2015 Medical Plan Comparison Chart

2015 Medical Plan Comparison Chart
WellStar Health System is committed to helping you control healthcare costs while providing more choices and personal control over your healthcare coverage through the following plan options. The plan premiums are withheld on a pre-tax basis, which is a tax advantage for you. All
our plan options are self-insured ERISA plans administered by Piedmont WellStar HealthPlans. This information is not intended or designed to replace or serve as an evidence of coverage or the Summary Plan Description (SPD). If you have specific questions regarding benefits
structure, limitation or exclusions, refer to the Employee Handbook SPD. There are no pre-existing condition exclusions under the plan. The SPD is the official document of the medical plan.
1
SUMMARY OF BENEFITS
2
WellShare Premium HDHP Plan Option with HSA /HRA
Health Savings Acount1 or Health
2
Reimbursement Account Funded by WellStar
$500 Team Member
$750 Team Member + 1
$1,000 Family
1
2
WellShare Select HDHP Plan Option with HSA /HRA
$500 Team Member
$750 Team Member + 1
Minimum Basic Plan Option
$1,000 Family
N/A
In-Network
You Pay
Out-of-Network
You Pay
In-Network
You Pay
Out-of-Network
You Pay
In-Network
You Pay
Out-of-Network
You Pay
$1,300 Team Member
$2,600 Team Member + 1
$2,600 Family
$2,500 Team Member
$3,750 Team Member + 1
$5,000 Family
$1,750 Team Member
$2,625 Team Member + 1
$3,500 Family
$3,500 Team Member
$5,250 Team Member + 1
$7,000 Family
$2,000 Team Member
$3,000 Team Member + 1
$4,000 Family
$4,000 Team Member
$6,000 Team Member + 1
$8,000 Family
$1,750 Team Member
$2,000 Team Member + 1
$3,500 Family
$3,500 Team Member
$5,250 Team Member + 1
$7,000 Family
$2,750 Team Member
$4,125 Team Member + 1
$5,500 Family
$5,500 Team Member
$8,250 Team Member + 1
$11,000 Family
$3,000 Team Member
$4,500 Team Member + 1
$6,000 Family
$8,000 Team Member
$12,000 Team Member + 1
$16,000 Family
$3,050 Team Member
$4,600 Team Member + 1
$6,100 Family
$6,000 Team Member
$9,000 Team Member + 1
$12,000 Family
$4,500 Team Member
$6,750 Team Member + 1
$9,000 Family
$9,000 Team Member
$13,500 Team Member + 1
$18,000 Family
$5,000 Team Member
$7,500 Team Member + 1
$10,000 Family
$10,000 Team Member
$15,000 Team Member + 1
$20,000 Family
OUT-OF-POCKET (OOP) EXPENSES
Annual Deductible3, 4 - a fixed dollar amount for
the plan year that you are required to pay before
the plan starts making payments for covered
medical services, prescriptions and supplies.
3, 4
Annual Coinsurance Maximum - after the
annual deductible has been satisfied, you are
required to pay a percentage of covered medical
services, prescriptions and supplies. The plan
pays the remaining percentage. Annual
coinsurance payments are capped according to
your elected coverage level.
4
Annual Out-of-Pocket Maximum - this is the
total of your annual deductible and annual
coinsurance amounts you are responsible for
paying.
Lifetime Benefits- some specific benefits have
limitations.
Unlimited
Unlimited
Unlimited
PREVENTIVE HEALTH SERVICES5
Routine Physical Exam - including well baby,
well child, adult exam and certain immunizations
and pathology.
OBGYN Exam8
Health Education & Promotion - prescribed by
a physician.
Manual Breast Pump - first 12 months
following birth.
Other Services Covered under Healthcare
Reform Guidelines
No Charge
40% after Deductible6, 7
No Charge
40% after Deductible6, 7
No Charge
50% after Deductible6, 7
1
2
WellShare Premium HDHP Plan Option with HSA /HRA
SUMMARY OF BENEFITS
PHYSICIAN SERVICES
WellShare Select HDHP Plan Option with HSA1/HRA2
Minimum Basic Plan Option
9
Primary Care Physician (PCP) Office Visit
0% after Deductible
Specialist (SP) Office Visit - including allergy
treatment (shots, serum and testing).
20% after Deductible
0% after Deductible
6
40% after Deductible
40% after Deductible
6
40% after Deductible
50% after Deductible6
40% after Deductible6
40% after Deductible
50% after Deductible6
20% after Deductible
Radiology
20% after Deductible
(WellStar Labs Only)
Pathology
40% after Deductible6
20% after Deductible
(WellStar Labs Only)
EMERGENCY SERVICES10
Emergency Room Services - includes all
physician, pathology, radiology and facility fees.
20% after Deductible
20% after Deductible
40% after Deductible
Ambulance Services- air and ground.
Urgent Care Facilities
HOSPITAL SERVICES
11
Inpatient Surgery & Services - including semiprivate room and board, operating room, intensive
care units, physician and assistant physician
services, general nursing care, extended hospital
care, rehabilitation, hospice care, pre-testing,
anesthesiology, radiology, medications, injections,
oxygen, blood and blood plasma.
11
Outpatient Surgery & Some Procedures including physician and assistant physician
services, general nursing care, facility charges, pretesting, anesthesiology, radiology, medications,
injections, oxygen, blood and blood plasma.
Cardiac Rehabilitation, Chemotherapy,
Radiation, Dialysis, Hemodialysis, Infusion
Therapy - including necessary supplies.
11
Respiratory Therapy - including necessary
supplies.
Physical, Occupational & Speech Therapy11 including necessary supplies. Limit of 60 days
per plan year. 12
Applied Behavior Analysis (ABA) Therapy11 including necessary supplies. Limit of 60 days
12
per plan year.
20% after Deductible
20% after Deductible
40% after Deductible6
40% after Deductible
40% after Deductible6
50% after Deductible6
1
2
WellShare Premium HDHP Plan Option with HSA /HRA
SUMMARY OF BENEFITS
Pathology
Mammography, Colonoscopy, Sigmoidoscopy,
Proctosigmoidoscopy and Prostate-Specific
Antigen (PSA)
WellShare Select HDHP Plan Option with HSA1/HRA2
Minimum Basic Plan Option
20% after Deductible
(WellStar Labs Only)
20% after Deductible
(WellStar Labs Only)
40% after Deductible
(WellStar Labs Only)
0% after Deductible
(WellStar Facilities & Lab Only)
0% after Deductible
(WellStar Facilities & Lab Only)
0% after Deductible
(WellStar Facilities & Lab Only)
20% after Deductible
20% after Deductible
40% after Deductible
SPECIALTY FACILITIES SERVICES
Inpatient Skilled Nursing Facility &
Rehabilitation Services11 - including semiprivate room and board, operating room, intensive
care units, physician and assistant physician
services, general nursing care, extended hospital
care, rehabilitation, hospice care, pre-testing,
anesthesiology, radiology, medications, injections,
oxygen, blood and blood plasma. Limit of 100
12
days per plan year.
11
Outpatient Surgery & Some Procedures including physician and assistant physician
services, general nursing care, facility charges, pretesting, anesthesiology, radiology, medications,
injections, oxygen, blood and blood plasma.
Cardiac Rehabilitation, Chemotherapy,
Radiation, Dialysis, Hemodialysis, Infusion
Therapy - including necessary supplies.
40% after Deductible6
6
6
40% after Deductible
50% after Deductible
Respiratory Therapy11- including necessary
supplies.
11
Physical, Occupational & Speech Therapy including necessary supplies. Limit of 60 days
12
per plan year.
11
Applied Behavior Analysis (ABA) Therapy including necessary supplies. Limit of 60 days
12
per plan year.
Pathology
Mammography, Colonoscopy, Sigmoidoscopy,
Proctosigmoidoscopy and Prostate-Specific
Antigen (PSA)
20% after Deductible
(WellStar Labs Only)
20% after Deductible
(WellStar Labs Only)
40% after Deductible
(WellStar Labs Only)
0% after Deductible
(WellStar Facilities & Lab Only)
0% after Deductible
(WellStar Facilities & Lab Only)
0% after Deductible
(WellStar Facilities & Lab Only)
SUMMARY OF BENEFITS
1
2
WellShare Premium HDHP Plan Option with HSA /HRA
WellShare Select HDHP Plan Option with HSA1/HRA2
Minimum Basic Plan Option
FAMILY PLANNING
Family Planning, Counseling & Medical
Devices5
No Charge
No Charge
No Charge
Contraception Methods & Counseling5
6
Infertility & In-Vitro Fertilization - $10,000
annual limit with combination medical services
and medications (through Rx plan).
6
40% after Deductible
20% after Deductible
50% after Deductible6
40% after Deductible
40% after Deductible
20% after Deductible
Vasectomy - does not include reversals.
PREGNANCY AND MATERNITY CARE13
Prenatal & Postnatal Office Visits & Delivery all necessary inpatient hospital services for normal
delivery, cesarean section, professional fees and
complications of pregnancy. Midwife services
preformed under the direct supervision of a
participating Obstetrician.
20% after Deductible
40% after Deductible6
20% after Deductible
40% after Deductible6
40% after Deductible
50% after Deductible6
40% after Deductible
6
40% after Deductible
50% after Deductible
40% after Deductible6
40% after Deductible
50% after Deductible6
MENTAL HEALTH AND CHEMICAL DEPENDENCY (Magellan)
Institutional & Professional Inpatient Care
(Alcohol, Substance Abuse & Behavioral
11
Health) - includes accommodations, ancillaries
and detox. Residential treatment is not covered.
20% after Deductible
20% after Deductible
40% after Deductible6
Institutional & Professional Outpatient Care
(Alcohol, Substance Abuse & Behavioral
Health)- including intensive outpatient therapy
and partial hospitalization. Half way housing is
not covered.
0% after Deductible
6
0% after Deductible
HOME HEALTH CARE
Home Visits - by a physician, nurse, physical
therapist, speech therapist or respiratory therapist
for a single illness or injury. Not to exceed a total
of 100 medically necessary days and/or visits per
12
plan year.
Home IV Therapy
20% after Deductible
40% after Deductible6
20% after Deductible
1
2
WellShare Premium HDHP Plan Option with HSA /HRA
SUMMARY OF BENEFITS
WellShare Select HDHP Plan Option with HSA1/HRA2
Minimum Basic Plan Option
SHORT-TERM REHABILITATIVE THERAPY - Outpatient
11
Rehabilitative Therapy Visits - by a Physical,
Occupational, Speech or Respiratory therapist for
a single illness or injury. Physical, Occupational
and Speech Therapy is not to exceed a total of 60
medically necessary days and/or visits per plan
12
year.
20% after Deductible
40% after Deductible6
20% after Deductible
40% after Deductible6
40% after Deductible
50% after Deductible6
20% after Deductible
(WellStar Facilities & Lab Only)
NA
20% after Deductible
(WellStar Facilities & Lab Only)
NA
40% after Deductible
(WellStar Facilities & Lab Only)
NA
20% after Deductible
40% after Deductible
20% after Deductible
40% after Deductible
40% after Deductible
50% after Deductible
20% after Deductible
N/A
20% after Deductible
N/A
40% after Deductible
NA
20% after Deductible
40% after Deductible
40% after Deductible
50% after Deductible6
BARIATRIC SERVICES11, 14
Surgery & Visits - limited to team members and
spouses. Services must be rendered at a WellStar
hospital.
RECONSTRUCTIVE SURGERY10, 11
Inpatient & Outpatient - surgery to repair or
alleviate bodily damage caused by illness or injury
and reconstructive surgery incidental to a
mastectomy.
6
6
6
TRANSPLANT SERVICES10,11
Evaluation Services - to determine candidacy for
transplantation.
Organ & Bone Marrow Transplants - including
search fees.
Travel & Lodging - organ transplants only.
$10,000 per transplant.
TREATMENT OF THE TEETH, GUMS, JAW, JOINTS OR JAWBONE15
ER Hospital & Professional Services - treatment
for tumors, gums and injuries to sound natural
teeth incurred while you are covered under the
WellStar Employee Medical Plan.
20% after Deductible
11
Oral Surgery - for infection, disease and
injuries of the jaw joints or jawbones, including
adjacent tissues, TMJ as specifically stated and
orthogenetic surgery for skeletal deformity.
6
40% after Deductible
6
SUMMARY OF BENEFITS
1
2
WellShare Premium HDHP Plan Option with HSA /HRA
WellShare Select HDHP Plan Option with HSA1/HRA2
Minimum Basic Plan Option
MICELANEOUS SERVICES
Diabetic Supplies
Durable Medical Equipment (Purchase or
Rental)11- including hearing aids. Coverage for
hospital-grade breast pumps for mothers of infants
whose infants are hospitalized during their first
year is covered at 100%.
Vision Hardware - lens and contacts covered
following cataract surgery only.
10
Prosthesis - one each, per member per lifetime
unless determined to be medically necessary due
to physiological changes of the member –
replacement prosthetics must be preauthorized.
20% after Deductible
40% after Deductible6
20% after Deductible
N/A
No Charge
10% ($125 max. per Rx)
after Deductible
6
40% after Deductible
6
40% after Deductible
50% after Deductible
Orthotics10, 11
Hospice Care (including at home) - a
practitioner must certify member as terminally ill
with a life expectancy of 6 months or less.
Chiropractic - Preauthorization required for
dependents under 13 years old. Limit 20 visits
12
annually.
PRECRIPTION COVERAGE - Subject to Annual Deductible
WellStar Pharmacy Network
Select Preventive Rx
Generic
Brand Formulary
Brand Non-Formulary
Retail
Generic
Brand Formulary
Brand Non-Formulary
Mail Order
Generic
Brand Formulary
Brand Non-Formulary
Specialty
Specialty11
No Charge
10% ($125 max. per Rx)
after Deductible
30% ($150 max. per Rx)
after Deductible
30% after Deductible
30% ($150 max. per Rx)
after Deductible
N/A
50% after Deductible
20% after Deductible
30% after Deductible
60% ($200 max. per Rx)
Deductible
N/A
50% after Deductible
N/A
40% after Deductible
10% ($150 max. per Rx)
after Deductible
N/A
20% after Deductible
10% ($150 max. per Rx)
after Deductible
40% after Deductible
after
N/A
after
N/A
60% after Deductible
N/A
40% after Deductible
N/A
No Charge
40% ($175 max. per Rx)
Deductible
40% after Deductible
N/A
60% after Deductible
N/A
10% ($150 max. per Rx)
after Deductible
N/A
SUMMARY OF BENEFITS
1
2
WellShare Premium HDHP Plan Option with HSA /HRA
WellShare Select HDHP Plan Option with HSA1/HRA2
Minimum Basic Plan Option
NOTES:
3
4
The deductible and coinsurance are aggregate. For deductible this
In-network and out-of-network are
means that the entire deductible must be met before coinsurance is
separate.
applied for any covered individual family member. For coinsurance this
means that the entire coinsurance maximun must be satisfied before the
plan pays 100% for any covered individual family member.
1
Open enrollee employer contribution to an opened HSA will be available in full
1/1/2015. New hires and status changes prorated employer contribution to an opened
HSA will be available in the month which coverage is effective. Members have until
11/30/15 to open their accunts and receive the WellStar employer contribution.
2
HRA option is only for team members not eligible for an HSA based on IRS
eligibility rules. Open enrollees employer contributon to the HRA will be
available in full 1/1/2015. New hire and status changes prorated employer
contribution to the HRA will be available on the first day coverage is
effective.
5
For a list of specific covered services refer to the 2015 Covered Preventive Service
List. Preventive services are defined by the Affordable Care Act (ACA).
7
6
Since there are no contractual arrangements with OON providers or facilities, OON preventive care services limited to routine exams, well child care
and immunizations.
they can charge any fee for their services. WellStar's medical plan
administrator processes claims for OON providers and facilities based on
industry standard OON rates (125% Medicare rates). You will be responsible
for a deductible, coinsurance and any charges over the OON rate.
8
Only one well-visit will be paid
100%. Members who go to an
OBGYN and PCP will be charged for
one of the visits.
9
10
12
All visit limits are combined In and
Out-of-Network unless otherwise
noted.
No referral required to see a specialist.
13
Claims processing is withheld by physician offices until birth.
14
Medical necessity or medical emergency only.
11
Precertification/Preauthorization of services may be required in order for
benefits to be payable.
Available to team members and spouses 18 and older. Not available to 15Treatment must begin within 90 days of injury to be covered by the plan;
dependents.
treatment must be completed within 12 months after the dental injury to be
covered by the plan. Initial extraction, replacement or other dental services of
sound natural teeth due to injury. Benefits will be paid only for expenses
incurred for the least expensive service.

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