HomeMy WebLinkAboutItem #01 - Minutes05-01-07 Agenda
Item #1
MINUTES
CITY OF OCOEE
WORKSHOP ON HEALTH INSURANCE PLAN
April 18, 2007, at 6:00 P.M.
A. CALL TO ORDER
Mayor Vandergrift called the workshop session to order at 6:00 p.m. in the Commission
Chambers of City Hall. City Clerk Eikenberry called roll and declared a quorum present.
Roll Call: Commissioner Hood, Commissioner Anderson, Mayor Vandergrift,
Commissioner Keller, and Commissioner Johnson.
Also Present: City Attorney Rosenthal, City Manager Frank, City Clerk Eikenberry,
Human Resources Director Carnicella; Mackie Branham, Ray Tomlinson, and Tina
Wittman from Crown Consulting; and several interested employees.
B. DISCUSSION REGARDING OPTIONS FOR RESOLVING THE
CURRENT HEALTH INSURANCE PRICE INCREASE.
Human Resources Director Carnicella said that our current health care plan is
following the trend in health care and anticipated to increase by 18%. It is currently a
$2,523,540 million dollar plan that would increase to $2,977,777.
He stated the options were; 1) for the City to come up with the additional money, 2) for
the employees to absorb the cost 2 approximately $125/month increase, or 3) to change
the plan and/or funding arrangement.
Human Resources Director Carnicella reviewed the current plan stating that 87% of
employees are on the HMO "free" plan, and 13% have opted for the PPO plan. He stated
that there are 119 employees on the "employee only" plan and 155 employees that have
the "family" plan. He said last when we kept the plan the same the 155 employees with
dependant coverage had an increase from $187/month to $210/month. He said he is
proposing the HRA plan, which was introduced during the budget cycle, because if an
employee ended up with a catastrophic illness they would have to pay a maximum out-of-
pocket of $3500. He said if we would have changed to this plan last year, 27 people
would have reached the $3500 maximum, and the City would have saved $458, 157.
Human Resources Director Carnicella said the HRA plan actually shifts the cost to
those employees who have to use it the most. He added that most jurisdictions are
shifting the cost of the plan to all of the employees, and some are shifting it to those who
use it the most. He made comparisons between current plans, the HRA Plan, and an "in
between plan. He said the in between plan would have saved the City $85,176 if it had
been proposed at budget time.
Ray Tomlinson of Crown Consulting introduced other members of his company; Tina
Wittman, the Account Executive assigned to Ocoee, and Mackie Branham, his business
partner.
Varian Brandon -Boles, Strategic Accountant Executive from United Health Care, was
also present to answer questions.
Mr. Branham said he would like to assist the City in long term planning for health
insurance. He gave a PowerPoint presentation and reviewed cost projections for
increases of 7%, 11% and 15% over the next five years. He stated the City is currently
under a fully insured contract and the following two components are controlled by the
carrier:
Pooling Levels — amount of exposure per member inside of a group health plan. The city
currently we has $125,000 risk exposure per member inside of the group plan. By having
a high pooling level, the carriers control what your loss ratio is going to be. The
catastrophic exposures in the Exposure's Claims Experience determine that loss ratio.
Blended Rate Factors- combination of your group plan claims experience in combination
with their manual rates to project a blended rate and determine your costs in that given
year.
Mayor Vandergrift asked if not paying the higher premium wouldn't raise the pooling
level. Mr. Branham said they are designing a little self insured plan inside of the fully
insured product, called a Health Reimbursement Account (HRA) which takes on more
exposures as a City, in form of the deductible, and we will be rewarded in a lesser
premium paid out to United. An HRA is part of a fully insured contract, it just takes on
more risk exposure under the deductible, and the City would have to choose how that
deductible will be paid out by City and the employees.
Human Resources Director Carnicella said the savings in premium cost is over
700,000, but the City has to fund the pool of $1000 exposure for each employee, leaving
a difference of $458,000 in savings to the City. That figure is based on having a $1500
deductible with City funding the first $1000 and the employee funding the next $500 of
the deductible. Mr. Branham said you are creating a little self insured bucket inside of
your fully insured plan, thus lowering your premium. He then reviewed a chart showing
estimated HRA Utilization for the plan year using a model of a plan that is similar to the
plan the City would have. Out-of-pocket expenditures ranged from 375 of 681 members
paying from $1 - $99 on the low end, up to 120 of 681 members paying $1000 - $3500 on
the high end, with the remaining members falling in the middle of the ranges between
$100 - $1,000.
Human Resources Director Carnicella said that it is possible to structure the plan so
the employee's unused money in the bucket could roll over to their plan for the next year,
increasing the City contribution from $1000 to $2000. The plan proposed $2000 credit in
the bucket for family plans.
N
Commissioner Keller said he is on an HRA plan and was part of the committed who
designed it. He said most people who don't suffer serious illness in the first year have a
chance to build up that bucket, and it is the build up that makes that plan work.
Human Resources Director Carnicella said if the City decides to open a clinic for one
or two days, those services would be free to the City. The services and some
prescriptions would be free to the employee and would not cut into their out-of-pocket
expenses. There still could be an opportunity to work closely with United (or their
competitors) to come up with a way to meld various plans that we spoke of and come
back with a plan that will be good for everyone. We need to find a way to reduce the cost
of the plan and reduce the amount of burden that we shift to the employees. Hopefully, if
most employees stay healthy long enough to build a large bank to take care of you,
should there be some catastrophic event. The only problem is the employee who has that
catastrophic event right after the plan starts. He stated he and the City Manager have
discussed the option of using saved money in the bucket, if we had a good plan year, to
reduce the burden to those employees who had a serious illness. The problem with this
type of plan is that there is no way to guarantee that, because you cannot predict what
will happen.
Human Resources Director Carnicella said if we have a good year, and United Health
Care is drawing down on an account that we set up with our money, there is an
opportunity to get a substantial premium break. He discussed other ways to the plan to
get premium breaks by passing minor costs off to employees such as raising the co -pays,
the hospital visit, the urgent care visit, or using a clinic.
Ray Tomlinson described the Administrative Services Only (ASO) model. The only
thing that changes with this model is the why we fund the program. They first need to
look at size and claims history of an organization. Under these self funded arrangements
the City would set the Pooling Level (for example $50,000) where the City would pay
any claims that fall under $50,000 plus the administrative costs to United Way or other
carrier. The funding would be transparent to employees. The city would pay the first
dollars up to an aggregate so that the City would be protected by capping your exposure;
you would know what the worst case scenario would be on individual claims and
aggregate claims. The maximum claims exposure that you would have in a horrible
claims year generally runs about 10% over a fully funded plan. Under an ASO the
maximum claims exposure would be capped at that level, which would be less then the
trend for increases in other types of insurance. On a good claims year, you would not
have to pay out claims and on a bad claims year you would know what the cap is.
Commissioner Anderson asked where the numbers in the estimated HRA Utilization
came from. Mr. Tomlinson said it is a model based on an account very similar to the
City of Ocoee's. Commissioner Anderson said that he wants to make sure employees are
paying a negotiated rate for health care and not the published inflated rate. Mr.
Tomlinson they are still obligated to honor the contracted rates from United Health Care.
Commissioner Anderson said if we did well and beat the model; can we come back and
reimburse employees some of the deductible? Commissioner Keller said that would not
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build a larger bank which would roll over into next year and that is how the plan works.
Human Resources Director Carnicella said it is possible to reimburse the employees
some portion of their out-of-pocket expenses, but the plan would have to be designed that
way. Mayor Vandergrift asked if we could pool the money long enough to use it to self
insure? Mr. Tomlinson said if the City wants to self insure, the model that works best is
to use an ASO carrier like United because the have done the contracting and discounting,
and do it better than TPAs who negotiate rental networks, and they could get better
discounts. Mayor Vandergrift said he believed it would be a good idea to move toward
being self insured.
Human Resources Director Carnicella said we are not done looking at ways to tweak
the plan and put together several different options. He also said Mr. Tomlinson is also
looking at the possibility of sharing the clinic with surrounding cities and have it remain
open for five days. Mayor Vandergrift asked where the clinic would be, who would run
it, choose the staff, etc. Mr. Tomlinson said the City would have agreement with a third
party provider with experience in clinic operations that would handle administrative
duties and hire doctors, etc., but the City would set the hours of operation. The City
would have to provide the facility for the clinic. The City of Port St. Lucie is using a
house they obtained through eminent domain. The clinic would benefit the city because
more than half of your claims dollars are being spent on office visits and prescriptions. It
would have a long term impact through wellness programs and good disease management
programs. He said medical services provided in a clinic area better and less costly than in
the open marketplace.
Commissioner Anderson asked about evening hours of operation for the clinic. Mr.
Tomlinson said some cities do that, but most want their clinic open during the day and
encourage employees to go to the clinic by not docking them for time off.
Commissioner Anderson asked if the funding mechanism for the clinic would come
from reduced premiums. Mr. Tomlinson said that is how most organizations do it, but
they would like to look into other creative ways to find savings not add an additional
budgetary item. One form of savings from the clinic would come from Worker's Comp
injuries. If other communities would like to use the clinic, it may be able to be opened
for five days.
Commissioner Johnson asked if there are a set number of visits they will pay for before
we have to pay? Mr. Tomlinson said it is priced out on a per-employee/per-month basis,
so an increase in employees would increase the cost, or conversely decrease the cost if
there were fewer employees. Commissioner Johnson asked about prescriptions. Mr.
Tomlinson said they look at historic usage of pharmaceuticals and decide what to stock,
but it is the city's call on what will be stocked in the clinic. He said he thinks it is a good
idea to go with generic pharmaceuticals, but that would be decided by the City.
Human Resources Director Carnicella said as part of the proposal for the budget we
would like to include more self funding in other areas such as general liability and
worker's comp. He said he hopes to bring back a comprehensive package that will allow
substantial savings. We would have to put money in reserves in case of catastrophic
events, but if we have a good statistical year similar to the last 8 to 10 years, the savings
would more than pay for the clinic. He said we have to use a long term strategy and
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move toward a more self funded program without shifting the burden to the employees.
If we create steerage by building up the "bucket," we may decide how to play with the
co -pays, or give more options to employees, etc.
Commissioner Keller asked if we are only look at one HRA plan, or can we give options
to employees to stay in a similar plan to what they have. What happens if there is a clinic
and employees do not want to use it? Mr. Branham said to get the maximum premium
break from this it is much better to have a one plan model. Human Resources Director
Carnicella said employees have demonstrated what they would want to do because 87%
are in the HMO plan that has the low deductibles, so we would not get much of a
premium break because no one would move to the HRA. He added that we have to come
back with the very best model, probably a one -plan HRA model with a clinic. The
employees still have choices, they can go to their specialist or primary care provider, but
it would cost a little more.
Commissioner Keller said the clinic then becomes the "in network" and going outside of
that would raise their deductible to the maximum out-of-pocket of $3500. Are we taking
away their share of the "bucket" if they do not use the clinic?
Human Resources Director Carnicella said don't assume it is gong to be the HRA
model, it may be a melding between the current HMO and the HRA model merged into
one plan that may have an out-of-pocket of $1500 or $2000.
Commissioner Anderson confirmed that if you go to your own doctors you would still
get the first $1000 money from the "bucket" as part of your $1500 deductible.
Human Resources Director Carnicella said the incentive to use the clinic is that the
City would save more money and may be able to pay co -pays if a specialist is necessary.
Mayor Vandergrift said he would like to see a hotline set up for employees so all of
their questions would be answered.
Commissioner Anderson asked the monthly cost to insure a family. HR Analyst
Bertling advised it was $1072.72 per month.
Commissioner Anderson said he has a concept that he would like the Commission to
consider that is being done right now outside the United States. He asked if we could
negotiate a family group health insurance price that we could also offer to residents of the
City of Ocoee. Could we firewall it to where a high risk scenario would not affect the
City employee's premiums. Human Resources Director Carnicella said the only
people who can be covered by the current plan are employees, or independent contractors
who work for us.
Mr. Tomlinson said that Congress has been trying to pass a plan of that concept called
an Association Plan, where there is a commonality of people. That has not been
approved yet, and at this time there has to be an employment relationship. The group
products out there are not able to do that yet. You could allow citizens to use the medical
clinic since it is not insurance and does not fall under the regulatory agencies that prohibit
it. The City would have to determine cost for citizens as opposed to free clinic for
employees. You would have to determine an eligibility list of those who could use the
clinic. Commissioner Johnson said employees would have to wait too long to use the
clinic if it were also opened to the residents. Mr. Tomlinson said there would be a lot of
details that would have to be worked out.
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Commissioner Anderson asked how the state offers insurance to people. Mr.
Tomlinson said that is a MEWA — multiple employer welfare association, which is more
of an association plan that the City cannot do.
Commissioner Anderson said he would like us to consider the idea of the clinic being
available idea to residents on a non-priority basis.
QUESTIONS FROM EMPLOYEES:
Nancy Cox asked if the deductibles cover the amount the doctor charges or just the co -
pay. Mr. Branham said under the co -pay arrangement, the $15 would be your out-of-
pocket exposure for that event. Other exposure such as in patient stay, surgical events,
and diagnostic events such as MRIs is covered by your deductible; anything else done in
the office is covered under the co -pay and the deductible exposure does not apply.
Mr. Lipton — did the city check to see if the state or county had a health insurance
program that we could join with them to save money. Mr. Tomlinson said there are
Interlocal or Consortium Plans such as the one with Marion County, Ocala, Dunedin, and
two other small cities. They came together to get a better leveraging power through a
purchasing alliance. They are self insured. Human Resources Director Carnicella said
they have not looked into that option. Mayor Vandergrift said it would be a good idea
to research that or contact Florida League of Cities to see if they have information.
Ricky Waldrip-said he understands the City is trying to save money, but there are not
many employees that could handle $3500 out-of-pocket if they had a serious illness.
Mayor Vandergrift said he does have a problem with putting the burden on the one who
needs the insurance most due to a serious illness. He would also like the city to look into
pooling money to give to others who become seriously ill. Commissioner Johnson said
we have to find a way to give the employees good insurance, but cut the costs to the City
to cover the plan so that we can keep other benefits where they need to be such as raises
and pensions.
Commissioner Anderson — said we changed to United Last year. Where would Blue
Cross be this year, now that United is so high? Have we looked into that to see if they
offer us last year's rate? Mr. Tomlinson said looked at Blue Cross at last renewal and
they were a little higher, but we can look at it again.
Mayor Vandergrift said he wants a newsletter and hotline set up to discuss this issue.
Commissioner Johnson said we also have to keep in mind what is going to happen with
the state legislature and what impact it will have on the City. City Manager Frank said
the House proposal, as it stands right now, would have between a three and five million
dollar impact on the city's revenue.
Commissioner Anderson asked what the out-of-pocket expense would be on the current
HMO plan, as opposed to the HRA plan. Human Resources Director Carnicella said
less that $1000 maximum.
Mayor Vandergrift said we need to keep the employees involved in the process. He
asked City Clerk Eikenberry to put together a newsletter to inform the employees what
was discussed with a telephone hotline and an FAQ section.
Kathy Lipton asked if they have surveyed the employees to see if they would even use a
clinic before they spend money to open one, and what about liability of a clinic and the
fact that they have no history on you. Mayor Vandergrift said the liability will be taken
on by the clinic provider. The usage of the clinic should fall under the FAQs that will be
answered.
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Human Resources Director Carnicella said you may still go to your regular doctor, but
the clinic has the capability of getting your records from other doctors should you decide
to go there.
Jean Grafton, retiree, said asked if the future plan will include retirees. Human
Resources Director Carnicella said the retirees will remain on our insurance as they
always have. There is no recommendation to remove coverage for retirees. There is an
unfunded liability issue that will have to be answered through the Finance Department in
the next year. Ms Grafton asked if the cost of the plan will go down. Human Resources
Director Carnicella said if we do nothing to change the existing plan, those that have to
pay for the plan such as retirees and dependent coverage, will suffer the increased every
year. Ms. Grafton said, retirees who are on a fixed income, must absorb all of the
insurance increase, while employees with dependant coverage only absorb a small
portion of the increase; will that change? Human Resources Director Carnicella said
the Pension Board needs to look at those issues and if the fund is doing better they can
build in that type of protection for retirees. Mayor Vandergrift said he would like to see
the retirees included in the insurance newsletter that is going out. How will this affect
retirees not living in this area that cannot use the clinic? Commissioners consented they
would lose that privilege and have to go their regular physicians. Ms. Grafton asked if
the fund for the catastrophic medical loss has started already, is the City prepared to
absorb the costs in the worst case scenario. Human Resources Director Carnicella said
we are currently still under the old plan and in the planning stages for the new plan. Ms.
Grafton asked how this will affect the present and future retirees once they are eligible
for Medicare. Human Resources Director Carnicella we have not given that too much
consideration yet, but that is an issue that will be coming up. We have to figure out how
to handle retirees after they are on Medicare, it may be possible to do a supplemental
plan. Mayor Vandergrift said he thinks there is a standardization of how to handle
Medicare. Ms. Grafton said if they will pay for Medicare Supplement instead of the full
policy, will the cost be reduced. Human Resources Director Carnicella said that it
should, but it still needs to be researched. Ms. Grafton said there are 37 retirees at this
time who are waiting to hear the answers.
The consensus of the commission was to hold another workshop at the
end of May so that we can get numbers together for the budget.
Mayor Vandergrift said before the next workshop he would like a newsletter to go out
with minutes of this meeting and a hotline for information. An email hotline would be
even better for FAQ's. He thanked the employees for coming here tonight to be involved
in the process.
The meeting adjourned at 8:11 p.m.
Attest:
Beth Eikenberry, City Clerk
h
APPROVED:
City of Ocoee
S. Scott Vandergrift, Mayor
YOUR BENEFITS
UnitedHealthcare
Choice Plus Plan 101
Choice Plus plan gives you the freedom to see any Physician or other
health care professional from our Network, including specialists,
without a referral. With this pplan, you will receive the highest level of
benefits when you seek care from a network physician, facility or other
health care professional. In addition, you do not have to worry about
any claim forms or bills.
You also may choose to seek care outside the Network, without a
referral. However, you should know that care received from a non -
network physician, facility or other health care professional means a
higher deductible and Copayment. In addition, if you choose to seek
care outside the Network, UnitedHealthcare only pays a portion of
those charges and it is your responsibility to pay the remainder. This
amount you are required to pay, which could be significant, does not
apply to the Out -of -Pocket Maximum. We recommend that you ask the
non -network physician or health care professional about their billed
charges before you receive care.
Some of the Important Benefits of Your Plan;
You have access to a Network of
physicians, facilities and other health care
professionals, including specialists, without
designating a Primary Physician or
obtaining a referral.
Benefits are available for office visits and
hospital care, as well as inpatient and
outpatient surgery.
Care CoordinationsM services are available
to help identify and prevent delays in care
for those who might need specialized help.
rLNGM 10104
Emergencies are covered anywhere in the
world.
Pap smears are covered.
Prenatal care is covered.
Routine check-ups are covered.
Childhood immunizations are covered.
Mammograms are covered.
Vision"and hearing screenings are covered.
Choice Plus Benefits Summary
Types of Coverage
Network Benefits I Copayment Amounts
Non -Network Benefits 1 Copayment Amounts
This Benefit Summary is intended only to highlightyour
s��
Annual Deductible: S5t1D par Covered Person per
Annual Deductible: $1,000 per Covered Person per
Benefits and should not be relied upon to fully
calendar year, not to exceed far alt Covered
calendar year, not to exceed 52,000 for all Covered
determine coverage. This benefit plan may not cover all
Persons in a family.
Persons in a family.
of your health care expenses. More complete
descriptions of Benefits and the terms under which
Out -o[ -Pocket Maximum: 52,000 per Covered Person,
Out -of -Pocket Mnximum. 54,000 per Covered Person,
they are provided are contained in the Cortifcote of
per calendar year, not to exceed $4,000 for all Covered
per calendar year, not to exceed 58,000 for nil Covered
Coverage that you will receive upon enrolling in the
Persons in a family. The Out -of -Pocket Maximum does
Persons in a family. The Out -of -Pocket Maximum does
Plan,
not include the Annual Deductible. Copayments for
not include the Annual Deductible. Copayments for
If this Bencfit Summary conflicts in any way with the
same Covered Health Services will never apply to the
Out -of -Packet Maximum as specified in Section i of the
some Covered Health Services will never apply to the
Out -of -Pocket Maximum as specified in Section 1 of the
Policy issued to your employer, the Policy shall prevail.
COC,
COC.
Terms that are capitalized in the Benefit Summary are
defined in the Certificate of Coverage.
Where Benefits are subject to day, visit and/or dollar
limits, such limits apply to the combined use of Benefits
whether in -Network or out -of -Network, except where
mandated by state law.
Network Benefits are payable far Covered Health
Services provided by or under the direction of your
Network physician.
*Prior Notification is required for certain services.
1. Ambulance Services - Emergency only
2. Dental Services - Accident only
3. Durable Medical Equipment
Network and Non -Network Benefits for Durable
Medical Equipment are limited to $2,500 per
calendar year. Limits do not apply to Durable
Medical Equipment classified as diabetic equipment
or supplies.
4. Emergency Health Services
5. Eye Examinations
Refractive eye examinations are limited to one
every other calendar year from a Network Provider.
6. Home Health Care
Network and Non-Natwork Benefits are limited to
60 visits for skilled care services per calendaryear.
7. Hospice Care
Network and Non -Network Benefits are limited to
360 days during the entire period of time a Covered
Person is covered under the Policy.
8. Hospital - Inpatient Stay
9. Injections Received in a Physician's Office
10. Maternity Services
11. outpatient Surgery, Diagnostic and Therapeutic
Services
Outpatient Surgery
Outpatient Diagnostic Services
Outpatient Diagnostic/Thempeutic Services - CT
Scans, Pet Scans, MRI and Nuclear Medicine
Outpatient Therapeutic Treatments
12, Physician's Oflice Services
Covered Health Services for preventive medical
care.
Covered Health Services for the diagnosis and
treatment of a Sickness or Injury received in a
Physician's office,
Mnximum Policy Benefit: No Maximum Policy
Benefit.
Ground Transportation: 10% ofEligible Expenses
Air Transportation: 10% of Eligible Expenses
* 10% ofEligible Expenses
*Prior notification is required before follow-up
treatment begins.
10% of Eligible Expenses
S 100 per visit
S10 per visit
1091a of Eligible Expenses
10:0 ofEligible Expenses
10% of Eligible Expenses
$10 per visit
Same as 8, 11, 12 and 13
No Copayment applies to Physician office visits for
prenatal care after the first visit.
10% ofEligible Expenses
For lob and mdiology/Xmy:
No Copayment
101% of Eligible Expenses
1090 of Eligible Expenses
Preventive Medical Care - $kU per visit, except that the
Copayment for a Specialist Physician Office visit is 530
per visit. No Copayment applies when a Physician
charge is not assessed.
Sickness or Injury - SOper visit, except that the
Copayment fora Specialist Physician Office visit is SSP
per visit. No Copayment applies when a Physician
charge is not assessed
Maximum Policy Benefit: $1,000,000 per Covered
Person.
Same as Network Benefit
*Same as Network Benefit
*Prior notification is required before follow-up
treatment begins.
*3G% ofEligible Expenses
*Prior notification is required when the cost is more
than S 1,000.
Same as Network Benefit
*Notification is required if results in an Inpatient Stay.
30% ofEligible Expenses
Eye Examinations for refractive errors are not covered.
*30% ofEligible Expenses
*30% of Eligible Expenses
*30% of Eligible Expenses
30% per injection
Same as 8, 11, 12 and 13
*Notification is required if inpatient Stay exceeds 48
hours following a normal vaginal delivery or 96 hours
following a cesarean section delivery.
30% of Eligible Expenses
30% of Eligible Expenses
30% ofEligible Expenses
30% ofEligible Expenses
No Benefits forpreventive care, except forChild Health
Supervision Services.
30% ofEligible Expenses
Additional Benefits
Bones or Joints of the Jaw and racial Region
Same as 8, 11, 13 and 13
YOUR BENEFITS
Types ofCovemge
Network Benefits I Copayment Amounts
Non -Network Benefits I Copayment Amounts
13. Professional Fees for Surgical and Medical
10% ofEligible Expenses
30% of Eligible Expenses
Services
Same as 8, It. 12, 13, and 16
*Same as 8, 11, 12, 13, and 16
14. Prosthetic Devices
10% of Eligible Expenses
30% of Eligible Expenses
Network and Non -Network Benefits for prosthetic
Same as 3, 11, 12 and 13
Same as 3, 11, 12 and 13
devices are limited to $3,500 per calendar year.
No Copayment
same as Network Benefit
15. Reconstructive Procedures
Same as 8, 11, 12,13 and 14
*Same as 8, 11, 12,13 and 14
16. Rehabilitation Services-OutpatientTherapy
S10per visit
30% of Eligible Expenses
Network and Non -Network Benefits are limited as
follows: 20 visits of physical therapy; 20 visits of
occupational therapy; 20 visits ofspeech therapy; 20
visits of pulmonary rehabilitation; and 36 visits of
cardiac rehabilitation per calendar year.
17. Skilled Nursing Facility/Inpatient Rehabilitation
10% of Eligible Expenses
*30% of Eligible Expenses
Facility Services
Network and Non -Network Benefits are limited to
60 days per calendar year.
18. Transplantation Services
• 10% ofEligibic Expenses
*30% of Eligible Expenses
19. Urgent Care Center Services
$50 per visit
30%of Eligible Expenses
Additional Benefits
Bones or Joints of the Jaw and racial Region
Same as 8, 11, 13 and 13
*30% of Eligible Expenses
Child Health Supervision Services
Same as 11, 12, 13 and 16
Same as 11, 12,13 and 16
Coverage fmm birth to age 16.
No Annual Deductible applies.
No Annual deductible applies.
Cleft Lip/Cleft Palate Treatment
Same as 8, It. 12, 13, and 16
*Same as 8, 11, 12, 13, and 16
Dental Procedures - Anesthesia and Hospitalization
Same as 8, 11. and 13
*Same as 8, 11 and 13
Diabetes Treatment
Same as 3, 11, 12 and 13
Same as 3, 11, 12 and 13
Mammography
No Copayment
same as Network Benefit
Mastectomy
Same as 8, 11, 12 and 13
*Same as 8, 11, 12 and 13
Mental Heulth and Substance Abuse Services -
S30 per individual visit; S25 per group visit
30% of Eligible Expenses
Outpatient
Must receive prior authorization through the Mental
Health/Substance Abuse Designee. Network and Non -
Network Benefits are limited to 30 visits per calendar
year.
Mental Health and Substance Abuse Services-
10% of Eligible Expenses
30% ofElieibleExpenses
Inpatient and intermediate
Must receive prior authorization through the Mental
Health/Substance Abuse Designee. Network and Non -
Network Benefits ore limited to 30 days per calendar
year.
Osteoporosis Treatment
Same as H, 12 and 13
Some as 11, 12 and 13
Prescription and Non -Prescription Enteral Formulas
10%of Eligible Expenses
30%ofEligible Expenses
Benefits for low protein food products for Covered
Persons through age 24 are limited to S2,500 per calendar
year.
Spinal Treatment
Benefits include diagnosis and related services and are
S30 per visit
3G% of Eligible Expenses
limited to one visit and treatment per day. Network and
Non -Network Benefits are limited to 24 visits per
calendar year.
Exclusions
Except as may be specifically provided in Section I of the Cenificate of Coverage (COC) art thmugh a
Rider to the Policy, tine following are not covered:
A. Alternative Treatments
Acupressure hypnotism; rolfing; massage therapy; aromatherapy; acupuncture; and other forms of
alternative treatment.
B. Comfort or Convenience
Personal comfort or convenience items or services such as television; telephone; barber or beauty
service; guest service; supplies, equipment and similar incidental services and supplies for personal
comfort including air conditioners, air puriftcrs and Filters, batteries and battery chargers,
dehumidifiers and humidifiers; devices or computers to assist in communication and speech.
C. Dental
Except as specifically described as covered in Section I ofthe COC under the headings Dental
Services - Accident only, Dental Services- Anesthesia and Hospitalization and Cleft Lip/Cleft Palate
Treatment, dental services are excluded. There is no coverage for services provided for the prevention,
diagnosis, and treatment ofthe teeth or gums (including extraction, restoration, and replacement of
teeth and services to improve dental clinical outcomes). Dental implants and dental braces are
excluded. Dented x-rays, supplies and appliances and all associated expenses arising out of such dental
services (including hospitalizations and anesthesia) aro excluded, except as might otherwise be
required far transplant preparation, initiation of in munosuppressives, the direct treatment ofacute
traumatic Injury, cancer, or cleft palate, oras described in Section I of the COC under the heading of
Dental Procedures- Anesthesia and Hospitalization. Treatment for congenitally missing,
malpositioned, or super numerary tcrvh is excluded, even if port Ora Congenital Anomaly except in
connection with cleft lip orcleft palate except as described in Section I ofthe COC under the heading
CIcR Lip/Clef Palate Treatment.
D. Drugs
Prescription drug products for outpatient use that am filled by a prescription order or refill. Self -
injectable medications except as described in Section I of the COC under die heading of Diabetes
Treatment Nan -injectable medications given in aPhysician's office except as required in an
Emergency. Over-the-counter drugs and treatments.
E. Experimental, Investigational or Unproven Services
Experimental, Investigational or Unproven Services are excluded, except (a) bone marrow transplants
and (b) medically appropriate medications prescribed for the treatment ofcancer, for a particular
indication, if that drug is recognized for the treatment of that indication in a standard reference
compendium or recommended in medical literature. The fact that an Experimental, Investigational or
Unproven Service, treatment, device or pharmacological ocuimen is the only available treatment for a
particular condition will nix mutt in Benefits ifthe procedure is considered to be Experimental,
Investigational or Unproven in the treatment of that particular condition.
E Foot Care
Routine foot care (including thecmiing orremoval creams and calluses); nail trimming, cutting, or
debriding; hygienic and preventive maintenance fool cave; treatment of flat feet or subluxation of the
root; shoo arthotics.
G. Medical Supplies and Appliances
Devices used specifically as safety items or to affect perf tamonce primarily in sports -related activities.
Prescribed or non -prescribed medical supplies and disposable supplies including but not limited to
clastic stockings, ace bandages, gwze and dressings, ostomy supplies, syringes and diabetic test strips.
Orthotic appliances that straighten or re -shape a body pan (including cranial banding and some type
ofbraces). Tubings and masks are not covered except when used with Durable Medical Equipment is
described in Section 1 of the COC.
H. Mental health/Substance Abuse
Services performed in connection with conditions not classified in die current edition ofthe
Diagnostic and Statistical Manual ofthe American Psychiatric Association. Services that extend
beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis intervention.
Mental Health treatment of insomnia and other sleep disorders, neurological disorders, and other
disorders with a Mown physical basis.
Treatment orconduct and impulse central disorders, personality disorders, paraphilias and other
Mensa] Illnesses that will not substantially improve beyond rile current level orfunctionina. or that are
not subject to favorable modification or management according to prevailing national standards of
clinical practice, as reasonably determined by the Mental Hcalth/Substance Abuse Designee,
Services utilizing methadone treatment as maintenance, L.A.A.M, (1-Aipha-Acetyl-Methadoi),
Cyclazocine, or their equivalents. Treatment provided in connection with or to comply with
involuntary commitments, police detentions and other similar arrangements, unless authorized by the
Menta HedthlSubstance Abuse Designee. Residential treatment services. Services or supplies that in
the reasonable judgment ofthe Mental Health/Substance Abuse Designee are not, rot example,
consistent with can -in national standards arprofessional research further described in Section 2 ofthe
COC.
1. Nutrition
Megavitamin and nutrition based therapy; nutritional counseling for either individuals or groups.
Enteral fecdinus and other nutritional and electrolyte supplements, including infant formula and donor
breast milk, except as described in Section 1 ofthe COC under the heading Prescription and Non-
prescription Enteral Formulas.
UnitedHealtheare Insurance Company
J. Physical Appearance
Cosmetic Procedures including, but not limited to, pharmacological regimens; nutritional procedures
or treatments; salabrtsioa, chemasurgery and other such skin abrasion procedures associated with the
removal of sears, tactics, and/or which we performed as a treatment for acne. Replacement of an
existing breast implant is excluded if the earlier breast implant was a Cosmetic Procedure.
(Replacement of an existing breast implant is considered reconstructive if the initial breast implant
followed mastectomy.) Physical conditioning programs such as athletic training, bodybuilding,
exercise, fitness, flexibility, and diversion or general motivation. Weight loss programs far medical
and non-medical reasons. Wigs, regardless of the reason for the hair loss.
IC. Providers
Services performed by a provider with your same [cwd residence or who is a family member by birth
or marriage, including spouse, brother, sister, parent or child. This includes any service the provider
may periarm on himself or herself. Services provided at a free-standing or Hospital-based diagnostic
facility without an order written by a Physician or other provider as further described in Section 2 of
the COC (this cxl4sion does not apply to mammography testing).
L, Reproduction
Health services and associated expenses for infertility treatments. Surrogate parenting. Tba reversal or
voluntary sterilization.
M. Services Provided under Another Plan
Health services for which coverage is paid under arrangements required by federal, state or local taw.
This includes, but is not limited to, coverage paid by workars' compensation, no-fault automobile
insurance, or similar legislation. Health services for treatment of military service -related disabilities,
.ben you are legally entitled to other coverage and facilities are reasonably available to you. Health
services while on active military duty.
N. Transplants
Health services far organ or tissue transplants are excluded, except those specified as covered in
Section t of the COC. Any solid organ transplant that is performed as a treatment for cancer. Health
services connected with the removal of an organ or tissue from you fur purposes ar a transplant to
another person. Health services for transplants involving mechanical or animal organs. Any multiple
organ transplant net fisted as a Covered Hcalth Service in Section 1 of the COC.
O. Travel
Health services provided in a foreign country, unless required as Emergency Health Services.
Travel or transportation expenses, even though prescribed by a Physician. Some travel expenses
related to covered transplantation services may be reimbursed at our discretion.
P. Vision and Hearing
Purchase cost of eye glasses, contact lenses, or hearing aids. Fitting charge for hearing aids, eye
glasses or contact lenses. Eye exercise therapy. Surgery that is intended to allow you to see better
without glasses or other vision correction including radial keratotomy, laser, and other refractive eye
surgery.
Q. Other Exclusions
Health services and supplies that do not meet tide definition ora Covered Health Service - see
definition in Section 10 of the COC.
Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or
nemments otherwise covered under lite Policy, when such services are: (1) required solely for
purposes of career, education, sports or comp, travel, employment, insurance, marriage or adoption;
(2) relating to judicial or administrative proceedings or orders; (3) conducted for purposes of medical
research; or (4) to obtain or maintain a license of any type.
Health services received as a mutt of war or any act of war, whcihcr declared or undeclared or caused
during service in the armed forces of any country.
Health services received after the date your coverage under the Policy ends, including health services
for medical conditions arising prior to the date your coverage under tine Policy ends.
Health services for which you have no legal responsibility to pay, or for which a charge would not
ordinarily be made in the absence of coverage under the Policy. In the event that a Nan -Network
provider waives Copayments and/or the Annual Deductible rat a panicular health service, no Benefits
are provided for die health service for which Copayments and/or the Annuat Deductible ate waived,
Charges in excess of Eligible Expenses of in excess of any specified limitation.
Services for the evaluation and treatment of temporomandibularjoint syndrome fines), whether the
services we considered to be medical or denial in nature, except as described in Section i of the COC
under the heading Bones or Joints ofthe law and Facial Region. Upper and lower jaw bone surgery
except as required for the direct treatment of acute imumatic Injury or cancer. Orthognathic surgery,
jaw alignment, and treatment for the temporomandibular joint, except as a treatment of obstructive
sleep apnea.
Surgical treatment and non-surgical tremmcm of obesity (including morbid obesity).
Growth hormone therapy; sex transformation operations; treatment of benign gynecomastia (abnormal
breast enlargement in males); medical and surgical treatment of excessive swerving (hyperhidrosis);
medical and surgical treatment for snoring, except when provided as pari ortrawment far documented
obstructive steep apnea Oral appliances for snoring. Custodial care; domiciliary care; private duty
nursing; respite care; rest cures.
Psychosurgery. Speech therapy except as required for treatment of a speech impediment or speech
dysfunction that results from Injury, stroke, cleft lip/claft palate or Congenital Anomaly.
This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care expenses. Please refer to the
Certificate of Coverage for a complete listing of service; limitations, exclusions and a description of all the farms and conditions of Coverage. Ifthis description conflicts in any way with tine Cmifewit of
Coverugc, the Certificate afCovemge prevails. Terms that we capitalized in the Benefn Summary are defined in the Certificate of Coverage.
02I HS_ChcPls FLNGM10104 AAF 213-1451 1004 rev05
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