Sample Large Group (90 lives)
06.01.2004
Prepared by Veritas Health Systems
2004 Health Insurance Proposal: DUAL OPTION
Insurance Provided by The Guardian
Presented by Broker
2521 Hilltop Drive, Suite 370 • Redding, CA 96002 • Toll Free: 877.313.7700 • Fax: 530.223.7719
dba Veritas Health Systems Administrators and Insurance Services CA License No. 0765129
Table of Contents
Introduction............................................................................................................ 1
What is a Consumer-Directed Health Program? ............................................................ 3
What is a Health Reimbursement Arrangement (HRA)? ................................................. 4
How Does the Veritas HRA Program Work? .................................................................. 5
How Does the Program Work for the Employer? ........................................................... 6
How Does the Program Work for the Employee?........................................................... 7
Five Reasons Why an HRA Makes Sense ..................................................................... 8
Services Provided by Veritas Health Systems............................................................... 9
Sample Report ...................................................................................................... 10
Questions and Answers .......................................................................................... 11
Veritas Rates and Plan Description .......................................................... Addendum
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
Introduction
Why do employers choose to offer health benefits?
Most employers today choose to provide group health benefits for their employees. The
majority of working people in the U.S. obtain health insurance through their employer.*
In comparison to the rest of the industrialized world, we are the only nation that provides
employer sponsored health benefits. There are two basic reasons for this:
1. In America, we believe the private sector can
provide a better medical delivery system than
the government.
2. The government also supports this notion as
they continue to allow favorable tax status
for employee benefits. Employer sponsored
Employer sponsored benefits
are popular because they are
one of the few forms of compensation that have complete
tax freedom.
benefits are popular because they are one of
the few forms of compensation that have complete tax freedom. Employee benefits
are exempt from state & federal taxes, both employee and employer payroll taxes,
unemployment taxes, workers compensation assessments and 401(k) employer
contributions.
It is no wonder that employee benefits are a popular way to provide compensation to
employees. They are free of all other encumbrances that come with wages.
* A 2002 survey conducted by the Kaiser Family Foundation and the Health Research and Educational Trust, found that 96% of
employers who have 50 employees or more provide group health insurance benefits.
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
1
Introduction
Is the current system broken and is there another way that will work
better?
Veritas believes the current system has flaws that can be repaired. In the past 15 years,
group health insurance has changed from being “health insurance” (insurance is
something that provides protection against the unforeseen and unaffordable) to being
“health benefits.” Imagine if we had “auto benefits” as opposed to “auto insurance.”
“Auto benefits” would pay for gas, oil changes, windshield wipers, car washes, tires, etc.
Sounds crazy doesn’t it? Do we believe that
“auto benefits” would cost significantly more
Imagine if we had “auto benefits”
as opposed to “auto insurance.”
“Auto benefits” would pay for gas,
oil changes, windshield wipers, car
washes, tires, etc.
than “auto insurance?
Employers provide health benefits because
they receive all the rewards of very favorable
tax savings, but there is a high price. If we
had “auto benefits” the premium cost would
most likely double compared to today’s “auto
insurance.” Employees use benefits because they are there to be used. This single fact
promotes inefficiencies and causes increased utilization (which translates to higher rates).
With an HRA program, employers provide “health insurance” for their employees and
families, while both the employee and employer still receive the tax advantages of “health
benefits.” As you will see in this proposal, the cost is less and the system is repaired so
future increases will be less.
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
2
What is a Consumer-Directed Health Program?
A Consumer-Directed Health Program in its most basic
sense is a method of funding and delivering health
care services that puts the consumer in charge. A way
to define Consumer-Directed Health Care is that it is
the Opposite of Managed Care. In managed care, the
provider is typically prepaid for their services. Since the
With a Consumer-Directed
Health Program, the plan
member is in charge of
how their health care
dollars are spent...
providers are prepaid a fixed amount for their services,
they actually make less money when they provide
more care. Therefore, another name for Managed Care could be “Budgeted Care.” With a
Consumer-Directed Health Program, the plan member (aka “consumer”) is in charge of how
their health care dollars are spent, and, therefore, the services they wish to receive.
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
3
What is a Health Reimbursement Arrangement (HRA)?
A Health Reimbursement Arrangement (HRA) is the official name that the Internal Revenue
Service (IRS) has given to identify these types of programs. Different plans and insurance
companies will use various names, but “HRA” is the government’s official name.
An HRA is an annual account established and funded by employers for participating
employees and their families. The eligible plan participants can use the dollars in their
account to receive reimbursements for eligible medical expenses (i.e. Dr. Office visits,
prescription drugs, lab work, surgery, hospitalization, etc.). These reimbursements are
tax free to the employee and tax deductible for the
HRA funds not used during
the annual term set by the
employer roll over into the
next year...
employer. Any HRA funds not used during the annual
term set by the employer roll over into the next year for
the plan member (employee) to use for possible next
year expenses.
This type of account has been in existence for several
years and used by employers in the same fashion as mentioned above. However, it was
just in June of 2002 that the IRS clarified that the reimbursed amounts are tax free to
the employee and tax deductible for the employer. The ruling also clarified the
rollover provision.
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
4
How Does the Veritas HRA Program Work?
The employer purchases, for each of the eligible
employees and their dependents, a high deductible
insurance plan (all eligible claims are charged
towards the deductible). The cost of this high
deductible insurance is far less expensive than
The cost of this high deductible
insurance is far less expensive
than traditional HMO and PPO
plans.
traditional HMO and PPO plans. The savings
realized from the high deductible insurance,
can now be used (it is the employer’s choice how much) to fund the HRA account. The
HRA funds are now available to the plan member to pay for health care expenses. It is
financially beneficial to plan members to utilize PPO providers, but any licensed provider
may be used.
$
$
$
HRA
Contribution
$
Traditional
Plan
Premium
$
$
$
$
$
High
Deductible
Premium
$
$
$
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
5
How Does the Program Work for the Employer?
1. Veritas bills employer for:
premiums, HRA deposits,
broker and Veritas fees.
2. Employer pays Veritas for:
premiums, HRA deposits,
broker and Veritas fees.
3. Veritas deposits premiums,
HRA deposits, broker and
Veritas fees in separate
fiduciary accounts.
4. Veritas remits premiums
to insurance carrier and
updates eligibility.
5. Veritas reimburses
employee for un-reimbursed
qualified medical expenses
through the HRA.
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
6
How Does the Program Work for the Employee?
1. Plan member visits eligible
provider.
2. Provider bills insurance
carrier
3. Insurance Carrier adjusts
claim and sends explanation
of benefits (EOB) to
provider and employee
4. Employee submits
request to Veritas for
reimbursement from
their HRA, based on
Insurance Carrier EOB.
5. Veritas confirms eligibility,
verifies qualified medical
expense, adjusts claim
and sends reimbursement
check and account balance
information to the employee
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
7
Five Reasons Why an HRA Makes Sense
Point 1:
Health insurance costs are becoming prohibitive.
This proposal provides an alternative plan that will save significant employer
dollars, not only this year, but in future years as well.
Point 2:
Plan Flexibility and Satisfaction
An HRA Consumer Directed Health Plan gives the consumer more choice,
responsibility and control. Quality of care and health plan satisfaction will
increase.
Point 3:
Entitlement Mentality is eliminated
When a person is not involved in the buying decision and not aware of the
actual cost, the “Entitlement Mentality” takes over, prudent plan usage
disappears, and rates continue to skyrocket! The HRA method eliminates this
problem.
Point 4:
Benefits vs. Insurance
Up until about 1990, employers provided group health “insurance,” now
employers provide group health “benefits.” Insurance is meant to protect
against unforeseen and unaffordable expenses, whereas benefits are meant to
be used. This simple difference is the primary factor in costs that are escalating
out of control. Consumers use benefits, while insurance is simply a safeguard
against the unknown. By providing benefits, as opposed to insurance, a system
has been created where those who use the benefits more than others are
causing costs to go up for everyone.
Point 5:
The current system is broken.
Managed Care of the 90’s was an excellent low cost alternative for employers.
But with the continued unprecedented increases and employee satisfaction
waning, a new method is needed.
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
8
Services Provided by Veritas Health Systems
1. Developing and maintaining relationships with quality, stable group health insurance
companies.
2. Working with brokers, employers and insurance carriers to design cost effective major
medical coverage.
3. Bidding major medical insurance each year to find the most cost effective coverage.
4. Writing and maintaining the employer’s “Plan Document” which defines the rules for the
HRA.
5. Keeping the employer updated with federal and state regulations regarding HRA’s.
6. Designing and distributing communication materials for plan participants.
7. Performing employee meetings to explain how the program works.
8. Maintaining a toll free number for plan members to call with questions and check account
balances.
9. Coordinating HRA and major medical eligibility with insurance carrier, employer and
Veritas.
10. Invoicing employer for premiums, fees and HRA amounts and distributing accordingly.
11. Adjusting HRA claim requests from plan members to determine if they are eligible
expenses under the HRA plan document.
12. Reimbursing plan members for qualified HRA expenses.
13. Completing Schedule A for the IRS form 5500.
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
9
Sample Report
Employer
Employee
Sample Group
Claim
Number
000001010
Ryan Ellis
Claim
Amount
Employee RollOver
Portion
Portion
HRA
Portion
Check
Amount
Benefit/Option
Date of
Service
195 HRA Non-Linked
Medical
01/02/2003
01/02/2003
Ryan Ellis
Office Visit
85.00
85.00
0.00
0.00
0.00
85.00
85.00
196 HRA Non-Linked
Medical
01/02/2003
01/02/2003
Ryan Ellis
Allergy
78.25
78.25
0.00
0.00
0.00
78.25
78.25
200 HRA Non-Linked
Medical
01/02/2003
01/02/2003
Ryan Ellis
Allergy
23.55
23.55
0.00
0.00
0.00
23.55
23.55
205 HRA Non-Linked
Medical
01/01/2003
01/01/2003
Rhonda Ellis
Chiropractic
55.00
55.00
0.00
0.00
0.00
55.00
55.00
206 HRA Non-Linked
Medical
01/02/2003
01/02/2003
Bobby Ellis
Lab
70.00
70.00
0.00
0.00
0.00
70.00
70.00
223 HRA Non-Linked
Medical
04/17/2003
04/17/2003
Ryan Ellis
Office Visit
130.00
130.00
0.00
0.00
0.00
130.00
130.00
Benefit
Claimant/Service
Maximum
Benefit
HRA Non-Linked
3600.00
YTD
Claims
441.80
Eligible
Amount
Co-Pay
YTD
Checks
Available
Benefit
441.80
3158.20
Scott Valley Bank - TEST ONLY
Redding, CA 96049-1510
90-625/1211
Veritas Health Systems
P.O. Box 493557
Redding, CA 96049-3557
DATE
05/06/2003
PAY Four Hundred Forty One Dollars and 80/100 Cents
000001010
AMOUNT
$*******441.80
TO THE RYAN ELLIS
ORDER 1234 TEST DRIVE
COTTONWOOD, CA 95544
OF
VOID AFTER 90 DAYS
121106252000001010 05026106
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
10
Questions & Answers
If the benefit dollars in the HRA are not all used, will they be forfeited?
The employer decides how much can be carried forward into the next plan year. In
the first year, it is recommended that the employer allow all unused amounts to roll
over into the following year. This promotes the employee to become a prudent and
thrifty consumer, and they are rewarded.
Does the employer have to make the same contribution amount to the HRA next
year?
No. Each year the employer determines how much they wish to provide in the employee’s
HRA account. This gives the employer greater control over how much they wish to spend on
employee health benefits each year.
Are my employees going to be exposed to much greater financial risk with this
plan?
Possibly. Some employees will pay more out of their own pocket if they incur high medical
claims. However, the amount in most cases is not that much different than traditional plans.
The main difference with an HRA plan is that the employee may have a small risk of paying
more out-of-pocket in the event in which they have a large claim. But if they use the plan
wisely, they will have surplus dollars to roll over into future years. Studies have shown that
the majority of employees on average spend less than $700/year on health care expenses.
Can the benefit dollars be spent on anything?
No! The benefit dollars can only be used for qualified medical expenses. With the assistance
of Veritas, the employer can design what they wish to cover.
Are there any requirements to use certain providers and pharmacies?
No! Members can receive treatment WHEN, WHERE, and by WHOM they desire. However,
out-of-pocket expenses are lower when members work with one of the many participating
providers and pharmacies.
What happens if an employee has a very large claim?
The insurance company will pay for the qualified expenses over the high-deductible.
Payments below the deductible can be reimbursed from the Health Reimbursement Account
(HRA) and the corridor between the deductible and the HRA is the member’s responsibility
as an out-of-pocket expense.
©2002 Veritas Health Systems dba: Veritas Health Systems Administrators & Insurance Services - CA Lic. #0765129
11
Sample Group - Rates & Funding (1500 - 100%)
Guardian Rates & HRA Contribution Schedule
Census
Breakdown
Medical Rates
& Fees
HRA
Funding*
Medical Rates,
Fees & HRA
Premiums, Fees &
HRA Amounts
Employee Only
42
$
221.33
$
46.88 $
268.20
$
11,264.43
Employee and Spouse
20
$
464.89
$
62.50 $
527.39
$
10,547.73
Employee and Child(ren)
7
$
434.44
$
62.50 $
496.94
$
3,478.59
Employee and Family
21
$
678.00
$
62.50 $
740.50
$
15,550.54
Monthly Medical Premium & Fees
$
35,872.53
Monthly HRA Funding
$
4,968.75
Monthly Medical Premium, Fees & HRA Funding
$
40,841.28
Annual Medical Premium & Fees
$
430,470.33
Annual HRA Funding
$
59,625.00
Annual Medical Premium, Fees & HRA Funding
$
490,095.33
90
*75% of actual employee HRA dollars was used to illustrate the expected ER actual cost. Due to employee turnover and roll-over caps, unused HRA dollars do not need to be funded by the employer.
National statistical results show that, on average, only 75% of all HRA dollars will actually be used.
Annual HRA available for employees:
*Actual expected maximum usage:
HRA contributions used for this illustration:
$
$
79,500.00
75%
59,625.00
GUARDIAN MEDICAL ASSUMPTIONS & CONTINGENCIES:
Medical rate/premium cannot be sold stand alone. Must be packaged with Life. See Guardian life quote addendum.
Group has been with current carrier at least 2 years & Clean Transferred Business Questionnaire. See Attached.
- The proposed plan meets all legal conditions and Guardian's underwriting requirements.
- Minimum participation requirement for contributory cases is 75% of the total number of employees, or 90% of those who do not have coverage elsewhere.
Non-contributory cases require 100% participation.
- Actual rates charged will be based on the employees' ages 6 months after the effective date.
-
GUARDIAN PROPOSAL CONDITIONS
The cost is based on census data submitted for Proposal purposes. The quoted medical rates assume fewer than 10% of the covered employees are on COBRA. The Final Rates may vary if the actual enrollment differs
from the census data submitted for quotation. This proposal is valid for 90 days from the proposal date. Coverage is limited to those charges that are medically necessary, as described in your plan document. We limit
benefits for pre-existing conditions, private duty nursing, and the following types of services: psychology, chiropractic, podiatry, speech therapy, obesity, and infertility. The plan does not pay for: experimental treatment;
services and supplies furnished by family members and business or professional associates, personal comfort and household items; custodial care, schooling, or training; rest or old age homes; physicals and related
charges (unless the plan provides specific benefits), routine care and exams for vision, hearing, foot care; eyeglasses, contacts, hearing aids; nurses aids, home attendants, nutritionists, dietitians, or massage therapists;
cosmetic surgery; hair replacement. (GP-1-R3-1.0 et al)
Created: 6/10/2004
© 2004 Veritas Health Systems dba: Veritas Health Systems Administrators Insurance Services - CA Lic. #0765129
Sample Group - Rates Summary & Comparison (1500 - 100%)
Census
EE Only
EE + Spouse
Veritas
Renewal
Current
PPO
42
EE + Child(ren)
20
EE + Family
7
Totals
21
90
PPO
$
237.18 $
601.83 $
572.38 $
879.23
EE Costs:
ER Costs:
$
$
$
237.18 $
364.65 $
237.18 $
335.20 $
237.18 $
642.05 $
237.18 $
PPO*
$
272.76 $
692.10 $
658.24 $
EE Costs:
ER Costs:
$
$
$
272.76 $
364.65 $
327.45 $
335.20 $
323.04 $
642.05 $
369.06 $
Medical & Fees
HRA Funding
$
221.33 $
46.88
464.89 $
62.50
434.44 $
62.50
678.00
62.50
Total Costs:
$
268.20 $
527.39 $
496.94 $
740.50
259.19
228.74
472.30
16,703
200,439
24,138 $
289,657
Annual
Monthly
23,122 $
21,346 $
1,011.11
Monthly
EE Costs:
$
268.20 $
268.20 $
268.20 $
268.20
Annual HRA Dollars Available: $
750 $
1,000 $
1,000 $
1,000
Total Dollars Available:
750 $
1,000 $
1,000 $
1,000
HRA
ER Costs:
-
$
277,469
256,154
Annual
23,122 $
28,016 $
Monthly
277,469
336,198
Annual
Funds Available for Plan Member
Out-of-Pocket Expenses
Buy-up 200
*Renewal rates based on 15 % increase over current
Medical & Fees
$
335.76 $
699.04 $
651.11 $
1,025.16
EE Costs:
ER Costs:
$
$
67.56 $
268.20 $
430.84 $
268.20 $
382.91 $
268.20 $
756.96
268.20
Veritas -VS- Renewal
Veritas Outlay
Renewal Premium
$ Difference
% Difference
Employee Cost:
$
200,439
$
277,469
$
(77,031)
-27.76%
Employer Cost:
$
289,657
$
336,198
$
(46,541)
-13.84%
Total Cost:
$
490,095
$
613,667
$
(123,572)
-20.14%
Created: 6/10/2004
© 2004 Veritas Health Systems dba: Veritas Health Systems Administrators Insurance Services - CA Lic. #0765129
Sample Group - Trend Savings & Plan Design (1500 - 100%)
Major
Medical
Insurance
1,200,000
4
Projected 5-year
Savings of $1,290,914
1,000,000
800,000
100%
After Deductible
200,000
$933,311
$1500 Plan Year Deductible
$654,507
3
$608,844
$811,575
$566,366
$705,717
$526,852
$490,095
$613,667
400,000
$1,073,308
600,000
Gap**
Out-of-Pocket
EO - $750
Optional
ES - $500
Flexible Spending
Account (FSA) Dollars
EC - $500
EF - $500
2
EO - $750
Health Reimbursment ES - $1000
Account (HRA) Dollars EC - $1000
0
2004
Renewal
2005
2006
2007
Veritas
Establish an FSA to close the
Out-of-Pocket Gap between the
employee's HRA and high
deductible
EF - $1000
2008
Insurance
1
** Dollar amounts shown as per individual
Annual Savings
2004
2005
2006
2007
2008
Projected 5-Year Savings:
1
$
$
$
$
$
$
123,572
178,865
245,209
324,467
418,801
1,290,914
2
3
4
Insurance (1st Dollar Benefit): 1) $30 Co-pay for office visits and preventative care;
2) Lab & X-Ray - 100% 3) Rx $35/$50 after $250 deductible (waived for mail order.)
Health Reimbursement Account (HRA): Dollars made available by employer.
These dollars are "trend-proof," and can "roll-over" from year to year.
Gap (Out of Pocket): Difference between HRA benefit dollars.
Major Medical Insurance: Lower premium, high deductible insurance coverage.
*Consumer-Directed Health Plans have proven to reduce
trend. Trend is the term used to describe the increasing
of healthcare costs.
Created: 6/10/2004
© 2004 Veritas Health Systems dba: Veritas Health Systems Administrators Insurance Services - CA Lic. #0765129
Sample Group - HRA and Plan Options Comparison
Census
Veritas
Total Premium
Option 1 (PROPOSAL)
EE Only
42
EE + Spouse
20
Renewal
Current
$613,667
$533,624
Total Premium/Fees
Rates
(Excluding HRA)
$430,470
$59,625
HRA Funding
Difference from Current
($43,528)
Difference from Renewal
($123,572)
Option 2
$392,694
$59,625
HRA Funding
Difference from Current
($81,305)
Difference from Renewal
($161,348)
Option 3
$424,121
$59,625
HRA Funding
Difference from Current
($49,877)
Difference from Renewal
($129,921)
Option 4
$386,980
$59,625
HRA Funding
Difference from Current
($87,019)
Difference from Renewal
($167,063)
Option 5
$367,085
$59,625
HRA Funding
Difference from Current
($106,914)
Difference from Renewal
($186,958)
Health Reimbursement Account (HRA)
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
$
$
$
$
EE + Child(ren)
7
EE + Family
21
Total
90
Deductible
Co-Insurance*
Co-pay
$
$
$
$
221.33
464.89
434.44
678.00
1500 (2x)
100/70
$30
$
$
$
$
202.95
423.70
396.11
616.86
1500 (2x)
80/60
$30
$
$
$
$
218.24
457.96
428.00
667.73
1500 (2x)
100/70
$40
$
$
$
$
200.16
417.47
390.31
607.61
1500 (2x)
80/60
$40
$
$
$
$
189.97
395.97
370.22
576.22
2500 (2x)
100/70
$50
Annual HRA Funding (x's 75%)
750.00
1,000.00
1,000.00
1,000.00
$59,625
* 100/70: 100% in-network coverage and 70% out-of-network coverage (OON OOP Max: $5000 Individual & $12500 Family)
* 80/60: 80% in-network coverage and 60% out-of-network coverage (In Network OOP Max: $2000 Individual & $5000 Family / OON OOP Max: $5000 Individual & $12500 Family)
Created: 6/10/2004
© 2004 Veritas Health Systems dba: Veritas Health Systems Administrators Insurance Services - CA Lic. #0765129
Sample Group - CDH Benefit Summary (1500 - 100%)
Plan Features
In Network
Out-of-Network
$1,500
2x Cumulative Family
$2,250
2x Cumulative Family
100%
70%
N/A
N/A
$5,000
$12,500
Unlimited
Unlimited
Plan Year Deductible
Individual
Family Maximum
In network and out-of-network deductibles accumulate separately
Co-Insurance
Out of Pocket Limit (excluding deductible)
Individual
Family Maximum
Medical Lifetime Maximum
Physician Office Visits
Office Visit
$30 Encounter Fee
70% Aftter Deductible
All Other Physician Charges
100% After Deductible
70% Aftter Deductible
Routine Physical Included
$30 Encounter Fee
70% Aftter Deductible
100% Coverage
70% After Deductible
Inpatient, Outpatient, Ambulatory, Surgical Facilities
100% After Deductible
70% Aftter Deductible
Emergency Room Charges
Maternity / Nursery Care
100% After Deductible
70% Aftter Deductible
100% After Deductible
70% Aftter Deductible
$30 Encounter Fee
70% Aftter Deductible
$30 Encounter Fee
70% Aftter Deductible
Outpatient (25 visits)
$30 Encounter Fee per visit,
maximum of up to 25 visits paid at 50%
1st 25 visits paid at 50% after deductible
Inpatient (30 days)
1st 30 days are covered at 100% after deductible;
thereafter at 50% for the next 60 days
1st 30 days are covered at 70% after deductible;
thereafter at 50% for the next 60 days
Radiology Services (Encounter fee & deductible waived in-network)
Hospital Charges
Physical Therapy
Spinal Manipulation (30 visits maximum)
Mental & Nervous Conditions, Alcohol and Drug Abuse
Combined in and out-of-network maximum of $50,000
Lifetime Maximum *
- Outpatient visits are limited to an annual maximum of 25 visits for in and out-of-network visits
- Co-payments for covered charges paid at a co-insurance percent for the treatment of mental and emotional conditions, drug abuse and alcohol abuse:
1) can't be used to meet this plan's out-of-pocket limits.
2) must be paid by the covered person even if the limit on out-of-pocket expenses has been met.
Prescription Drug Benefits
$250 Deductible (3 per family)
Generic
$35 co-pay
$35 co-pay
Brand Name
$50 co-pay
$50 co-pay
(Oral Contraceptives Included)
Deductible Waived
Mail Order (90 day supply)
Generic
$35 co-pay
$35 co-pay
Brand Name
$50 co-pay
$50 co-pay
Dependent Eligibility
Up to age 20, Full Time Student to age 26
Health Reimbursement Account (HRA)
Annual HRA Amount Funded by employer
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
$750
$1,000
$1,000
$1,000
HRA dollars are available from first day of coverage.
HRA dollars can be used to reimburse eligible expenses including: **
- Co-pays & Encounter Fees
- Deductibles (in network and out-of-network)
- Prescription drugs and over-the-counter drugs
- Co-Insurance
* If the plan is subject to the Mental Health Parity Act, only the benefits we pay for the treatment of alcohol and drug are subject to a payment limit of $50,000 during the covered person's lifetime. If the plan is not subject to the Mental Health
Parity Act, benefits for the treatment of mental and nervous conditions are also included in the payment limit of $50,000.
** Available for all eligible health expenses with guidelines set at the discretion of the employer.
Created: 6/10/2004
© 2004 Veritas Health Systems dba: Veritas Health Systems Administrators Insurance Services - CA Lic. #0765129
Sample Group - Benefit Summary Traditional PPO 200 (Buy-Up Option)
Plan Features
In Network
Out-of-Network
$200
3x Family
$500
3x Family
80%
60%
$2,000
$5,000
$4,000
$10,000
Unlimited
Unlimited
Plan Year Deductible
Individual
Family Maximum
In network and out-of-network deductibles accumulate separately
Co-Insurance
Out of Pocket Limit (excluding deductible)
Individual
Family Maximum
Medical Lifetime Maximum
Physician Office Visits
Office Visit
$10 Encounter Fee
60% After Deductible
All Other Physician Charges
80% After Deductible
60% After Deductible
Routine Physical Included
$10 Encounter Fee
60% After Deductible
80% Coverage
60% After Deductible
Inpatient, Outpatient, Ambulatory, Surgical Facilities
80% After Deductible
60% After Deductible
Emergency Room Charges
Maternity / Nursery Care
80% After Deductible
60% After Deductible
80% After Deductible
60% After Deductible
$10 Encounter Fee
60% After Deductible
$10 Encounter Fee
60% After Deductible
Outpatient (25 visits)
$10 Encounter Fee per visit,
maximum of up to 25 visits paid at 50%
1st 25 visits paid at 50% after deductible
Inpatient (30 days)
1st 30 days are covered at 80% after deductible;
thereafter at 50% for the next 60 days
1st 30 days are covered at 60% after deductible;
thereafter at 50% for the next 60 days
Radiology Services (Encounter fee & deductible waived in-network)
Hospital Charges
Physical Therapy
Spinal Manipulation (30 visits maximum)
Mental & Nervous Conditions, Alcohol and Drug Abuse
Combined in and out-of-network maximum of $50,000
Lifetime Maximum *
- Outpatient visits are limited to an annual maximum of 25 visits for in and out-of-network visits
- Co-payments for covered charges paid at a co-insurance percent for the treatment of mental and emotional conditions, drug abuse and alcohol abuse:
1) can't be used to meet this plan's out-of-pocket limits.
2) must be paid by the covered person ev
Prescription Drug Benefits
No Deductible
Generic
$10 co-pay
$10 co-pay
Brand Name
$20 co-pay
$20 co-pay
(Oral Contraceptives Included)
Mail Order (90 day supply)
No Deductible
Generic
$10 co-pay
$10 co-pay
Brand Name
$20 co-pay
$20 co-pay
Dependent Eligibility
Up to age 20, Full Time Student to age 26
* If the plan is subject to the Mental Health Parity Act, only the benefits we pay for the treatment of alcohol and drug are subject to a payment limit of $50,000 during the covered person's lifetime. If the plan is not subject to the Mental Health
Parity Act, benefits for the treatment of mental and nervous conditions are also included in the payment limit of $50,000.
Created: 6/10/2004
© 2004 Veritas Health Systems dba: Veritas Health Systems Administrators Insurance Services - CA Lic. #0765129