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
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
Maternity Program:
Maternity Program offers digital education and support.
Quitline Program:
24-Hour Nurse Line:
Fitness Discounts:
Weight Watchers Program:
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
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
HSA ELIGIBILITY REQUIREMENTS
To have an HSA and make contributions to the account, you must meet several basic qualifications.
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
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)
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.
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
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.
In order to enroll in the coverages, please complete the necessary enrollment form which can be provided by Human Resources
Heather Wellhouse
heatherw@ajgates.com
440-498-0123
