ANNUAL BENEFITS ELECTION PERIOD NOVEMBER 7, 2016 NOVEMBER 30, 2016

Transcription

1 ANNUAL BENEFITS ELECTION PERIOD NOVEMBER 7, 2016 NOVEMBER 30, 2016 Enroll Online at Or contact the Benefits Enrollment Call Center at (Monday through Friday; 8am to 8pm EST) This is your opportunity to review your current benefit elections, plan changes, new features and options so you are able to select the benefits that are the best fit for you and your family.

2 WHAT S NEW IN BRIEF Medical Good News! 2017 Associate Medical Contributions Remain at 2016 Levels New, Two-tiered MonteCare EPO and MonteCare PPO, the for Facility Charges (Preferred and Non-preferred Facilities) Increased MonteCare PPO Deductible Prescription Drugs Expanded Express Scripts Utilization Management Features New Voluntary Dental Buy-up Enhancement Option Lower Deductible, Higher Annual Maximum Benefits and Higher Reimbursement Levels for Major Restorative Services. Enhanced Life and AD&D Insurance Coverage Options New Life Insurance Carrier Securian Life Insurance Company One-time Opportunity to newly Enroll for Basic Coverage or Increase Your Voluntary Life Insurance (by one level) and Dependent Life Insurance (by up to two levels) Without Providing Evidence of Insurability (EOI) Lower Voluntary Supplemental Life and AD&D Insurance Rates and Higher Maximum Benefits New Voluntary Supplemental Family AD&D Insurance 2

3 WHAT S CHANGING FOR 2017 MEDICAL Changes to MonteCare EPO and MonteCare PPO, the Under the MonteCare EPO and MonteCare PPO, the will have two tiers of coverage for facility charges Network Preferred Facilities and Network Non-Preferred Facilities. Your share of the cost will be higher when you use a Non-Preferred Facility for inpatient, outpatient and High-Tech Radiology Services*. Network Non-Preferred Facilities are non-montefiore** inpatient, outpatient and free-standing diagnostic imaging facilities located in the Bronx, Westchester and Manhattan (only). These facilities include, but are not limited to: CareMount Medical (Mount Kisco Medical Group) Hospital for Special Surgery Memorial Sloan-Kettering Mount Sinai Health System New York Presbyterian System (including Lawrence Hospital, Columbia University, Weill Cornell Medical Center) Northwell Health (including Lenox Hill Hospital, Northern Westchester Hospital, Phelps Memorial Hospital) NYU Langone Medical Center Westchester Medical Center High-Tech Radiology Services. * High-Tech Radiology Services include, but are not limited to, diagnostic MRIs, MRAs, CAT Scan, PET Scan and Nuclear Radiology. ** This does not include Montefiore affiliates White Plains Hospital, Riverside HealthCare System, Burke Rehabilitation and St. Joseph s. 3

4 Cost Comparison for Facility Charges Your cost if you use: Row Heading Tab1 Heading INPATIENT FACILITY Tab1 Content Tab2 Heading Tab2 Content Tab3 Heading Tab3 Content Tab4 Heading Tab4 Content Row Heading Tab1 Heading Preferred Facility MonteCare EPO 20% 1 coinsurance after deductible if precertified by Conifer Value Based Care; otherwise 30% 1 coinsurance after deductible MonteCare PPO $1,000 copay if precertified by Conifer Value Based Care; otherwise $1,500 copay Non-preferred Facility MonteCare EPO 40% 1 coinsurance after deductible if precertified by Conifer Value Based Care; otherwise 50% 1 coinsurance after deductible MonteCare PPO $2,000 copay if precertified by Conifer Value Based Care; otherwise $2,500 copay except in the case of an emergency MonteCare PPO 40% 2 coinsurance after $1,000 copay if precertified by Conifer Value Based Care; otherwise $1,500 copay OUTPATIENT FACILITY Tab1 Content Tab2 Heading Tab2 Content Tab3 Heading Tab3 Content Tab4 Heading Tab4 Content Row Heading Tab1 Heading Preferred Facility MonteCare EPO 20% 1 coinsurance after deductible MonteCare PPO $500 copay Non-preferred Facility MonteCare EPO 40% 1 coinsurance after deductible MonteCare PPO $1,000 copay MonteCare PPO 40% 2 coinsurance after deductible HIGH-TECH RADIOLOGY SERVICES (include, but not limited to diagnostic MRI, MRA, CAT SCAN, PET, NUCLEAR CARDIOLOGY) Tab1 Content Tab2 Heading Tab2 Content Tab3 Heading Tab3 Content Tab4 Heading Tab4 Content Preferred Facility MonteCare EPO 20% 1 coinsurance after deductible MonteCare PPO $250 copay Empire BlueCard PPO Provider Non-preferred Facility MonteCare EPO 40% 1 coinsurance after deductible MonteCare PPO $500 copay MonteCare PPO 40% 2 coinsurance after deductible 4

5 Higher MonteCare PPO Deductible The MonteCare PPO Deductible will increase in The deductible is the amount you must pay before benefits for certain covered services are paid. The deductible applies to each covered individual once each calendar year. The covered expenses of all family members may be used to help meet the family maximum. The amount of the deductibles depends on the option and level of coverage you elect, as follows. Row Heading Tab1 Heading Tab1 Content Tab2 Heading INDIVIDUAL/FAMILY DEDUCTIBLE MonteCare EPO None MonteCare PPO None Tab2 Content MonteCare EPO $500/$1,000 MonteCare PPO $500/$1,000 Tab3 Heading Tab3 Content MonteCare PPO $1,000/$2,500 5

6 PRESCRIPTION DRUGS Expanded Utilization Management Reviews Utilization management reviews strengthen the quality and safety of the Express Scripts Prescription Drug Program. Montefiore has contracted with Express Scripts to reduce administrative fees through streamlined and automated processes. Expanded Utilization Management reviews helps to reduce costs and ensure safe and appropriate prescription drug usage. For new prescriptions, Express Scripts will notify you directly if you are affected by any of the following guidelines: Drug Utilization Review Express Scripts reviews your prescriptions and will alert your physicians and pharmacists for situations that indicate: drug interactions, allergies or disease; excessive daily dosing or duration of therapy; gender contraindications; potential drug name confusion; refills toolate or too-soon; severe drug interactions; sub-therapeutic dosing or therapy duplication. Quantity/Dose Limitations Prescriptions for generic and brand name medications will only be filled in quantities and doses that are consistent with manufacturer and FDA clinical guidelines. If your doctor prescribes a drug in a quantity/dose that exceeds these guidelines, your prescription will be filled according to the guidelines. Preferred Drug Step Therapy (PDST) Before using a higher cost non-preferred drug, you are required to try a generic alternative or preferred brand name medication first. If your doctor prescribes a non-preferred drug, Express Scripts will work with your doctor to see if a generic alternative or preferred brand name medication would be equally effective. (In some cases, special circumstances may require you to use a non-preferred drug.) Note: If your prescription history shows that you have already tried preferred drugs, your prescription will be filled without a review. Drug Specific Prior Authorization If you doctor prescribes a drug that requires prior authorization, Express Scripts will review your prescription and contact your doctor to determine if your prescription qualifies for drug coverage based on nationally accepted clinical guidelines and standards. 6

7 DENTAL The New Cigna DPPO Enhanced Dental Plan provides: A lower deductible and higher annual maximum benefits than the Cigna DPPO and Higher reimbursement for major restorative services than our current plans provide. Here s an overview of your costs for services under the enhanced plan compared to our current plans. Row Heading Preventive and Diagnostic Services Tab1 Content Preventive and Diagnostic $0 Cigna DHMO - $0 Cigna DPPO $0 Cigna Enhanced DPPO - $0 Row Heading Tab1 Content Row Heading Tab1 Content Row Heading Tab1 Content Row Heading Tab1 Content Row Heading Tab1 Content Row Heading Tab1 Content Annual Deductible Preventive and Diagnostic None Cigna DHMO - None Cigna DPPO $100 individual; $300 family (basic, major and orthodontic services combined) Cigna Enhanced DPPO - $50 individual; $100 family Basic Services Preventive and Diagnostic Not covered Cigna DHMO - $0 Cigna DPPO 20% coinsurance after deductible Cigna Enhanced DPPO - 20% coinsurance after deductible Major Services Preventive and Diagnostic Not covered Cigna DHMO - 30% 1 coinsurance Cigna DPPO 50% coinsurance after deductible Cigna Enhanced DPPO - 40% coinsurance after deductible Annual Maximum Benefits (for each covered person) Preventive and Diagnostic None Cigna DHMO - None Cigna DPPO $1,500/$2,500 if you use a Montefiore dentist Cigna Enhanced DPPO - $2,500 regardless of the dentist you use Orthodontics Preventive and Diagnostic Not covered Cigna DHMO - 50% 1 coinsurance Cigna DPPO 20% coinsurance after deductible Cigna Enhanced DPPO - 20% coinsurance after deductible Lifetime Orthodontic Maximum Preventive and Diagnostic None Cigna DHMO - None Cigna DPPO $2,000 Cigna Enhanced DPPO - $2,000 If you elect the new Cigna DPPO Enhanced Dental Plan, you pay the difference in cost between the Cigna DPPO and the Enhanced Plan. 7

8 NEW LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE OPPORTUNITIES Montefiore has selected Securian Life Insurance Company as the new insurance carrier for our Life and AD&D Insurance Plans. Life Insurance helps protect your family against the unexpected loss of your life and income during your working years. Life insurance proceeds can be an important tool in helping your family afford final expenses, such as funeral and medical bills, as well as day-to-day financial obligations. AD&D Insurance provides additional financial protection if an insured s death or dismemberment is due to a covered accident, whether it occurs at work or elsewhere. Enhancements to the plans include the ability to: Elect up to 8X your annual base salary in Supplemental Life and AD&D Insurance Increase your maximum Supplemental Life benefit up to $1,000,000 Increase your Supplemental Life Insurance coverage at lower rates Elect Dependent AD&D coverage for your spouse and children and only during this Annual Enrollment, you may newly enroll or increase your life insurance coverage by 1X your annual base salary up to 3X your annual base salary or $1,000,000 (whichever is less) without providing Evidence of Insurability (EOI). Securian also provides access to LifeSuite Services at no additional cost. These services include Legacy Planning Resources, Travel Assistance Services and Legal, Financial and/or Grief resources. 8

9 Life Insurance - Evidence of Insurability (EOI) For 2017, EOI requirements will be waived if you may make the following changes to your Life Insurance during the annual enrollment period: Basic Life Insurance: If you previously waived Basic Life Insurance coverage, you may elect either 1X your annual base salary (or $50,000 to avoid imputed income). Imputed income is the value the IRS assigns to the premium of any Montefiore-provided Basic Life Insurance coverage over $50,000. Supplemental Life Insurance: If you previously waived Supplemental Life Insurance coverage, you may elect coverage equal to 1X your annual base salary (up to a maximum of $1,000,000). If your current Supplemental Life Insurance is equal to 1X or 2X your annual base salary, you may increase your coverage by 1X your annual base salary (up to a maximum of $1,000,000). Note: If you wish to elect Voluntary Life Insurance to 4X-8X your annual base salary, you must provide Evidence of Insurability. If your election requires EOI, coverage and contributions won t begin until you receive written approval from the insurance company and are actively at work. Supplemental Life Insurance premiums are based on your age, nicotine use and the amount of coverage you elect. Use this opportunity to review your current Supplemental Life Insurance coverage and see how the lower rates impact your premiums. Go to the Supplemental Life Insurance Premium Calculator [link to Life Insurance section on Rate Sheet]to determine your cost. Dependent Life Insurance: If you previously waived coverage, you may elect either (1) $10,000 for your spouse and$5,000 for each child or (2) $20,000 for your spouse and $10,000 for each child If you previously elected coverage of $10,000/$5,000, you may increase coverage to $20,000/$10,000 If you elect Dependent Life Insurance, your bi-weekly cost is: o o $1.49 $10,000 for your spouse and $5,000 for each child $2.97 $20,000 for your spouse and $10,000 for each child. 9

10 Accidental Death & Dismemberment (AD&D) You may elect Supplemental AD&D Insurance coverage from 1X to 8X your annual base salary (up to a maximum of $750,000) or elect no coverage. You must elect Basic AD&D coverage to elect Supplemental AD&D. If you elect Supplemental AD&D Insurance, you may also choose coverage for your spouse and/or child(ren) in $10,000 increments (up to a maximum of $350,000 for your spouse and $50,000 for each child). Your monthly Supplemental AD&D premium is: $0.018 per $1,000 of coverage for yourself $0.018 per $1,000 of coverage for your spouse $0.015 per $1,000 of coverage for each child. NOTE: The above summary of plan provisions is related to the Montefiore Employee Benefit Plans for Non-Union and Management Associates. In the event of a conflict between this summary and the policies and/or certificates, the policies and/or certificates shall dictate the insurance provisions, exclusions, all limitations and terms of coverage. 10

11 RATE SHEET ASSOCIATE MONTECARE EPO/MONTECARE PPO BI-WEEKLY PREMIUMS SALARY BAND UNDER $39,999 BI-WEEKLY PREMIUM Full-time You Only MonteCare EPO - $48.71 MonteCare PPO - $74.77 Full-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ Part-time You Only MonteCare EPO - $63.34 MonteCare PPO - $ Part-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ SALARY BAND $40,000 $64,999 BI-WEEKLY PREMIUM Full-time You Only MonteCare EPO - $55.88 MonteCare PPO - $81.94 Full-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ Part-time You Only MonteCare EPO - $ MonteCare PPO - $ Part-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ SALARY BAND $65,000 $99,999 BI-WEEKLY PREMIUM Full-time You Only MonteCare EPO - $63.04 MonteCare PPO - $89.10 Full-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ Part-time You Only MonteCare EPO - $ MonteCare PPO - $ Part-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ SALARY BAND $100,000 $149,999 BI-WEEKLY PREMIUM Full-time You Only MonteCare EPO - $74.50 MonteCare PPO - $ Full-time You and Your Family 11

12 MonteCare EPO - $ MonteCare PPO - $ Part-time You Only MonteCare EPO - $ MonteCare PPO - $ Part-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ SALARY BAND $150,000 $199,999 BI-WEEKLY PREMIUM Full-time You Only MonteCare EPO - $80.23 MonteCare PPO - $ Full-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ Part-time You Only MonteCare EPO - $ MonteCare PPO - $ Part-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ SALARY BAND $200,000 $249,999 BI-WEEKLY PREMIUM Full-time You Only MonteCare EPO - $85.96 MonteCare PPO - $ Full-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ Part-time You Only MonteCare EPO - $ MonteCare PPO - $ Part-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ SALARY BAND $250,000 AND OVER BI-WEEKLY PREMIUM Full-time You Only MonteCare EPO - $91.69 MonteCare PPO - $ Full-time You and Your Family MonteCare EPO - $ MonteCare PPO - $ Part-time You Only MonteCare EPO - $ MonteCare PPO - $ Part-time You and Your Family MonteCare EPO - $ MonteCare PPO - $

13 UNITEDHEALTHCARE VISION PLAN - BI-WEEKLY PREMIUMS LOW OPTION You Only $2.30 You and One Family Member $4.10 You and Your Family $6.95 HIGH OPTION You Only $3.54 You and One Family Member $6.79 You and Your Family $9.39 DENTAL BI-WEEKLY PREMIUMS CIGNA DHMO You Only $8.57 You and Your Family $21.43 PREVENTIVE & DIAGNOSTIC DENTAL CARE ONLY You Only Your first year at Montefiore $3.37 After your first year at Montefiore $0 You and Your Family Your first year at Montefiore $9.43 After your first year at Montefiore $0 CIGNA DPPO DENTAL PLAN You Only Your first year at Montefiore $17.76 After your first year at Montefiore $8.52 You and Your Family Your first year at Montefiore $49.71 After your first year at Montefiore $27.84 CIGNA DPPO ENHANCED DENTAL PLAN You Only Your first year at Montefiore $22.20 After your first year at Montefiore $12.96 You and Your Family Your first year at Montefiore $62.14 After your first year at Montefiore $

14 LIFE INSURANCE Basic Life Insurance Montefiore provides Basic Life Insurance at no cost to you after you complete one year at Montefiore. Your Basic Life Insurance monthly premium is $0.08 for every $1,000 of your annual base salary. If you elect to opt down to $50,000, your monthly premium is $4.00 ($1.85 bi-weekly). Supplemental Life Insurance Under 25 Age Group Non-nicotine user $0.026 per $1,000 Nicotine user $0.028 per $1, Age Group Non-nicotine user $0.028 per $1,000 Nicotine user $0.030 per $1, Age Group Non-nicotine user $0.035 per $1,000 Nicotine user $0.038 per $1, Age Group Non-nicotine user $0.044 per $1,000 Nicotine user $0.046 per $1, Age Group Non-nicotine user $0.057 per $1,000 Nicotine user $0.063 per $1, Age Group Non-nicotine user $0.091 per $1,000 Nicotine user $0.101 per $1, Age Group Non-nicotine user $0.146 per $1,000 Nicotine user $0.162 per $1,000 14

15 55-59 AGE GROUP Non-nicotine user $0.249 per $1,000 Nicotine user $0.277 per $1, AGE GROUP Non-nicotine user $0.354 per $1,000 Nicotine user $0.393 per $1, AGE GROUP Non-nicotine user $0.598 per $1,000 Nicotine user $0.664 per $1, Age Group Non-nicotine user $0.939 per $1,000 Nicotine user $1.043 per $1,000 15

16 DEPENDENT LIFE INSURANCE If you elect Dependent Life Insurance, the bi-weekly cost is: $1.49 $10,000 for your spouse; $5,000 for each child $2.97 $20,000 for your spouse; $10,000 for each child. AD&D INSURANCE BASIC AD&D Montefiore provides Basic AD&D Insurance at no cost to you after you complete one year at Montefiore. Your Basic AD&D Insurance monthly premium is $0.014 for every $1,000 of your annual base salary. SUPPLEMENTAL AD&D For every $1,000 of coverage you elect, your Supplemental AD&D monthly premium is based on: $0.018 for yourself $0.018 for your spouse $0.015 for each child. GROUP LEGAL SERVICES If you elect Group Legal Services, the bi-weekly cost is: $3.62 for yourself $4.85 for you and your family. 16

17 2017 MONTECARE EPO MONTECARE PPO MEDICAL COMPARISON INDIVIDUAL/FAMILY DEDUCTIBLE MonteCare EPO None MonteCare PPO None MonteCare EPO $500/$1,000 MonteCare PPO $500/$1,000 MonteCare PPO $1,000/$2,500 INDIVIDUAL/FAMILY OUT-OF-POCKET MAXIMUM (DEDUCTIBLE + COPAYMENT+ COINSURANCE) MonteCare EPO $5,350/$10,700 MonteCare PPO $5,350/$10,700 MonteCare EPO $5,350/$10,700 MonteCare PPO $5,350/$10,700 MonteCare PPO $6,000/$17,500 INPATIENT CARE * HOSPITALIZATION ILLNESS OR INJURY * MENTAL HEALTH/SUBSTANCE ABUSE CARE * PHYSICAL/OCCUPATIONAL THERAPY OR REHAB Preferred Facility MonteCare EPO 20% 1 coinsurance after deductible if precertified by Conifer Value Based Care; otherwise 30% 1 coinsurance after deductible MonteCare PPO $1,000 copay if precertified by Conifer Value Based Care; otherwise $1,500 copay Non-preferred Facility MonteCare EPO 40% 1 coinsurance after deductible if precertified by Conifer Value Based Care; otherwise 50% 1 coinsurance after deductible MonteCare PPO $2,000 copay if precertified by Conifer Value Based Care; otherwise $2,500 copay except in the case of an emergency MonteCare PPO 40% 2 coinsurance after $1,000 copay if precertified by Conifer Value Based Care; otherwise $1,500 copay 17

18 OUTPATIENT SURGERY Preferred Facility MonteCare EPO 20% 1 coinsurance after deductible MonteCare PPO $500 copay Non-preferred Facility MonteCare EPO 40% 1 coinsurance after deductible MonteCare PPO $1,000 copay MonteCare PPO 40% 2 coinsurance after deductible HIGH-TECH RADIOLOGY SERVICES (INCLUDE, BUT NOT LIMITED TO DIAGNOSTIC MRI, MRA, CAT SCAN, PET, NUCLEAR CARDIOLOGY) Preferred Facility MonteCare EPO 20% 1 coinsurance after deductible MonteCare PPO $250 copay Non-preferred Facility MonteCare EPO 40% 1 coinsurance after deductible MonteCare PPO $500 copay MonteCare PPO 40% 2 coinsurance after deductible EMERGENCY ROOM IN A BONA FIDE EMERGENCY MonteCare EPO $100 copay (waived if admitted) MonteCare PPO $100 copay (waived if admitted) MonteCare EPO $100 copay (waived if admitted) MonteCare PPO $100 copay (waived if admitted) MonteCare EPO $100 copay (waived if admitted) MonteCare PPO $100 copay (waived if admitted) EMERGENCY ROOM OTHER THAN A BONA FIDE EMERGENCY MonteCare EPO 20% 1 coinsurance MonteCare PPO 30% 1 coinsurance after deductible MonteCare EPO 20% 1 coinsurance after deductible MonteCare PPO 30% 1 coinsurance after deductible 18

19 URGENT CARE FACILITY MonteCare EPO $30 copay/visit MonteCare PPO $30 copay/visit URGENT CARE PROFESSIONAL MonteCare EPO $15 copay/visit MonteCare PPO $15 copay/visit MonteCare EPO $30 copay/visit MonteCare PPO $30 copay/visit PREVENTIVE CARE * ROUTINE PHYSICAL EXAM WITH PCP INCLUDING OB/GYN * ROUTINE WELL CHILD EXAMS/IMMUNIZATIONS * ROUTINE MAMMOGRAPHY PRIMARY CARE PHYSICIAN OFFICE VISITS INCLUDING MENTAL HEALTH/SUBSTANCE ABUSE CARE MonteCare EPO $15 copay/visit MonteCare PPO $15 copay/visit MonteCare EPO 20% coinsurance after deductible MonteCare PPO 10% coinsurance after deductible 19

20 SPECIALIST OFFICE VISITS MonteCare EPO $15 copay/visit MonteCare PPO $15 copay/visit MonteCare EPO 20% coinsurance after deductible MonteCare PPO 10% coinsurance after deductible CHIROPRACTIC CARE OFFICE VISITS (10 VISITS) MonteCare EPO $50 copay/visit MonteCare PPO $35 copay/visit MonteCare EPO 20% coinsurance after deductible MonteCare PPO 10% coinsurance after deductible SURGERY MonteCare EPO $50 copay/visit MonteCare PPO 10% coinsurance after deductible MATERNITY MonteCare EPO 20% 1 coinsurance after deductible MonteCare PPO 10% 1 coinsurance after deductible 20

21 ALLERGY TEST AND TREATMENT MonteCare EPO $15 copay/visit; $0 for treatment MonteCare PPO $15 copay/visit; $0 for treatment MonteCare EPO 20% 1 coinsurance after deductible MonteCare PPO 10% 1 coinsurance after deductible OUTPATIENT DIAGNOSTIC AND LABORATORY TESTS * X-RAYS, BONE DENSITY, BLOOD, URINE MonteCare EPO 20% 1 coinsurance after deductible MonteCare PPO 10% 1 coinsurance after deductible HOSPICE 210 DAYS SKILLED NURSING FACILITY 120 DAYS 21

22 HOME HEALTH CARE 200 VISITS after deductible PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY MonteCare EPO 20% 1 coinsurance after deductible MonteCare PPO 10% 1 coinsurance after deductible DURABLE MEDICAL EQUIPMENT MonteCare EPO Professional provider: 20% 1 coinsurance; Facility: $0 MonteCare PPO Professional provider: 20% 1 coinsurance; Facility: $0 MonteCare EPO Professional provider: 20% 1 coinsurance; Facility: 20% 1 coinsurance after deductible MonteCare PPO Professional provider: 20% 1 coinsurance; Facility: 10% 1 coinsurance after deductible MonteCare PPO Professional provider: 20% 1 coinsurance; Facility: 20% 1 coinsurance after deductible 1 Percentage is applied to covered charges which are based on the rate paid to like-kind Empire in-network facilities if the facility is within the Empire area (i.e. the New York metropolitan area including NJ and CT) or the facility s actual charge if it is outside of the Empire area. 2 Reasonable and Customary charges are based on 150% of Medicare s National Provider Rate. The Plan benefit is then determined by applying the cost-sharing percentage (70%/80%) to this amount; you are responsible for paying the balance of the bill to the provider. 22