South Central Ohio Insurance Consortium

Transcription

1 South Central Ohio Insurance Consortium Health Plan Amendment No.: 31 Summary Plan Description: South Central Ohio Insurance Consortium Health Plan for Employees of Logan-Hocking Local Schools Certified/Classified Staff Dated: October 1, 2008 Pursuant to the Section 4.1 entitled Right to Amend, of the Plan Document for South Central Ohio Insurance Consortium Health Plan (the Plan ), the Plan is hereby amended effective July 1, 2010 as follows: I. Within the above named Summary Plan Description, the SCHEDULE OF BENEFITS is hereby deleted in its entirety and REPLACED by the attached SCHEDULE OF BENEFITS Effective July 1, Whereupon, to record the adoption of the foregoing, South Central Ohio Insurance Consortium, has caused this document to be executed, on its behalf on this day of, 20. PLAN SPONSOR: South Central Ohio Insurance Consortium By: Title PARTICIPATING EMPLOYER: Logan-Hocking Local Schools By: Title South Central Ohio Insurance Consortium Health Plan Page 1 of 12

2 SCHEDULE OF BENEFITS Effective July 1, 2010 COMPREHENSIVE MEDICAL BENEFITS (Eligible Employees and Dependents) All benefit considerations of the Plan are subject to the Usual, Customary, and Reasonable (UCR) Allowance and Necessary Medical Services provisions of the Plan. LIFETIME MAXIMUM BENEFIT... $5,000,000 Network and Non-Network benefits are combined CALENDAR YEAR DEDUCTIBLE Per Covered Person... $250...$500 Per Covered Family... $ $1,000 Network and non-network deductibles do not accumulate toward each other. Before any benefits are payable from the Plan, the Calendar Year Deductible has to be satisfied for covered services unless it is specifically waived in this Schedule of Benefits. OUT OF POCKET LIMIT Per Covered Person... $2, $4,500 Per Covered Family... $5, $9,000 Network and non-network out-of-pocket-limits do not accumulate toward each other. The Out-of-Pocket Limit includes Deductibles and Co-insurance incurred by the Covered Person within the Calendar Year except for the following: Preventive Care services Prescription Drug benefits Non-network Human Organ and Tissue Transplant services Co-Payments as required herein COVERED SERVICES PREVENTIVE CARE (Deductible is waived)...100%...deductible and Co- Insurance is based On the setting where Service is performed. HOSPITAL BENEFIT Inpatient... 80%... 60% Outpatient Surgical Facilities (includes alternative care facility)... 80%... 60% Diagnostic X-Ray and Lab (including their interpretations) %... 70% (Deductible Waived for In-Network services only) South Central Ohio Insurance Consortium Health Plan Page 2 of 12

3 SCHEDULE OF BENEFITS (continued) NOTE: Allergy testing, MRA, MRI, PET scan, CAT scan, nuclear cardiology imaging studies and non-maternity related ultrasound services are covered under All OTHER COVERED MEDICAL SERVICES below EMERGENCY ROOM (Deductible is waived)...$200 Co-Pay... Paid same Facility and Physician Charges per visit, then 100% Co-payment is waived if admitted URGENT CARE CENTER...$25 Co-Pay...Paid same AMBULANCE BENEFIT... 80%...Paid same SKILLED NURSING FACILITY EXPENSE BENEFIT...80%...60% Maximum Confinement per Calendar Year (Combined) days days HOSPICE CARE BENEFIT... 90%... Paid same HOME HEALTH CARE...80%... 60% Maximum visits per Calendar Year (Combined) Maximum Private Duty Nursing Care rendered in the home (combined) 1 : $50,000 per Calendar Year $100,000 per Lifetime PHYSICIAN EXPENSE BENEFIT Office or home Visits...$25 Co-Pay... 60% (Includes Primary Care Physician, Specialty Care Physician, or surgery performed in the office.) Related covered charges not billed by the Physician will be paid at the appropriate benefit percentage as indicated by the place of service. Allergy Injections... 80%... 60% The Allergy Injection coinsurance applies when the injection is billed by itself. The office visit co-payment/co-insurance applies if an office visit is billed with an allergy injection. Allergy testing, services are covered under All OTHER COVERED MEDICAL SERVICES as described herein. Surgery and Assistant Surgeon... 80%... 60% Anesthesia... 80%...Paid Same As Network Hospital Inpatient Physician Visits... 80%... 60% Other In-patient or Outpatient Professional Services... 80%... 60% South Central Ohio Insurance Consortium Health Plan Page 3 of 12

4 SCHEDULE OF BENEFITS (continued) Mammogram (Routine or Diagnostic), Diabetes Self-Management training, or Network Only Medical Nutritional Therapy %... 60% MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, APPLIANCES EXPENSE BENEFIT... 80%... 60% Maximum per Calendar Year: (Combined) 1 for all prosthetic devices received on an outpatient basis -$10,000 (not including surgical prosthetics) for all Durable Medical Equipment and orthotics - $10,000 NOTE: Because additional discounts may be available, ACMS notification is encouraged prior to rental or purchase of any durable medical equipment exceeding $750. THERAPY SERVICES... 80%... 60% Maximum Visits per Calendar Year (Combined) 1 for Physical Therapy for Occupational Therapy for Speech Therapy NOTES: The above limits apply when rendered as Physician Office visits or as outpatient services. When rendered in the home, Home Health Care limits apply for the above services. MANIPULATION THERAPY...$25 Co-pay... 70% Maximum Visits per Calendar Year (Combined) Manipulation Therapy is not covered in the home. RADIATION, RESPIRATORY THERAPIES, CHEMOTHERAPY, KIDNEY DIALYSIS AND CARDIAC REHABILITATION EXPENSE BENEFIT... 80%... 60% MENTAL HEALTH/ SUBSTANCE ABUSE TREATMENT...Paid based on the type of service(s) received. TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMJ)... 80%... 60% INDEPENDENT LAB EXPENSE BENEFIT (Calendar Year deductible is waived) (Including their Interpretation) %... Paid same South Central Ohio Insurance Consortium Health Plan Page 4 of 12

5 SCHEDULE OF BENEFITS (continued) NOTE: MRA, MRI, PET scan, CAT scan, nuclear cardiology imaging studies and nonmaternity related ultrasound services are covered under All OTHER COVERED MEDICAL SERVICES below. ORGAN AND/OR TISSUE TRANSPLANTS (Calendar Year Deductible is waived) %... 50% FLU SHOTS - seasonal only (deductible waived) % % Maximum Benefit per shot: $25 ALL OTHER COVERED MEDICAL SERVICES...80%...60% 1 For purpose of benefits described in this Schedule, the term Combined means that Network and Non-Network charges are combined for one Maximum Benefit allowance. All expenses must be submitted within 12 months from the date such charges were incurred to be eligible for benefit payment under this Plan South Central Ohio Insurance Consortium Health Plan Page 5 of 12

6 PRESCRIPTION DRUG PROGRAM (Eligible Employees and Dependents) CO-PAYMENT PER PRESCRIPTION OR REFILL RETAIL RX PROGRAM (30-day supply) Generic Prescription...$5 Preferred Brand-Name...$30 Non-Preferred Brand-Name...$60 MAIL-ORDER RX PROGRAM (90-day supply) Generic Prescription...$12.50 Preferred Brand-Name...$75 Non-Preferred Brand-Name...$150 SPECIALTY DRUGS PROGRAM (30-day supply) Generic Prescription... 25% up to a $250 maximum Preferred Brand-Name... 25% up to a $250 maximum Non-Preferred Brand-Name... 25% up to a $250 maximum If you obtain services from a non-network pharmacy, The Pharmacy Benefit Manager (PBM) will provide 50% reimbursement after a co-payment of $60. You must pay the full amount of the bill for the Prescription Drug at the time of purchase. Then you must file a standard claim form which can be obtained from the PBM, and payment will be made directly to you. You may be responsible for any amount in excess of the Prescription Drug Covered Charges. NOTE: Prescription drug expenses under the Prescription Drug Program do not apply to the Calendar Year Deductible nor to the Out-of-Pocket Maximum under Comprehensive Medical Expense Benefits. South Central Ohio Insurance Consortium Health Plan Page 6 of 12

7 Summary of Material Modification To all Participants under the South Central Ohio Insurance Consortium Health Plan This notice, called a Summary of Material Modification, advises you of a change in the information presented in your Summary Plan Description with respect to the South Central Ohio Insurance Consortium Health Plan (the Plan ). Please do three things: (1) Read this notice. If you have any questions, contact the Plan Administrator; (2) Keep this notice with your Summary Plan Description; and (3) Mark the sections of your Summary Plan Description that have been changed, so when you look at that section of your Summary Plan Description, you will be reminded that the change described in this notice has occurred. Effective July 1, 2010, the following changes apply: I. Within the Summary Plan Description for the above named Plan titled SOUTH CENTAL OHIO INSURANCE CONSORTIUM HEALTH BENEFIT PLAN FOR EMPLOYEES OF LOGAN-HOCKING LOCAL SCHOOLS CERTIFIED/CLASSIFIED STAFF, the SCHEDULE OF BENEFITS is hereby deleted in its entirety and REPLACED by the attached SCHEDULE OF BENEFITS Effective July 1, If you have questions about this Summary of Material Modification or about the Plan, or need a copy of the Summary Plan Description, please check with your employer s benefits office. South Central Ohio Insurance Consortium Health Plan Page 7 of 12

8 SCHEDULE OF BENEFITS Effective July 1, 2010 COMPREHENSIVE MEDICAL BENEFITS (Eligible Employees and Dependents) All benefit considerations of the Plan are subject to the Usual, Customary, and Reasonable (UCR) Allowance and Necessary Medical Services provisions of the Plan. LIFETIME MAXIMUM BENEFIT... $5,000,000 Network and Non-Network benefits are combined CALENDAR YEAR DEDUCTIBLE Per Covered Person... $250...$500 Per Covered Family... $ $1,000 Network and non-network deductibles do not accumulate toward each other. Before any benefits are payable from the Plan, the Calendar Year Deductible has to be satisfied for covered services unless it is specifically waived in this Schedule of Benefits. OUT OF POCKET LIMIT Per Covered Person... $2, $4,500 Per Covered Family... $5, $9,000 Network and non-network out-of-pocket-limits do not accumulate toward each other. The Out-of-Pocket Limit includes Deductibles and Co-insurance incurred by the Covered Person within the Calendar Year except for the following: Preventive Care services Prescription Drug benefits Non-network Human Organ and Tissue Transplant services Co-Payments as required herein COVERED SERVICES PREVENTIVE CARE (Deductible is waived)...100%...deductible and Co- Insurance is based On the setting where Service is performed. HOSPITAL BENEFIT Inpatient... 80%... 60% Outpatient Surgical Facilities (includes alternative care facility)... 80%... 60% Diagnostic X-Ray and Lab (including their interpretations) %... 70% (Deductible Waived for In-Network services only) South Central Ohio Insurance Consortium Health Plan Page 8 of 12

9 SCHEDULE OF BENEFITS (continued) NOTE: Allergy testing, MRA, MRI, PET scan, CAT scan, nuclear cardiology imaging studies and non-maternity related ultrasound services are covered under All OTHER COVERED MEDICAL SERVICES below EMERGENCY ROOM (Deductible is waived)...$200 Co-Pay... Paid same Facility and Physician Charges per visit, then 100% Co-payment is waived if admitted URGENT CARE CENTER...$25 Co-Pay...Paid same AMBULANCE BENEFIT... 80%...Paid same SKILLED NURSING FACILITY EXPENSE BENEFIT...80%...60% Maximum Confinement per Calendar Year (Combined) days days HOSPICE CARE BENEFIT... 90%... Paid same HOME HEALTH CARE...80%... 60% Maximum visits per Calendar Year (Combined) Maximum Private Duty Nursing Care rendered in the home (combined) 1 : $50,000 per Calendar Year $100,000 per Lifetime PHYSICIAN EXPENSE BENEFIT Office or home Visits...$25 Co-Pay... 60% (Includes Primary Care Physician, Specialty Care Physician, or surgery performed in the office.) Related covered charges not billed by the Physician will be paid at the appropriate benefit percentage as indicated by the place of service. Allergy Injections... 80%... 60% The Allergy Injection coinsurance applies when the injection is billed by itself. The office visit co-payment/co-insurance applies if an office visit is billed with an allergy injection. Allergy testing, services are covered under All OTHER COVERED MEDICAL SERVICES as described herein. Surgery and Assistant Surgeon... 80%... 60% Anesthesia... 80%...Paid Same As Network Hospital Inpatient Physician Visits... 80%... 60% Other In-patient or Outpatient Professional Services... 80%... 60% South Central Ohio Insurance Consortium Health Plan Page 9 of 12

10 SCHEDULE OF BENEFITS (continued) Mammogram (Routine or Diagnostic), Diabetes Self-Management training, or Network Only Medical Nutritional Therapy %... 60% MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, APPLIANCES EXPENSE BENEFIT... 80%... 60% Maximum per Calendar Year: (Combined) 1 for all prosthetic devices received on an outpatient basis -$10,000 (not including surgical prosthetics) for all Durable Medical Equipment and orthotics - $10,000 NOTE: Because additional discounts may be available, ACMS notification is encouraged prior to rental or purchase of any durable medical equipment exceeding $750. THERAPY SERVICES... 80%... 60% Maximum Visits per Calendar Year (Combined) 1 for Physical Therapy for Occupational Therapy for Speech Therapy NOTES: The above limits apply when rendered as Physician Office visits or as outpatient services. When rendered in the home, Home Health Care limits apply for the above services. MANIPULATION THERAPY...$25 Co-pay... 70% Maximum Visits per Calendar Year (Combined) Manipulation Therapy is not covered in the home. RADIATION, RESPIRATORY THERAPIES, CHEMOTHERAPY, KIDNEY DIALYSIS AND CARDIAC REHABILITATION EXPENSE BENEFIT... 80%... 60% MENTAL HEALTH/ SUBSTANCE ABUSE TREATMENT...Paid based on the type of service(s) received. TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMJ)... 80%... 60% INDEPENDENT LAB EXPENSE BENEFIT (Calendar Year deductible is waived) (Including their Interpretation) %... Paid same South Central Ohio Insurance Consortium Health Plan Page 10 of 12

11 SCHEDULE OF BENEFITS (continued) NOTE: MRA, MRI, PET scan, CAT scan, nuclear cardiology imaging studies and nonmaternity related ultrasound services are covered under All OTHER COVERED MEDICAL SERVICES below. ORGAN AND/OR TISSUE TRANSPLANTS (Calendar Year Deductible is waived) %... 50% FLU SHOTS - seasonal only (deductible waived) % % Maximum Benefit per shot: $25 ALL OTHER COVERED MEDICAL SERVICES...80%...60% 1 For purpose of benefits described in this Schedule, the term Combined means that Network and Non-Network charges are combined for one Maximum Benefit allowance. All expenses must be submitted within 12 months from the date such charges were incurred to be eligible for benefit payment under this Plan South Central Ohio Insurance Consortium Health Plan Page 11 of 12

12 PRESCRIPTION DRUG PROGRAM (Eligible Employees and Dependents) CO-PAYMENT PER PRESCRIPTION OR REFILL RETAIL RX PROGRAM (30-day supply) Generic Prescription...$5 Preferred Brand-Name...$30 Non-Preferred Brand-Name...$60 MAIL-ORDER RX PROGRAM (90-day supply) Generic Prescription...$12.50 Preferred Brand-Name...$75 Non-Preferred Brand-Name...$150 SPECIALTY DRUGS PROGRAM (30-day supply) Generic Prescription... 25% up to a $250 maximum Preferred Brand-Name... 25% up to a $250 maximum Non-Preferred Brand-Name... 25% up to a $250 maximum If you obtain services from a non-network pharmacy, The Pharmacy Benefit Manager (PBM) will provide 50% reimbursement after a co-payment of $60. You must pay the full amount of the bill for the Prescription Drug at the time of purchase. Then you must file a standard claim form which can be obtained from the PBM, and payment will be made directly to you. You may be responsible for any amount in excess of the Prescription Drug Covered Charges. NOTE: Prescription drug expenses under the Prescription Drug Program do not apply to the Calendar Year Deductible nor to the Out-of-Pocket Maximum under Comprehensive Medical Expense Benefits. South Central Ohio Insurance Consortium Health Plan Page 12 of 12