient Services
CareFirst PPN 2017 Active Benefit Plan Comparison Charts
35
Physical, Speech & Occupational Therapy (Represented)
90% Allowed Benefit - limit 60 visits combined
70% Allowed Benefit - limit 60 visits combined
facility $10 copay; office 100% allowed benefit - precertification required after 10th lifetime visit - limited to 100 combined visits per calendar year
80% allowed benefit for 100 visits per calendar year for physical, speech and occupational therapies combined. Pre-certification required after first 10 visits.
Pre-Admission Testing 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Allergy Testing 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
Allergy Serum
($200 Annual Maximum) 90% after Deductible up to annual maximum
70% allowed benefit up to annual maximum
100% allowed benefit up to annual maximum
80% allowed benefit up to annual maximum
Pre & Post-Natal (Physician Services)
covered in full 80% Allowed Benefit 100% allowed benefit 80% allowed benefit
Fertility Testing & Family Planning
90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
In-Vitro Fertilization
( Pre-Authorization Required) 90% Allowed Benefit
$100,000 lifetime maximum 70% Allowed Benefit
$100,000 lifetime maximum
100% allowed benefit;
$12,000 maximum lifetime.
80% allowed benefit;
$12,000 maximum lifetime
Inpatient Alcohol & Substance Abuse/Mental Health
(Maps & Unrepresented)
Pre-Authorization Required
90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit
$100 deductible per admission, then plan pays 70% up to $1,500 out of pocket maximum per admission, then 100% allowed benefit.
Inpatient Alcohol & Substance Abuse/Mental Health (Represented)
Pre-Authorization Required
90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit
$100 deductible per admission, then plan pays 80% up to $1,500 out of pocket maximum per
CareFirst PPN 2017 Active Benefit Plan Comparison Charts
** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount. Standard Option Plan
In-Network Out-of-Network**
High Option Plan
In-Network Out-of-Network**
Maternity
Fertility Testing & Family Planning
Inpatient Mental Health & Substance Abuse- Benefits Provided by Beacon Health Options
Outpatient Services Continued
36
Inpatient Alcohol &
Substance Abuse/Mental
Health
(Maps & Unrepresented)
Pre-Authorization Required
90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit
$100 deductible per
admission, then plan
pays 70% up to $1,500
out of pocket
maximum per
admission, then 100%
allowed benefit.
Inpatient Alcohol &
Substance Abuse/Mental
Health (Represented)
Pre-Authorization Required
90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit
$100 deductible per
admission, then plan
pays 80% up to $1,500
out of pocket
maximum per
admission, then 100%
allowed benefit.
Outpatient Mental
Health/Alcohol & Substance
Abuse (Maps &
Unrepresented)
$25 Copay 80% Allowed Benefit$20 copay per visit;
100% allowed benefit. 80% allowed benefit.
Outpatient Mental
Health/Alcohol & Substance
Abuse (Represented)
$25 Copay 80% Allowed Benefit$10 copay per visit;
100% allowed benefit. 80% allowed benefit.
Nutrition Counseling
$25 primary/$40 specialist
copay then 100% allowed
benefit.
70%
Covered same as any
office visit- based on
diagnosis.
80% allowed benefit,
for specific diagnosis
only
Diabetic Supplies 90% Allowed Benefit 70% Allowed Benefit
100% allowed benefit,
includes lancets test
strips & glucometers
100% allowed benefit,
includes lancets, test
strips & glucometers
Durable Medical Equipment 90% Allowed Benefit 70% Allowed Benefit See major medical
benefit
See major medical
benefit
Private duty nursing
(Pre-Authorization required)
Outpatient Only
90% Allowed Benefit 70% Allowed Benefit
based on medical
necessity; See major
medical benefit
based on medical
necessity; See major
medical benefit
Hospice Care 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 100% allowed benefit
Prosthetic Devices (IE: as
artificial limbs)90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit
** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount.
Standard Option Plan
In-Network Out-of-Network**
High Option Plan
In-Network Out-of-Network**
Miscellaneous Supplies & Services
Insulin & Syringes Covered by Rx Plan
Inpatient Mental Health & Substance Abuse- Benefits Provided by Beacon Health Option
Outpatient Mental Health & Substance Abuse- Benefits Provided by Beacon Health Option
CareFirst PPN 2017 Active Benefit Plan Comparison Charts
37
Major Medical Annual
Deductible
(Maps & Unrepresented)
NA NA
Major medical
expenses only - $250
deductible per person
per year
Major medical
expenses only - $250
deductible per person
per year
Major Medical Annual
Deductible (Represented)NA NA
major medical
expenses only; $200
deductible per person
per year
major medical
expenses only; $200
deductible per person
per policy year
Major Medical Yearly Out-Of-
Pocket Maximum
(Maps & Unrepresented)
NA NA
Deductible then 100%
first $30,000, then
50% of allowed
benefit
Deductible then 100%
first $30,000, the 50%
of allowed benefit
Major Medical Yearly Out-Of-
Pocket Maximum
(Represented)
NA NADeductible then 80%
of allowed benefit
Deductible then 80% of
allowed benefit
CareFirst PPN 2017 Active Benefit Plan Comparison Charts
** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount.
Standard Option Plan
In-Network Out-of-Network**
High Option Plan
In-Network Out-of-Network**
Major Medical- Applies to CareFirst Plans Only
38
Kaiser HMOUnitedHealthcare
Choice HMO
Open Access Aetna
Select (HMO)
Are Referrals Required? Yes No No
Out- Of- Pocket Maximum$3,500 per individual;
$9,400 per family
$1,100 per Individual;
$3,600 per family
$1,100 per individual;
$2,200 per family
Plan Lifetime Maximum Benefit Unlimited Unlimited Unlimited
Physician's Office Visit (Annual
Physical)Covered in full Covered in full Covered in full
Well Baby/Child Care Covered in full Covered in full Covered in full
Routine GYN Examination Covered in full Covered in full Covered in full
Immunizations Covered in full Covered in full Covered in full
Screenings: Mammography,
Colorectal & Prostate
Covered in full - call plan
for details
Covered in full - call plan
for details
Covered in full - call plan
for details
Specialist Office Visit $5 copay per visit $5 copay per visit $5 copay per visit
Hearing Exams $5 copay per visit $5 copay per visit $5 copay per visit
Ambulance Service
(Based on medical necessity)
Covered in full for
emergency only
Covered in full for
emergency only
Covered in full for
emergency only
Emergency Room (Waived if
admitted)$50 copay $50 copay $50 copay
Urgent Care $5 copay per visit $5 copay per visit $5 copay per visit
HMO Plans
2017 Active Benefit Plan Comparison Charts
NOTE: Out-of-Network Services are not covered under HMO unless an emergency
Routine & Preventive Services
Emergency Room and Urgent Care Services
Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of
student or marital status.
Physician Office Visit (Non-Routine)
39
Kaiser HMOUnitedHealthcare
Choice HMO
Open Access Aetna
Select (HMO)
Anesthesia Covered in full Covered in full Covered in full
Hospital Services Including Room,
Board & General Nursing ServicesCovered in full Covered in full Covered in full
Diagnostic Lab Work & X-rays Covered in full Covered in full Covered in full
Medical Surgical Physician Services Covered in full Covered in full Covered in full
Physical, Speech & Occupational
TherapyCovered in full Covered in full Covered in full
Organ Transplant
Pre-Authorization Required
Covered in full for
non-experimental
transplants
Covered in full for
non-experimental
transplants
Covered in full for
non-experimental
transplants
Acute In-Patient Rehab Covered in full Covered in full Covered in full
Cardiac Rehab $5 copay per visit $5 copay per visit $5 copay per visit
Chemotherapy & Radiation $5 copay per visit $5 copay per visit $5 copay per visit
Renal Dialysis $5 copay per visit covered in full covered in full
Diagnostic Lab Work & X-rays covered in full covered in full covered in full
Outpatient Surgery $5 copay per visit covered in full covered in full
Physical, Speech & Occupational
Therapy
$5 copay per visit call plan
for visit limits
$5 copay per visit 90 visits
per therapy type per year
$5 copay per visit
Call plan for visit limits
Pre-Admission Testing $5 copay per visit covered in full covered in full
Allergy Testing $5 copay per visit $5 copay per visit $5 copay per visit
Allergy Serum covered in full covered in full $5 copay per visit
NOTE: Out-of-Network Services are not covered under HMO unless an emergency
Hospital Inpatient Services
HMO Plans
2017 Active Benefit Plan Comparison Charts
Outpatient Services
40
Kaiser HMOUnitedHealthcare
Choice HMO
Open Access Aetna
Select (HMO)
Pre and Post-Natal (Physician
Services)Covered in full Covered in full Covered in full
Delivery (Inpatient) covered in full covered in full covered in full
Newborn Care (Inpatient) covered in full covered in full covered in full
Fertility Testing & Family Planning
$5 copay per visit for family
planning. Fertility testing
office visit and any other
fertility services covered at
50%
$5 copay per visit for
family planning and
fertility testing; other
fertility services 50%
Member cost sharing
based on type of service
performed and place of
service where rendered
In-Vitro Fertilization
50% of allowable charges;
$100,000 maximum
lifetime benefit for up to 3
attempts per live birth
50% of allowable charges;
$100,000 maximum
lifetime benefit for up to
3 attempts per live birth
Call plan for specific
state mandated benefits
Inpatient
Mental Health/Alcohol & Substance
Abuse
covered in full covered in full
covered in full;
pre-authorization
required
Outpatient
Mental Health/Alcohol & Substance
Abuse
$5 copay per visit $5 copay per visit $5 copay per visit
Nutrition & Health Education $5 copay per visit $5 copay per visit $5 copay per visit
Diabetic Supplies Covered in full
Lancets & test strips,
generic covered by a $5
copay and brand covered
by a $20 copay at
pharmacy. Diabetic
Supplies covered in full
through DME benefit.
Glucometers covered in
full with pre-
authorization.
$5 copay
NOTE: Out-of-Network Services are not covered under HMO unless an emergency
HMO Plans
2017 Active Benefit Plan Comparison Charts
Maternity
Fertility Testing & Family Planning
Mental Health & Substance Abuse Benefits
Miscellaneous Supplies & Services
41
Kaiser HMOUnitedHealthcare
Choice HMO
Open Access Aetna
Select (HMO)
Durable Medical Equipment
Preauthorization requiredCovered in full Covered in full Covered in full
Private Duty Nursing
Preauthorization requiredCovered in full Not covered Not covered
Hospice Care Covered in full Covered in full Covered in full
Prosthetic Devices Such As Artificial
Limbs)
preauthorization required
Covered in full Covered in full Covered in full
NOTE: Out-of-Network Services are not covered under HMO unless an emergency
HMO Plans
2017 Active Benefit Plan Comparison Charts
Insulin & Syringes Covered by Rx plan
42
Provider Phone Number Website
CareFirst PPN 1-800-535-2292 www.carefirst.com
UnitedHealthcare HMO & PPO Plans 1-877-462-5027 www.myuhc.com
Aetna HMO & PPO Plans 1-800-900-7562 www.aetna.com
Kaiser Permanente HMO 1-866-248-0715 www.kaiserpermanente.org
Beacon Health Options (CareFirst Members 1-866-468-5633 www.achievesolutions.net/baltimore
Express Scripts Prescription Plan 1-800-354-8123 www.express-scripts.com
CareFirst Select Vision 1-800-535-2292 www.carefirst.com
Minnesota Life (Claims) 1-888-658-0193 www.lifebenefits.com/baltimorecity
Minnesota Life (Beneficiary System) 1-877-494-1754 www.lifebenefits.com/baltimorecity
Vantagen Flexible Spending Accounts 1-800-307-0230 www.myflexdollars.com
Dental Dental PPO 1-800-471-7081 www.deltadentalins.com/city-of-baltimore
DeltaCare USA (Dental HMO) 1-855-830-6581 www.deltadentalins.com/city-of-baltimore
ADP COBRA 1-800-526-2750 www.benedirect.adp.com
Contact Phone Numbers & websites
43