HMO Options
January 1, 2015–December 31, 2015
Benefits
Open Access Aetna Select HMO
Network Coverage
Nationwide Network
CareFirst Open Access HMO
Regional Network
(MD, DC and Northern VA)
COST SHARING LIFETIME LIMITS
Calendar Year Deductible
Individual
Family
None
None
None
None
$2,000 (includes copays)
$6,000 (includes copays)
$2,000
$6,000
Coinsurance
100%
100%
Lifetime Maximum
None
None
Primary Care Office Visit
$10 copay
$10 copay
Gynecology Office Visit
$10 copay for Well Woman visit or
$15 copay for all other visits
$10 for Well Woman visit or
$15 copay for all other visits
Specialist Office Visit
$15 copay
$15 copay
Physical Therapy Office Visit
100% after copay (120 visits
combined with Occupational
Therapy).
100% after copay (30 visits per
condition per calendar year)
Speech Therapy Office Visit
100% after copay (60 visits)
100% after copay (30 visits per
condition per calendar year)
Occupational Therapy Visit
100% after copay (120 visits
combined with Physical Therapy)
100% after copay (30 visits per
condition per calendar year)
Chiropractic Office Visit
100% after copay (limited to 30
visit maximum combined in and out
of network) Preauthorization not
required
100% after copay (limited to 20
visits per benefit period)
Allergy Shots/Other Covered
Injections
100% after copay
100% after copay
Calendar Year Out-of-Pocket
Maximum
Individual
Family
PROFESSIONAL SERVICES
Retiree Plan Participants under age 65 and over age 65: Expenses for non-covered services and charges in
excess of reasonable and customary do not apply toward the out-of-pocket limit.
The purpose of this Open Enrollment Guide is to give you basic information about your benefits options
and how to enroll for coverage or make changes to existing coverage. This guide is only a summary of
your choices and does not fully describe each benefit option. Please refer to your Certificates of Coverage
provided by your health plan carriers for important additional information about the plans. Every effort has
been made to make the information accurate; however, in the case of any discrepancy, the provisions of
the legal documents will govern.
32 • Howard County Public School System—Benefits Enrollment Guide for Retirees
HMO Options
January 1, 2015–December 31, 2015
Benefits
Open Access Aetna Select HMO
Network Coverage
Nationwide Network
CareFirst Open Access HMO
Regional Network
(MD, DC and Northern VA)
Allergy Serum
100% after copay
Allergy Testing
Covered as either a PCP or Specialist Covered as either a PCP or
office visit
Specialist office visit
Diagnostic tests
Included with PCP or Specialist
copayment
Diagnostic tests performed by
100%
lab or other testing facility and
billed separately from office visit
100% after copay
100% after copay
100%
PREVENTIVE CARE
Well Child Visit/Immunization
$10 copay
$10 copay
Routine Adult Physical
$10 copay
$10 copay
Routine Gynecological Exam
$10 copay, one exam per calendar
year
$10 copay, one exam per calendar
year
Routine Pap Smear
100% when included with routine
gynecological exam. One exam per
calendar year.
100% when included with routine
gynecological exam. One exam per
calendar year.
Routine Mammogram
100% baseline between age 35-39.
100% unlimited visits
One per calendar year age 40 and over
PSA Testing
Covered based on place of service.
One per calendar year for males age
40 and over
Covered based on place of service.
One per calendar year for males
40 and over
INPATIENT CARE (Pre authorization required)
Room and Board
100% Pre-authorization required
100% Pre-authorization required
Physician/Surgical Services
100%
100%
Anesthesia Services
100%
100%
Intensive Care Unit/Critical Care
Unit
100%
100%
Maternity/Nursery/Birthing
Center
100%
100%
Skilled Nursing/Rehab Facility
Care
100% limited to 120 days per
calendar year
100% unlimited days
Dialysis/Radiation/
Chemotherapy
100%
100%
Hospice (Preauthorization
Required)
100%
100%
Physical/Speech/
Occupational Therapy
100%
100%
Howard County Public School System—Benefits Enrollment Guide for Retirees • 33
HMO Options
January 1, 2015–December 31, 2015
Benefits
Open Access Aetna Select HMO
Network Coverage
Nationwide Network
CareFirst Open Access HMO
Regional Network
(MD, DC and Northern VA)
OUTPATIENT HOSPITAL SERVICES
Surgical/Anesthesia Services
100%
100%
Dialysis/Radiation/
Chemotherapy
100%
100%
Outpatient Diagnostic Services
100%
100%
MATERNITY/INFERTILITY SERVICES
1st prenatal visit
100% after copay
100% after copay
Pre-and Postnatal care and
delivery
100%
100%
Routine nursery care
100%
100%
Sterilization/Reverse
Sterilization requires
preauthorization
100% Reverse Sterilization is not
covered
100% Reverse Sterilization is not
covered
Artificial Insemination (AI)
50% of Allowed Benefit
(preauthorization; limited to 6
courses of treatment per lifetime)
50% of Allowed Benefit (limited
to 6 courses of treatment per
lifetime)
In Vitro Fertilization (IVF)–
maximum of 3 IVF attempts/
lifetime (Preauthorization
Required)
50% of Allowed Benefit
50% of Allowed Benefit
MEDICAL EMERGENCIES (USE OF ER)
Emergency Room
Urgent Care Center
100% after $50 ER copay
100% after $50 copay
(waived if admitted)
(waived if admitted)
100% after $15 copay
100% after $15 copay
Retiree Plan Participants under age 65 and over age 65: Expenses for non-covered services and charges in
excess of reasonable and customary do not apply toward the out-of-pocket limit.
The purpose of this Open Enrollment Guide is to give you basic information about your benefits options
and how to enroll for coverage or make changes to existing coverage. This guide is only a summary of
your choices and does not fully describe each benefit option. Please refer to your Certificates of Coverage
provided by your health plan carriers for important additional information about the plans. Every effort has
been made to make the information accurate; however, in the case of any discrepancy, the provisions of
the legal documents will govern.
34 • Howard County Public School System—Benefits Enrollment Guide for Retirees
HMO Options
January 1, 2015–December 31, 2015
Benefits
Open Access Aetna Select HMO
Network Coverage
Nationwide Network
CareFirst Open Access HMO
Regional Network
(MD, DC and Northern VA)
MEDICAL EQUIPMENT/SUPPLIES
Durable Medical Equipment
100%
100%
Prosthetic Devices
100%
100%
Orthopedic Devices
100%
100%
Foot Orthotics
100%
100%
(Pre-authorization required)
(Subject to medical necessity)
MENTAL HEALTH AND SUBSTANCE ABUSE (Preauthorization required for inpatient only)
Mental Health:
Inpatient
100%
100%
Outpatient
$15 copay
$15 copay
Inpatient
100%
100%
Outpatient
$15 copay
$15 copay
Ground: 100% non-emergency—not
covered
Ground: 100% non-emergency—
not covered
Air: 100% non-emergency—not
covered
Air: Covered 100% nonemergency—not covered
Kidney, Cornea Bone Marrow
Transplants
Covered in full. The National Medical
Excellence (NME) unit will arrange
transplant services by a facility that
is part of the Institutes of Excellence
(IOE) transplant network.
100%
Heart, Heart-Lung, Lung,
Pancreas, Liver Transplants
Covered in full. The National Medical
Excellence (NME) unit will arrange
transplant services by a facility that
is part of the Institutes of Excellence
(IOE) transplant network.
100%
Substance Abuse:
OTHER SERVICES
Ambulance
Performed at approved IOE facility.
If non-IOE facility no coverage.
Cardiac Rehabilitation
100% if performed in an outpatient
hospital setting;100% after copay in
office setting or freestanding cardiac
rehabilitation center
100% after $15 copay
Howard County Public School System—Benefits Enrollment Guide for Retirees • 35
HMO Options
January 1, 2015–December 31, 2015
Benefits
Open Access Aetna Select HMO
Network Coverage
Nationwide Network
CareFirst Open Access HMO
Regional Network
(MD, DC and Northern VA)
OTHER SERVICES (continued)
Hearing Aids
Hearing aids: 100% to a maximum of 100% to a maximum of $1,400 per
$1,400 per ear during any 36 month ear during any 36 month period
period for a child up to age 19.
for a child up to the age of 18.
Hearing exam: 100% after specialist
copay. One exam every 12 months.
Acupuncture
Acupuncture therapy includes services
provided by a licensed acupuncturist
covered at 100% no copay subject to
R&C
100% of Allowed Benefit
no copay
Vision (Routine eye exam)
Routine eye exam covered at 100%
after $15 copay. One exam every 12
months.
Routine eye exam covered at
100% after a $10 copay. One exam
per calendar year
Retiree Plan Participants under age 65 and over age 65: Expenses for non-covered services and charges in
excess of reasonable and customary do not apply toward the out-of-pocket limit.
The purpose of this Open Enrollment Guide is to give you basic information about your benefits options
and how to enroll for coverage or make changes to existing coverage. This guide is only a summary of
your choices and does not fully describe each benefit option. Please refer to your Certificates of Coverage
provided by your health plan carriers for important additional information about the plans. Every effort has
been made to make the information accurate; however, in the case of any discrepancy, the provisions of
the legal documents will govern.
36 • Howard County Public School System—Benefits Enrollment Guide for Retirees