Benefits Overview
Medical - Medical Mutual
IN NETWORK - Plan Summary - PPO HSA 3000
The HDHP is similar to the PPO Plan in that you have the option to choose any provider when you need care. However, in exchange for a lower per-paycheck cost, you must satisfy a higher deductible that applies to almost all health care expenses, including those for prescription drugs.
All expenses are your responsibility until the deductible is reached, with the exception of preventive care, which is covered at 100% when you visit a physician in the network. Once the deductible is met, you are responsible for coinsurance for medical expenses and a copay for prescription drug expenses.
Enrolling in this plan allows you to contribute tax free dollars to a health savings account (HSA). Any dollars that you wish to contribute can be used towards any eligible medical, Rx, dental and/or vision expenses that you may incur while covered under the plan. See HSA section of this guide for additional details.
DEDUCTIBLE
Single/Family Total Deductible - $3,000/$6,000
Member Cost Share % - 0% after deductible
PRESCRIPTION DRUGS
Tier 1 (Value Generic) - 100% after deductible
Tier 2 - 100% after deductible
Tier 3 - 100% after deductible
Tier 4 - 100% after deductible
Programs & Discounts
Chronic Condition Management Program:
This program offers digital and telephonic options that are customized to meet your needs and help you achieve your personal health goals
- Asthma
- Heart Failure
- Coronary Artery Disease
- COPD
- Diabetes
- Hypertension
Maternity Program:
Maternity Program offers digital education and support.
- Access to specialty – trained maternity health coach
- Provides knowledge, advice, and comfort during pregnancy
Quitline Program:
- One on one coaching
- Personalized plan & educational materials
- May qualify for nicotine patches or gum at no cost
- Learn more by calling 1-866-845-7702
24-Hour Nurse Line:
- Health question, minor injury or medical question – get answers 24/7 from a clinical expert
- No Charge to members
- Call 1-888-912-0636 & have your ID number ready
Fitness Discounts:
- Discounted gym memberships at more than 10,000 fitness clubs through Medical Mutual’s partner, GlobalFit
Weight Watchers Program:
- Save up to 50% off regular cost of WW membership
- Digital & Studio programs to help achieve health goals
Virtual Visits
A virtual visit lets you see and talk to a doctor from your mobile device or computer. When you use one of the provider groups in our virtual visit network, you have benefit coverage for certain non-emergency medical conditions. Costs must be paid by you at the time of the virtual visit and will apply toward your deductible and out-of-pocket maximum.
WHEN CAN I USE A VIRTUAL VISIT?
When you have a non-emergency condition and:
–your doctor is not available
–When you are considering visiting a hospital emergency room for a non-emergency health condition.
*Your covered children may also use Virtual Visits when a parent or legal guardian is present for the visit.
Examples of Non-Emergency Conditions:
Bladder Infection / Rash / Bronchitis / Seasonal Flu / Diarrhea / Sinus / Fever / Sore Throat / Pink Eye / Stomach
HOW DO I GET ACCESS?
Learn more about Virtual Visits and access direct links to provider sites by logging into your www.my.clevelandclinic.org/online-services/express-care-online
HSA - Health Savings Account
ENROLLED IN AN HSA ELIGIBLE HEALTH PLAN?
A Health Savings Account (HSA) is a tax-free savings account is owned by you, is 100% vested from day one, and let’s you build up savings for future needs. The funds may be used to pay for qualifying healthcare expenses not covered by insurance or any other plan for yourself, your spouse, or tax dependents. You decide how much you would like to contribute, when and how to spend the money on eligible expenses, and how to invest the balance.
UNDERSTANDING YOUR HSA
- Pre-tax contributions are deducted through payroll and deposited into your HSA account;
- You can use your HSA available funds to pay for qualified medical expenses tax-free;
- HSA funds can be used for non-eligible expenses but will be subject to regular income taxes and a 20% excise tax penalty.
- Unused funds remain in your account for future use and roll over each calendar year;
- HSAs remain with you even if you change health plans or companies. If you open an HSA and later become ineligible to make contributions, you can still use your remaining funds; and
- You can change your HSA contribution at any time during the plan year for any reason.
HSA ELIGIBILITY REQUIREMENTS
To have an HSA and make contributions to the account, you must meet several basic qualifications.
- To be eligible to open and contribute to an HSA, you must have coverage under a qualified High Deductible Health Plan (HDHP).
- Participants cannot be covered by any other health insurance plan (this exclusion does not apply to certain other types of insurance, such as dental, vision, disability or long-term care coverage);
- Participants cannot participate in a Healthcare FSA or spouse/domestic partner’s Healthcare FSA or Health Reimbursement Account (HRA).
- Participants cannot be enrolled in Medicare or Medicaid.
- You cannot be eligible to be claimed as a dependent on someone else’s tax return.
- You have not received Department of Veterans Affairs Medical benefits in the past 90 days, unless the Veteran has a disability rating. (There may be additional special circumstances, check with your tax preparer).
Dental - Guardian
Your dental coverage is through Guardian and the dental network is DentalGuard Preferred. Network dentists accept Guardian’s In-Network benefits and bill as covered services. Non-network dentists may bill you for any difference in cost between the Guardian allowed amount and the dentist’s fee (known as balance billing). Please utilize network dentists to avoid balance billing. Frequency limitations apply to certain services. You can access plan information and a provider network directory by registering at www.GuardianAnytime.com.
Plan Options (In Network)
DHMO
Deductible for Type 1 - $0
Calendar Year Maximum - None
Type 1 Services - (Oral exams/Routine cleanings/Bitewing X-rays/Fu;; Mouth X-rays) - Benefits provided on a per procedure schedule by ADA Code
Type 2 Services - (Fillings/General Anesthesia/Scaling & Root Planing/Simple Extractions) - Benefits provided on a per procedure schedule by ADA Code
Type 3 Services - (Crowns/Dentures) - Benefits provided on a per procedure schedule by ADA Code
Type 4 Services - Orthodontia (children to age 19 only) - Per Procedure Code
PPO Buy-Up
Deductible for Type 1 - $50
Calendar Year Maximum - $1,500
Type 1 Services - (Oral exams/Routine cleanings/Bitewing X-rays/Fu;; Mouth X-rays) - 100%
Type 2 Services - (Fillings/General Anesthesia/Scaling & Root Planing/Simple Extractions) - 90%
Type 3 Services - (Crowns/Dentures) - 60%
Type 4 Services - Orthodontia (children to age 19 only) - $1,000
Vision - Guardian
VSP - In-Network
Vision Exam - $20 copay
COVERED SERVICES – LENSES / FRAMES
Single Lenses - $20 copay
Bifocals - $20 copay
Trifocals - $20 copay
Lenticular - $20 copay
Frames - $150 retail allowance, then 20% discount
COVERED SERVICES
Contact Lenses - $150 allowance
Contact Lens Evaluation Fitting - 15% off professional fee
BENEFIT FREQUENCY
Exams - Once every 12 Months
Lenses - Once every 12 Months
Frames - Once every 24 Months
Contacts - Once every 12 Months (contacts in lieu of frames/lenses)
Life and AD&D
Basic Life and AD&D
Life and Accidental Death & Dismemberment (AD&D) benefit is a flat $20,000 with premiums paid in full by A.J. Gates for all full-time employees and is provided through Guardian Insurance.
Supplemental Life Insurance
Employees have the opportunity to enroll in supplemental Life insurance. If you choose to enroll in employee coverage, this will be in addition to your employer provided Basic Life coverage. Coverage is also available for your spouse and/or child dependents. It is typically required that you elect coverage for yourself in order to be eligible for coverage on your dependents.
Disability
Short-Term Disability (STD)
Everyday illnesses or injuries can interfere with your ability to work. Even a few weeks away from work can make it difficult to manage household costs.
Short Term Disability coverage provides financial protection for you by paying a portion of your income, so you can focus on getting better and worry less about keeping up with your bills.
Voluntary Benefit - Employee is responsible for 100% of the cost
Long-Term Disability (LTD)
Serious illnesses or accidents can come out of nowhere. They can interrupt your life, and your ability to work for months – even years.
Long Term Disability provides financial protection for you by paying a portion of your income, so you have financial support to manage your disability and your household.
Employer Paid Benefit - Employer is responsible for 100% of the cost
Spousal Surcharge Notice
In an effort to control costs, a spousal surcharge has been instituted for employees enrolled on the healthcare plan whose spouses are eligible for Medicare or healthcare insurance through their employer but opt to take A.J. Gate’s healthcare program. The criteria are as follows:
- Spousal surcharge applies only to employees that cover their spouse on the healthcare program
- Eligible employee’s spouse maintains full time employment and is eligible for an employer sponsored health plan through their full-time employment, but chooses to enroll under the healthcare program
- Eligible employee’s spouse is eligible for Medicare and chooses to enroll under the healthcare program
The spousal surcharge will be $300 per month as long as the spouse remains eligible for other coverage.
How To Enroll?
In order to enroll in the coverages, please complete the necessary enrollment form which can be provided by Human Resources
Contact Us
Client Contacts
Heather Welhouse
heatherw@ajgates.com
440-498-0123