Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Schedule of Benefits… Specially Designed for Tee Jaye's Country Place Restaurants Calendar Year Deductible Amount Employee pays before coshare percentages Single: $ 3,000 Single: $ 3,000 Family: $ 5,000 Family: $ 5,000 Coshare Percentage 0% Plan Coshare Hospital Charges: Inpatient/Outpatient 0% Plan Coshare Coshare max doubles per family Emergency Room Charge Copay is waived if admitted to the hospital Sickness/Injury – Physician Charges – Office Visit WellCare – Provider Services – Office Visit Other Covered Expenses Example: Supplies, lab & X-ray, Durable Medical Equipment, injections, etc. Retail Prescription Drug (Network provider for prescription services is Caremark) Mail-Order Prescription Drug (Network provider for prescription services is Caremark) (Outpatient & Inpatient) Care Advocacy Pathway (CAP) Care Advocacy Pathway is often referred to as Chronic Care or Disease Management THEN 0 % FOR BALANCE OF YEAR 20% Plan Coshare AFTER $ 200 PER OCCURANCE DED. $ 200.00 Copay 20% Plan Coshare 0% of Plan Coshare 0% of Target Prices $ 30.00 Per Visit 0% of Target Prices 0% Plan Coshare 0% of Target Prices Deductible Waived $ 30 o.v. COPAY 0% of Target Prices 0% Plan Coshare 0% of Target Prices GENERIC : $ 10.00 PREFERRED : $ 30.00 NON-PREFERRED : $ 50.00 GENERIC : $ 20.00 PREFERRED : $ 60.00 NON-PREFERRED : $ 100.00 INPATIENT Mental and Nervous, Alcohol and Drug Disorders 20% of 1st $ 10,000 0% for 30 days per year OUTPATIENT 0% for 30 visits per year 20% Plan Coshare ALL DEDUCTIBLES APPLY 20% Plan Coshare ALL DEDUCTIBLES APPLY INPATIENT 20% for 10 days per year OUTPATIENT 20% for 10 visits per year 0% Plan Coshare 0% of Target Prices DEDUCTIBLE WAIVED DEDUCTIBLE WAIVED • L ifetime Maximum for all Benefits paid under this plan is $1,000,000. ***This is a summary in outline form of the Benefits. Eligible persons who choose to participate should review the SUMMARY PLAN DESCRIPTION and PLAN DOCUMENT (Benefit Booklet) for information about; participation, benefits, limitations, and exclusions. This is not a contract, policy or guarantee of coverage.*** Schedule of Benefits… Specially Designed for Tee Jaye's Country PlaceRestaurants Out-of-area Benefits will be paid the same as in-network except: 1.The annual Benefit for Mental & nervous, alcohol & drug disorders is limited to 10 days inpatient and 10 visits outpatient. Target Prices – are used as the maximum allowable payment for out-of-network (nonparticipating) providers. The Target Price fee schedule applies to provider procedure codes (called CPT-4’s) and will cover most charges made by a Physician. The Target fee schedule is 115% of the Medicare reimbursement rate, which means that reimbursement is set at 15% more under this Plan than is paid for providing the same service to a Medicare patient. Any provider charge in excess of the Target Price will not be a covered expense under the terms of this Plan and will be the responsibility of the Covered Person. If you choose to see an out-of-network Physician, you should ask prior to treatment if he or she will accept Target Price (115% of the Medicare reimbursement) as payment-in-full. If the Physician agrees you will not be responsible for any excess charge. Therefore, it is important that you obtain written verification. If not, you will be responsible for paying the balance of the charges. Out-of-network provider charges that are not based upon CPT-4 codes, which include most Hospitals and other facilities and charges for which there are no Target Prices, will be paid at the in-network Coshare percentage minus twenty (20) percentage points. Other Coverage Notes: • Second Surgical Opinion requested by BAC, Hospice, Centers of Excellence, and Pre-Admission Testing recommended by BAC, and Optional Benefits are paid by the Plan at 100% (0% member out of pocket) of covered expenses. • Deductible waived for Maternity Care (if treatment begins within 1st trimester) •Lifetime Maximum for substance abuse disorders paid is $15,000. Increased coshare does not apply to substance abuse disorders. • Annual Maximum for Tempomandibular Joint Dysfunction Syndrome (TMJ ) is $1,500. •Chiropractic Services limited to a maximum benefit of $ 500.00 per year. Available PPO Networks: • Ohio – SuperMedPlus www.supermednetwork.com ***This is a summary in outline form of the Benefits. Eligible persons who choose to participate should review the SUMMARY PLAN DESCRIPTION and PLAN DOCUMENT (Benefit Booklet) for information about; participation, benefits, limitations, and exclusions. This is not a contract, policy or guarantee of coverage.***