EMMC is self insured and offers five medical options that are administered by CIGNA. Four of the plans are Preferred Provider Organization (PPO) plans (High Option PPO, Account Based Plan, Comprehensive Plan, and Safety Net Plan). The fifth plan is an Indemnity Plan (Option 1). A PPO is a network of healthcare providers, including doctors, hospitals, labs and other healthcare facilities that have contracted with a provider (CIGNA) to provide services at a discounted rate. Each PPO provides three tiers of coverage: in-system (which includes the EMHS System Providers), in-network (which includes the CIGNA Network providers) and out-of-network (which includes qualified providers that are not part the EMHS System or the CIGNA Network). The three tiers provide the freedom to see any qualified provider. Services may not always be available In-System or In-Network. Below is a chart of the PPO tiers.
|
PPO TIERS OF COVERAGE |
|
|
In-System (EMHS) |
In-Network (CIGNA) |
Out-of-network |
|
Where |
Services are rendered and billed by an EMHS System provider/facility |
Services are rendered and billed by any provider/facility within the CIGNA Open Access Plus ONLY network |
Services are rendered and billed by a qualified provider/facility outside the EMHS System and the CIGNA Open Access Plus ONLY Network |
|
Special Features |
Preventive care covered at 100% |
Out-of-pocket costs based on negotiated rates |
Out-of-pocket costs based on reasonable and customary charges |
|
Claims |
No claims to file |
No claims to file |
May be required to file claims |
All medical options have a pre-existing condition limitation. A pre-existing condition is an injury or a sickness for which a person receives treatment, incurs expenses, or receives a diagnosis from a physician during the 90-day period before becoming covered under the EMHS Medical Plan. Payments will not be made for covered expenses related to an injury or a sickness which is a pre-existing condition, unless those expenses are incurred after a continuous one-year period of coverage under the EMHS Medical Plan. CIGNA will reduce any pre-existing condition limitation period under this plan by the number of days of prior creditable coverage one had under a creditable health plan or policy. Break in coverage between the old plan and new EMHS Medical Plan may not exceed 63 days. A Certificate of Creditable Coverage must be provided to CIGNA in order to reduce/eliminate the 12 month limitation period.
The following benefits are available to benefits-eligible employees. (See the General Benefit Information link for an explanation of benefits-eligible and non benefits-eligible statuses).
The five medical options provide employees with unique choices to fit his/her specific medical needs. Below is an explanation of the four PPO plans.
|
HIGH OPTION PPO |
|
Plan Feature |
In-System |
In-Network |
Out-of-Network |
|
Annual Deductible |
$0 Individual
$0 Family |
$200 Individual
$400 Family |
$375 Individual
$750 Family |
|
Preventive Care |
100% |
80% after deductible |
70% after deductible |
|
Primary Care
(Office Visits) |
90% |
80% after deductible |
70% after deductible |
|
All Other Inpatient & Outpatient Services |
90% |
80% after deductible |
70% after deductible |
|
Emergency Room |
80% |
80% after deductible |
70% after deductible |
|
Annual Out-of-Pocket Maximum |
$500 Individual
$1,000 Family |
$1,000 Individual
$2,000 Family |
$1,175 Individual
$2,350 Family |
|
HIGH OPTION PPO PRESCRIPTION DRUG COVERAGE |
|
|
In-System |
In-Network |
Out-of-Network |
|
Retail (Up to a 30-Day Supply) |
|
Generic |
$7 copay |
$20 copay |
Not Covered |
|
Formulary Brand |
$15 copay |
$35 copay |
|
Nonformulary Brand |
$30 copay |
$55 copay |
|
90-Day Supply- Available at Affiliated Pharmacy Services (APS) Only (In-System) |
|
Generic |
$21 copay |
Not Covered |
Not Covered |
|
Formulary Brand |
$45 copay |
|
Nonformulary Brand |
$90 copay |
|
ACCOUNT BASED PLAN |
|
Plan Feature |
In-System |
In-Network |
Out-of-Network |
|
Annual Deductible |
$1,050 Individual
$2,100 Family |
$1,500 Individual
$3,000 Family |
$3,000 Individual
$6,000 Family |
|
Employer-Funded
Choice Fund
(exclusively for deductible & co-insurance only; prescription copays are not eligible) |
$750 Individual
$1,500 Family |
$750 Individual
$1,500 Family |
$750 Individual
$1,500 Family |
|
Deductible Gap |
$300 Individual
$600 Family |
$750 Individual
$1,500 Family |
$2,250 Individual
$4,500 Family |
|
Preventive Care |
100% (not subject to deductible) |
100% (not subject to deductible) |
70% after deductible |
|
Primary Care
(Office Visits) |
90% after deductible |
80% after deductible |
70% after deductible |
|
All Other Inpatient & Outpatient Services |
90% after deductible |
80% after deductible |
70% after deductible |
|
Emergency Room |
80% after deductible |
80% after deductible |
70% after deductible |
|
Annual Out-of-Pocket Maximum |
$2,250 Individual
$4,500 Family |
$5,000 Individual
$10,000 Family |
$8,000 Individual
$16,000 Family |
|
COMPREHENSIVE PLAN |
|
Plan Feature |
In-System |
In-Network |
Out-of-Network |
|
Annual Deductible |
$500 Individual
$1,000 Family |
$1,500 Individual
$3,000 Family |
$3,000 Individual
$6,000 Family |
|
Preventive Care |
100% (not subject to deductible) |
80% after deductible |
70% after deductible |
|
Primary Care
(Office Visits) |
90% after deductible |
80% after deductible |
70% after deductible |
|
All Other Inpatient & Outpatient Services |
90% after deductible |
80% after deductible |
70% after deductible |
|
Emergency Room |
80% after deductible |
80% after deductible |
80% after deductible |
|
Annual Out-of-Pocket Maximum |
$3,000 Individual
$6,000 Family |
$6,000 Individual
$12,000 Family |
$7,500 Individual
$15,000 Family |
|
|