2010 AMN Plan Summary of Benefits
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1 2010 AMN Plan Summary of Benefits Medical/Dental/Rx/Life Ins. Coverage Plan Options CIGNA Healthcare is the provider for medical, dental, prescriptions and life insurance. Open Access In-Network Plan OAIN (EPO) Using Open Access In-Network Providers Only This plan has no out-of-network benefits (Unless OOA applies) Open Access Plus OAP (PPO) Using Open Access Plus (OAP) In-Network Providers (Unless OOA applies) Using Non-OAP Providers Eligibility: 1st Day Coverage 1st of the month following 30 days on assignment Calendar Year Deductible: Individual $900 $400 $400 Family $1800 $1200 $1200 Physician Services: No Deductible Applies No Deductible Applies Deductible Applies Primary Care Office Visits $30 co-pay $25 co-pay 40% after deductible Specialty Care Office Visits $45 co-pay $40 co-pay 40% after deductible (see separate X-Ray & Lab Benefits Below) Deductible Applies Deductible Applies Hospital visits 70% after deductible 70% after deductible 40% after deductible Inpatient, outpatient and office surgery 70% after deductible 70% after deductible 40% after deductible Radiologists, Pathologists, and Anesthesiologists 70% after deductible 70% after deductible 40% after deductible Outpatient Services: Deductible Applies Deductible Applies Durable Medical Equipment 70% after deductible 70% after deductible 70% after deductible Hospice Care 70% after deductible 70% after deductible 70% after deductible Home Health Care no deductible, 100 visits no deductible, 100 visits no deductible, 100 visits All Other Covered Services 70% after deductible 70% after deductible 40% after deductible Preventive Care: No Deductible Applies No Deductible Applies Deductible Applies Well Child Care $30 co-pay $25 co-pay 40% after deductible Well Woman Exams after PCP or Specialist co-pay after PCP or Specialist co-pay 40% after deductible Mammograms 40% after deductible Wellness Care: Limited to $300 per calendar year* No Deductible Applies No Deductible Applies Deductible Applies Routine Physical Exams $30 co-pay $25 co-pay 40% after deductible Adult Immunizations 40% after deductible Lab & X-Ray in connection with Exams 40% after deductible *Well Child Care, Mammograms, Pap Smears, and PSA testing are not subject to the $300 wellness care calendar year limitation. Diagnostic X-Ray and Lab: Deductible Applies Deductible Applies Diagnostic x-ray and lab 70% after deductible 70% after deductible 40% after deductible
2 Plan Options Open Access In-Network Plan OAIN (EPO) Open Access Plus OAP (PPO) Using Open Access In-Network Providers Only Using Open Access Plus (OAP) In-Network Providers Using Non-OAP Providers Hospital Services: Deductible Applies Deductible Applies Inpatient (includes room & board; miscellaneous) $500 per stay deductible, then 70% $500 per stay deductible, then 70% $500 per stay deductible, then 40% Emergency Room (Illness or injury) $175 co-pay, then 70% ($175 co-pay will be waived if you are admitted to the hospital from the emergency room) No Deductible Applies No Deductible Applies $175 co-pay, then 70% ($175 co-pay will be waived if you are admitted to the hospital from the emergency room) $175 co-pay, then 70% ($175 co-pay will be waived if you are admitted to the hospital from the emergency room) Pre-admission Certification and Utilization Review Required for all Inpatient Admissions and Outpatient Surgeries. Pre-Certification number is All In-Network Providers have agreed to Pre-Admission Certification. Failure of Healthcare Professional to receive authorization Out of Network will result in $250 penalty. Short-Term Rehabilitative Therapy and Chiropractic Services includes physical, speech, occupational, chiropractic, pulmonary rehab and cognitive therapy: 20 days maximum per calendar year for all therapies combined Outpatient Cardiac Rehabilitation: up to 36 days maximum per calendar year. Deductible Applies Deductible Applies Office Visit 70% after deductible 70% after deductible 40% after deductible Mental Health & Substance Abuse: Deductible Applies Deductible Applies Inpatient Mental Health $500 co-pay, then 70% $500 co-pay, then 70% after deductible $500 co-pay, then 50% after deductible Outpatient Mental Health (MH) $45 co-pay $40 co-pay 50% after deductible Inpatient Substance Abuse $500 co-pay, then 70% $500 co-pay, then 70% after deductible $500 co-pay, then 50% after deductible Outpatient Substance Abuse (SA) $45 co-pay $40 co-pay 50% after deductible Calendar Year Maximums: Participant Out of Pocket Maximum (excludes deductible and co-pays) After an individual s out of pocket in-network costs reach $15,000 in a calendar year, services will be covered at. After families out of pocket in-network costs reach $45,000 in a calendar year, services will be covered at. All services out of network are covered under the stated level of out of network reimbursement. There is no out of pocket maximum for out of network services on the OAP Plan. Individual Out of Pocket $15,000 $15,000 Not Applicable Out of Network Family Out of Pocket $45,000 $45,000 Not Applicable Out of Network Calendar Year Maximum for all covered expenses (Maximum that will be paid by the Plan in a calendar year) $100,000 $150,000
3 Lifetime Maximum: Lifetime Benefit of Plan (Maximum amount the plan will pay in a covered person s lifetime) Retail Prescription Drugs (30 day supply): OAIN Plan $125 Deductible Applies for Brand Prescription drug coverage is based on a formulary; the Preferred and Non-Preferred Drugs formulary list for CIGNA can be found through the *No Deductible for Generic* CIGNA website Or call CIGNA Healthcare 24/7 at In-Network Pharmacy (No Non-Network Coverage) $1,000,000 OAP Plan $125 Deductible Applies for Brand Preferred and Non-Preferred Drugs *No Deductible for Generic* In-Network Pharmacy Non-Network Pharmacy Prescription drug coverage is based on a formulary; the formulary list for CIGNA can be found through the CIGNA website Or call CIGNA Healthcare 24/7 at Generic $10 co-pay $10 co-pay 50% after $10 co-pay Brand Preferred $45 co-pay $40 co-pay 50% after $40 co-pay Non-Preferred $75 co-pay $65 co-pay 50% after $65 co-pay Covered expenses in the out-of-network tier are reimbursed at the 50 th percentile of what is considered "usual & customary" for your area. You are considered an out-ofarea (OOA) plan participant if there are no OAP providers available within your current geographic area. Please contact us if you feel that you may be in a location outside of the CIGNA Healthcare OAP service area to ensure you receive the highest level of reimbursement available to you. Pre-Existing Condition Limitation: A Covered Person will be subject to a Pre-Existing Condition Limitation if a person becomes covered under the plan and does not have Prior Credible Coverage. A condition is considered Pre-Existing if the Covered Person has consulted a doctor; has taken prescribed medication; is receiving or has received medical care in the three months before his/her enrollment date. Benefits for that condition will not be covered for 12 consecutive months following the Covered Person s enrollment date. Important Notice About Your Rights Under Your Group Health Plan: Do you know that your plan, as required by the Women s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymph edemas? Call your Plan Administrator at for more information. For questions regarding your coverage or network availability, please call CIGNA Healthcare Customer Service toll-free at or visit their website at CIGNA Customer Service Representatives are available 24 hours /7 days a week! The Company is committed to maintaining the confidentiality of your private medical information. The Company has adopted policies and procedures to ensure that your information is maintained and used only for permissible purposes, as required by the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ). All Healthcare Professionals enrolled in the Plan receive a Notice of Privacy Practices ( Privacy Notice ) within 60 days of enrolling in the Plan. The Privacy Notice describes how private medical information is maintained and protected by the Company, and describes Healthcare Professional s rights to inspect and receive copies of private medical information in the Company s possession. If you do not receive a copy of the Privacy Notice, or would like to receive an additional copy, you may request a copy by writing to the Traveler Benefits Department, High Bluff Drive, San Diego, California You may also request a copy of the Privacy Notice, or ask any questions you may have regarding the Company s privacy policies, by calling and asking for a Service Team Representative, who will be happy to assist you. The information provided is only a brief summary of benefits and does not encompass the complete program exclusions and limitations. Refer to your summary plan description (i.e., Certificate of Coverage) for specific conditions of your coverage. Benefits stated in the carrier booklet/certificate of Coverage will take precedence should a discrepancy arise. These benefits are effective January 1, 2010.
4 Dental Coverage *Please note that if you use an out-of-network provider, the same coverage will apply but you can be balanced billed by dental providers. If you use an in-network OAP dentist, you will not be balanced billed due to the negotiated contracts that are in place with those providers. Using an in-network provider equals savings for you. You can locate dental providers by calling CIGNA Healthcare or visiting their website at Plan Options: Basic Dental Packaged w/oain Medical Plan Expanded Dental Packaged w/ OAP Medical Plan Eligibility: 1st Day Coverage 1st of the month following 30 days on assignment Calendar Year Deductible: Per Individual $100 combined in & out of network Calendar Year Maximum Benefit: Per Individual $500 combined in & out of network $1000 combined in & out of network Preventive Care Services: No Deductible Applies No Deductible Applies Oral Exam Prophylaxis (Cleanings) X-rays Pit & Fissure Sealants (Dependent Children) Fluoride Treatments (Dependent Children) 2 times per calendar year, but not more than once in a 5 month period (2 times per calendar year) Bitewing: 2 times per calendar year Full-mouth: 1 every 36 months 2 times per calendar year, but not more than once in a 5 month period (2 times per calendar year) Bitewing: 2 times per calendar year Full-mouth: 1 every 36 months Deductible Applies Deductible Applies 80% 80% Deductible Applies No Deductible Applies 80% Basic Care: Deductible Applies Deductible Applies Extractions and Fillings, Oral Surgery, Endodontic & Periodontic Treatment 50% 50% Major Services: Deductible Applies Bridges, Crowns No coverage for Major Services Oral Surgery Surgery and treatment for disease, injury or defects of oral cavity Extractions Removal of a tooth Endodontic Treatment Root canal therapy Periodontic Treatment Gum and tissue treatments of the mouth Covered treatments are paid at the applicable coinsurance level according to usual & customary rates in your geographic area. A pre-estimation of dental benefits is recommended if your dental treatment will be $300 or more. 50% The information provided is only a brief summary of benefits and does not encompass the complete program exclusions and limitations. Refer to your summary plan description (i.e., Certificate of Coverage) for specific conditions of your coverage. Benefits stated in the carrier booklet/certificate of Coverage will take precedence should a discrepancy arise. These benefits are effective January 1, 2010.
5 Life Insurance and Supplemental Life Insurance Basic Life and Accidental Death & Dismemberment (Provided only when Medical/Dental is elected, Company Paid) Employee Coverage Optional Life Insurance (Employee Paid) Employee Coverage Spouse Coverage Child(ren) Coverage Benefit: $10,000 Maximum: $10,000 Guarantee Issue Amount: $10,000 Age Reductions for AD&D: Convertible (Life Only):** Accelerated Benefit 75% to $7,500 Benefit: Increments of $10,000 up to $100,000 Maximum: $100,000 Guarantee Issue Amount: Age Reductions: Portable* Up to age 70, 50% up to $100,000 Convertible** Benefit included Accelerated Benefit 75% of benefit Waiver of Premium Included Benefit: Maximum: $50,000 Guarantee Issue Amount: Age Reductions: Healthcare Professionals can convert coverage to whole life policy within 31 days following termination of employment. $100,000 (Please note: late applicants will be subject to medical evidence for all amounts of coverage if you do not enroll when first eligible for coverage). Increments of $10,000 up to $50,000 (amount cannot exceed 50% of employee coverage of basic and optional life) $50,000 (Please note: late applicants will be subject to medical evidence for all amounts of coverage if you do not enroll when first eligible for coverage). Portable* Up to age 70 Convertible** Benefit included Benefit: Increments of $1,000 up to $10,000 Maximum: $10,000 Maximum Age: To age 19 or 23 if a full-time student with proof full-time student status Guarantee Issue Amount: $10,000 Portable* Employee Optional Life Rates per $1,000 of coverage per month effective January 1, 2010: Age: < age Employee Rate: $0.075 $0.09 $0.12 $0.135 $0.15 $0.225 $0.345 $0.645 $0.99 $1.905 $3.09 Divide the amount selected by $1,000 then multiply by your rate. Example: $50,000 divided by 1,000= 50 x.15 (age 40-44) = $7.50 per month Spouse: $0.21 per $1,000 of coverage per month Child(ren) $0.20 per $1,000 of coverage per month (Pay one rate, regardless of the number of Dependent Children) *Portability Healthcare Professionals may continue this coverage at the group rates should they cease employment. See age limitations above. **Convertibility Healthcare Professionals/Dependents can convert coverage to whole life policy within 31 days following termination of employment. Products and services are offered by CIGNA Healthcare. Your initial election for Life and Optional Life will be unchanged unless there is a status change event. The information provided is only a brief summary of benefits and does not encompass the complete program exclusions and limitations. Refer to your summary plan description (i.e., Certificate of Coverage) for specific conditions of your coverage. Benefits stated in the carrier booklet/certificate of Coverage will take precedence should a discrepancy arise. These benefits are effective January 1, 2010.
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