HomeMy WebLinkAbout09/02/2009 B A K E R S F I E L D
Staff: City Council members:
John W. Stinson, Assistant City Manager Ken Weir, Chair
Steven Teglia, Administrative Analyst Irma Carson
Zack Scrivner
SPECIAL MEETING NOTICE - PERSONNEL COMMITTEE
of the City Council - City of Bakersfield
Wednesday, September 2, 2009
11 :00 a.m.
City Hall North
Conference Room A
1600 Truxtun Avenue, First Floor
Bakersfield, California 93301
AGENDA
1. ROLL CALL
2. ADOPT JULY 7, 2009 AGENDA SUMMARY REPORT
3. PUBLIC STATEMENTS
4. DEFERRED BUSINESS
A. Committee Discussion and Recommendation regarding the Replacement
of Anthem Blue Cross PPO and HMO with the Riverside JPA Retiree
Medical Plan for Retirees - Lozano
B. Committee Discussion and Recommendation regarding the Anthem Blue
Cross PPO Surplus - Tandy
5. COMMITTEE COMMENTS
6. ADJOURNMENT
B A K E R S F I E L D
WC✓ City Council members:
Staff: John W. Stinson Ken Weir, Chair
Assistant City Manager Irma Carson
Zack Scrivner
SPECIAL MEETING OF THE PERSONNEL COMMITTEE
Tuesday, July 7, 2009
1 :00 P.M.
City Hall South - Caucus Room
1501 Truxtun Avenue
Bakersfield, CA 93301
AGENDA SUMMARY REPORT
Meeting called to order at 1 :20:00 PM
1. ROLL CALL
Committee members: Councilmember Ken Weir, Chair
Councilmember Zack Scrivner
Councilmember Irma Carson was absent
City staff: Alan Tandy, City Manager
John W. Stinson, Assistant City Manager
Rhonda Smiley, Assistant to the City Manager/ PIO
Steven Teglia, Administrative Analyst- City Manager's Office
Rick Kirkwood, Management Assistant-City Manager's Office
Robert Sherfy, Deputy City Attorney
Pamela McCarthy, City Clerk
Nelson Smith, Finance Director
Javier Lozano, Human Resources Manager
Ginger Rubin, Benefits Technician
Derek Tisinger, Fire Captain / BFLO
Brian West and Todd Dickson, Police Detectives / BPOA
Retired employees: Margaret Ursin
Others present: Marlene Valdez and Chuck Waide, SEIU Local 521
Chris Kim and Tom Morrison -Segal Company
SACouncil Committees\2009\Personnel\July\July 7 ASR.doc
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2. ADOPTION OF MARCH 11, 2008 AGENDA SUMMARY REPORT
Adopted as submitted
3. PUBLIC STATEMENTS
None
4. DEFERRED BUSINESS
A. Update regardinq City Proposals to Insurance Committee for Health Insurance
Renewals and Health Plan Cost Reduction Options - Lozano
Tom Morrison with Segal summarized the contents of information distributed at this
meeting and that of the Insurance Committee earlier in the day.
a. Renewal of Active plans with no benefit changes
1. Anthem HMO
ii. Anthem PPO
iii. Kaiser HMO
Active employees would see a rate decrease of 4.8% in the Anthem HMO
plan; a decrease of 0.9% in the Anthem PPO plan; and a 9.6% increase in
the Kaiser HMO plan.
b. Renewal of Retiree plans with no benefit changes
i. Anthem HMO- Under 65
ii. Anthem PPO - Under 65
iii. Kaiser HMO - Under 65
Retirees under the age of 65 would see a rate increase of 41 .6% in the
Anthem HMO plan; a 22.6% increase in the Anthem PPO plan; and a 2.3%
increase in the Kaiser HMO plan. The rates for the Blue Cross Senior Secure
and Kaiser HMO Senior Advantage will not be available until the fall when it
comes up for approval by the Center for Medicare CMS.
There would be no change in the vision rates for any of these plans.
Additionally, the basic life insurance plan rates would decrease by 28.6%.
The accidental death and dismemberment insurance rate would not
change.
S:\Council Committees\2009\Personnel\July\July 7 ASR.doc
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C. Elimination of Duplicate MH/SA under Anthem PPO
Beginning January 1, 2010, the City must comply with the Mental Health
Substance Dependency Parity Act. Neither Active employees nor retirees
will see an increase in rates. Approximately I% will be built into plan costs in
order to be compliant with Federal law. There will be no differentiation in
reimbursement levels, or frequency or duration of visits.
d. Acceptance of Metropolitan bid regarding Dental RFP
Segal sent out an RFP to dental program providers, both preferred providers
and pre-paid plans. Based on the proposals received, Segal recommends
the following: Replace Anthem with Metropolitan Life Insurance Company
as the preferred provider; retain United Healthcare as the
and replace DDS with United Healthcare as the lower-cost pre-paid plant.
e. Alternative Plans for Retirees
I. Riverside Retiree JPA
ii. AARP Voluntary Group Plan for Medicare Eligible Retirees
The County of Riverside, by use of a Joint Powers Agreement, operates a
plan that draws from a pool consisting of multiple entities. Costs are kept
low due to the large number of participants. The Insurance Committee will
continue to explore and discuss this plan as a possible option for the future,
as well as a plan administered by AARP. This may be a viable option to
reduce costs for both the City and the retirees.
City Clerk Pam McCarthy spoke on behalf of the Insurance Committee. She reported
that, by unanimous vote of those in attendance, the Insurance Committee endorses
Segal's recommendations, and they will continue to review the Riverside Retiree JPA
and AARP options for retirees.
Committee member Scrivner made a motion to approve Items a, b, c and d, and to
continue to investigate Item e. It was unanimously approved, with Committee
member Carson absent.
5. COMMITTEE COMMENTS
None
6. ADJOURNMENT
The meeting was adjourned at 1:47:
SACouncil Committees\2009\Personnel\July\July 7 ASR.doc DRAFT Page
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B A K E R S F 1 E L D
MEMORANDUM
TO: Alan Tandy, City Manager
FROM: Javier Lozano, HR Manager
SUBJECT: August 25, 2009 Insurance Committee Update
DATE: August 26, 2009
Following is a brief update regarding the Insurance Committee meeting of August 25, 2009.
• The Segal Company presented the Riverside JPA Medical Insurance information and
addressed any questions raised by the Insurance Committee members in attendance.
• The City proposed the replacement of the Anthem Blue Cross PPO and HMO with the
Riverside "Exclusive Care Select" for retirees only. The 42% currently applied to the
Anthem Blue Cross PPO would be applied to the Riverside Plan premiums. Also the Years
of Service Credit will continue as currently applied.
• The Insurance Committee has agreed to this City proposal with the following stipulations:
I. Identification of the Tier 1 Hospital.
2. Address the loss of the Accidental Injury benefit under the current Anthem Blue
Cross plan under the Dental Plan.
3. Opportunity to review the agreement with Riverside prior to Council.
4. Assurance if the Riverside plan fails that the City will create a comparable plan.
• The City also presented the Anthem Blue Cross Surplus letter from Anthem and proposed the
following options with the $1.3 million.
1. Payout of the employee's 20%of the $1.3 million back to employees as in previous
surplus efforts.
2. Placement of this surplus into an irrevocable OPEB Trust to reduce GASB liability.
3. Place into a contingency account to be designated to stabilize Anthem Blue Cross
HMO premiums.
• For this proposal the Insurance Committee wanted to review further.
We are scheduled to meet with the Insurance Committee again on the morning of September 2,2009
to address any outstanding issues.
CD
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Exclusive Care Select
Exclusive Care Select Early Retiree Medical Plan
General Information Proposed Plan Design
EC Contracted Hospitals Clinics& Blue Shield Network
Physicians (CA&Outside of CA) Out-of-Network
Maximum Lde6me Benefit
Coinsurance Maximum(Per person/family Per plan year) $5,000,000
1st Dollar Deductible-applies to coinsurance NOT copays $1.500/$4,500 $2,500/$7,500 $5,000/$15,000
Non-Preauthorization Patient Penalty $250/$750 $5001$1,500 $1,000/$3,000
50%reduction in benefits for inpatient, 50%reduction in benefits 50%reduction in benefits for inpatient,
outpatient and outpatient diagnostic for inpatient,outpatient outpatient and outpatient diagnostic testing
testing and outpatient diagnostic
• - testing
Retail Pharmacy(30 day supply)
$15 generic,$25 brand,$40 non-formulary
Mail order(90 Da deductible does not apply,Medco pharmacies only
Y Supply)pp y)-MANDATORY
Si nificant or New Therapeutic Class 2 times retail(Medco pharmacies only)
50% Medco harmacies only)
Medical/Maternity/Surgical Intensive Care(Semi-private room)'
10% 20% 40%
Medical/Maternity/Surgical Intensive Care(In-patient Ancillary
10% 20%
40%
Skilled Nursing Facility-maximum 100 days
Medical/Surgical Care(outpatient) 10% 20%
0
Emergency Room(ER) 10% 20% 40%40%
Major Diagnostic Test,CT Scan,MRI,NMR(Outpatient) $50 copay plus 10%10% $100 copay plus 20%
o $100 copay plus 20%
Minor Diagnostic Test,X-ray,Lab(Inpatient) 20% 40%
Minor Diagnostic Test,X-ray,Lab(Outpatient including ER) 10% 20% 40%
Instacare Clinic 10% 20%
_ 10% 20% 40%
Inpatient-physical,speech 40%
,occupational,cardiac,or pulmonary
10% 2046
40%
Outpatient-physical,speech,occupational,cardiac,or pulmonary
10% 20%
_ 40%
Medical/Surgical-Physical/Facility/ER Covered as any other condition Covered as an other
Y Covered as Tier 2
Ambulance Land/Air(Life Threatening Only) condition
Orthodontic Injury Treatment 10% 20%
Dental Injury Not covered 20%
Treatment Not covered Not covered
• Not covered Not covered
Not covered
Physician Office Visits(Primary Care)
Physician Office Visits(After Hours) $10 copay $25 copay
$20 copay 40%
Physician Office Visits(Specialty Care) $50 copay 40%
Physician Visits(Inpatient) $20 copay $50 copay
$10 coy 40%
pa
Physician Visits(Outpatient Including ER) $25 copay 40%
Major Diagnostic Test,CT Scan,MRI,NMR(Office) $10 copay $25 copay
Minor Diagnostic Test,X-ray,Lab(Office) 10% 20% 40%40%
Minor Diagnostic Test,X-ray,Lab(Outpatient Including ER) 10% 20%
40%
Minor Diagnostic Test,X-ray,Lab(Inpatient) 100 20% 40%
Radiology/Pathology(inpatient) 70% 20%
Radiology/Pathology(outpatient including ER) 10% 20% 40%40%
Radiology/Pathology(office) 10% 20%
40%
Injections(office) 10% 20°� 40%
Surgery(office) $10 copay $25 copay 40%
Surgery(Inpatient) 10% 20%
10% 40%
Specialty Surgery'-CENTERS OF EXCELLENCE ONLY' 0 20% 40%
Surgery(Outpatient including ER) 10/° 20%
40%
Anesthesiology(Office) 10% 20% 40%
Anesthesiology(Inpatient) 10% 20%
Anesthesiology(Outpatient including ER) 10% 20% 40%40%
Home Health Care(In lieu of Hospital,up to 100 days) 10% 20%
Hospice 10% 0 40%
20%
Chiropractic Therapy 10% 20% 40%
Allergy Testing Not covered 40%
Not covered Not covered
Aller Treatment/Serum 10% 20%
10% Not covered
20% Not covered
Routine Physical Exam
Routine Vision Exam $10 copay $25 copay
Routine Hearin Exam $10 copay Not covered
$10 co a
$25 copay Not covered
$25 cc a
Not covered
5032452_1 XLS/ECS Benefits
1
Exclusive Care Select
Exclusive Care Select Early Retiree Medical Plan
General Information Proposed Plan Design
Tier 1 Tier 2
EC Contracted Hospitals Clinics& Tier 3
Blue Shield Network OUt-of-Network
Transplant Benefit Physicians (CA&Outside of CA)
Heart,Liver,Pancreas,Bone Marrow,Comea,-Lung - Covered as any other condition Covered as any other Not covered You Pay
CENTERS OF EXCELLENCE ONLY3
condition
Medical Supplies
Medical Supplies(office) 10% 20% 40°,6
Durable Medical Equipment;annual maximum of$1,000 10% 20% 40%
Orthotic Supplies 10% 20% 40%
• Not covered Not covered Not covered
Inpatient Facility semi-private room-CENTERS OF EXCELLENCE Not covered unless a severe mental Not covered unless a WEIM
ONLYZ illness,then covered like any other severe mental illness;then Not covered
benefit covered like any other
Inpatient Facility Ancillary benefit
tY ry-CENTERS OF EXCELLENCE ONLY3 Not covered unless a severe mental Not covered unless a
illness;then covered like any other severe mental illness;then Not covered
benefit covered like any other
Inpatient Facility Physician Visits-CENTERS OF EXCELLENCE Not covered unless a severe mental Not co benefit
a
ONLY° illness;then covered like any other severe mental illness;then Not covered
benefit covered like any other
I benefit
Physician Office Visits:Psychologist/MCSW/APRN/Psychiatrist - $20 copay up to 30 visits per year;unless a severe mental ill Not covered
s ness
• then covered like any other benefit
Hearing Tests-Annual maximum$1,000 once every 5 years
Hearing Aids
-Annual maximum$1,000 once every 5 years 10 ° 20% Not covered
20% Not covered
1'1 Center of Excellence coverage only for certain procedures such as:Orthopedic,Cardiac,Oncology
(2)Bariatric Surgery is excluded from coverage.
431 Centers of Excellence are designated by Exclusive Care and Blue Shield and are characterized by exemplary results in the area of specialty.
Note:Deductible does not apply to any copays and does apply to coinsurance.
Note:Deductibles and coinsurance maximums do not cross apply through Tiers.
Note:Tier 3 coverage is based on Medically Necessary Reasonable and Customary charges
5032452_1.XLS/ECS Benefits
2
City of Bakersfield
Medical Exclusive Care Select
2010 Plan Rates
ExcCus00.04" early ee P(an
Retiree Only(<65, no MC) $650.53
Retiree+ 1 (all<65, no MC)
$1,181.88
Retiree+2(all<65,no MC)
$1,70109
rdna#ion Plane
RETIREE ONLY `
Retiree>65 with MC parts A& B
Retiree>65 with MC part B only $486.42
$719.48
RETIREE W/1 DEPENDENT
One>65 with MC parts A& B
One>65 with MC part B only $1,136.93
$
Two>65 with MC parts A& B 972.
Two>65 with MC part B only $ 81 1
$1,,4343 8.93
RETIREE W/2 DEPENDENTS
One>65 with MC parts A& B
One>65 with MC part B only $1,787.46
$2,020.52
Two>65 with MC parts A& B
$1,492.02
Two>65 with MC part B only
$1,958.14
Three>65 with MC parts A& B
$1,459.21
Three>65 with MC part B only
$2,158.39
Retiree Only(>65, no MC) "°
$991.89
Retiree+ 1 (all >65, no MC)
_ Retiree+2 (>65 no MC) $1,804 49
$2,616.10
x ..,, ., Care Spec#Meilcare Supple►nen#at-Plan
Retiree Only(>65 with MC)
Retiree+ 1(>65 with MC $269.20
$538.38
Assumptions:
1)If enrollment changes by more than+/_10%from the assumed enrollment of 250 rates are subject to change.
2)18 months of PPO month by month enrollment and claims are needed before rates are final.
3)No commissions are included.
4)Due to the current economic circumstances,no guarantees will be offered.
5)Rates are estimated prior to being approved by COR BOS.
SEGAL
Doc 5044331 Riverside Plan Doc 5044991
8/24/2009
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Anthem,O
August 11, 2009
Mr. Thomas Morrison
Senior Vice President
The Segal Company
330 North Brand Blvd, Ste 1100
Glendale, CA 91203
Re: City of Bakersfield 2008 Year End Accounting
Dear Tom,
Enclosed is the Year End Accounting exhibit for the City of Bakersfield 2008
Policy year, for your review. The exhibit shows a surplus of $3,896,998.
After accounting for
• a $354,209 reserve necessary for the claim runoff of the dental
coverage terminating 1/1/10 and
• a reserve of $2,242,789 protecting the plan against impact of large
claim swings,
there is a $1,300,000 surplus available for release to the City.
In the event the City wishes to withdraw the $1,300,000, please forward a
letter from the City making the request and we will generate a check or wire
transfer. If the City wishes to leave the funds on deposit, we will pay
interest on the surplus as we do on all funds held.
Please let me know if you have any questions.
Sincerely,
Tim Snyder
Regional Vice President
Strategic Accounts
Cc: Natalie Seaman, Jennifer Thomas
Anthem,,O,
Blue Cross
Anthem Blue Cross is the trade name of Blue Cross of California.Anthem Blue Cross and Anthem Blue
Insurance Company are independent licensee® s of the Blue Cmss Ass Cross Life and Health
ociation.®ANTHEM is a registered C tradema of Anthem
Insurance Companies.Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Associationrk.
F ====an=FBA ERSFIELD
Annual Accounting
Case No. C00403
January 1, 2008 through December 31, 2008
Income Received
$12,366,680
Paid Claims
$8,897,764
+Ending Reserve
- Beginning Reserve $1,159,969
+ Large Claim Charge ($1,196,
- Large Claim Credit $1,088,8860 60
($667,929)
Incurred Claims
$9,282,047
Retention
$696,751
Total Expense
$9,978,798
Expense Ratio
80.69%
Surplus for this Period
$2,387,882
Amount in Stabilization Fund at January 1,2008
$1,473,027
Interest for this Period
$36,089
Prior Year Deficit Carried Forward
$0
Accumulated Surplus through December 31,2008
$3,896,998
Reserve for Dental Runout
($354,209)
Amount Allocated to Stabilization Fund
($2,242,789)
Ending Surplus
$1,300,000
11-Aug-09
The following documents pertain to the:
SPECIAL MEETING
OF THE PERSONNEL COMMITTEE
on
Wednesday, September 2, 2009
at 11 :00 a.m.
Exclusive Care Select
Exclusive Care Select Early Retiree Medical Plan
Proposed
General Information Tier 1 Tier 2 Tier 3
EC Contracted Hospitals Clinics& Blue Shield Network •
Outside Physicians (CA& of
Maximum Lifetime Benefit $5,000,000
Coinsurance Maximum(Per person/family Per plan year) $1,500/$4,500 $2,500/$7,500 $5,000/$15,000
1st Dollar Deductible-applies to coinsurance NOT copays $250/$750 $500/$1,500 $1,000/$3,000
Non-Preauthorization Patient Penalty 50%reduction in benefits for inpatient, 50%reduction in benefits 50%reduction in benefits for inpatient,
outpatient and outpatient diagnostic for inpatient,outpatient outpatient and outpatient diagnostic testing
testing and outpatient diagnostic
testin
Prescription Drug Benefits(Nledco national network) You Pay
Retail Pharmacy(30 day supply) $15 generic,$25 brand,$40 non-formulary
deductible does not apply,Medco pharmacies only
Mail order(90 Day Supply)-MANDATORY 2 times retail(Medco pharmacies only)
Si nificant or New Therarieutic Class 50%(Medco gharmacies onl
Hospital/Facility Benefits You Pay
Medical/Maternity/Surgical Intensive Care(Semi-private room) 10% 20% 40%
Medical/Maternity/Surgical Intensive Care(In-patient Ancillary)' 10% 20% 40%
Skilled Nursing Facility-maximum 100 days 10% 20% 40%
Medical/Surgical Care(outpatient) 10% 20% 40%
Emergency Room(ER) $50 copay plus 10% $100 copay plus 20% $100 copay plus 20%
Major Diagnostic Test,CT Scan,MRI,NMR(Outpatient) 10% 20% 40%
Minor Diagnostic Test,X-ray,Lab(Inpatient) 10% 20% 40%
Minor Diagnostic Test,X-ray,Lab(Outpatient including ER) 10% 20% 40%
Instacare Clinic 10% 20% 40%
Rehabilitation Therapy Benefit You Pay
Inpatient-physical,speech,occupational,cardiac,or pulmonary 10% 20% 40%
Outpatient-physical,speech,occupational,cardiac,or pulmonary 10% 20% 40%
Accident and Life Threatening Condition You Pay
Medical/Surgical-Physical/Facility/ER Covered as any other condition Covered as any other Covered as Tier 2
condition
Ambulance Land/Air(Life Threatening Only) 10% 20% 20%
Orthodontic Injury Treatment Not covered Not covered Not covered
Dental n1upt Treatment Not covered Not covered Not covered
Physical&Professional Services You Pay
Physician Office Visits(Primary Care) $10 copay $25 copay 40%
Physician Office Visits(After Hours) $20 copay $50 copay 40%
Physician Office Visits(Specialty Care) $20 copay $50 copay 40%
Physician Visits(Inpatient) $10 copay $25 copay 40%
Physician Visits(Outpatient Including ER) $10 copay $25 copay 40%
Major Diagnostic Test,CT Scan,MRI,NMR(Office) 10% 20% 40%
Minor Diagnostic Test,X-ray,Lab(Office) 10% 20% 40%
Minor Diagnostic Test,X-ray,Lab(Outpatient Including ER) 10% 20% 40%
Minor Diagnostic Test,X-ray,Lab(Inpatient) 10% 20% 40%
Radiology/Pathology(inpatient) 10% 20% 40%
Radiology/Pathology(outpatient including ER) 10% 20% 40%
Radiology/Pathology(office) 10% 20% 40%
Injections(office) $10 copay $25 copay 40°%
Surgery(office)2 10% 20% 40%
Surgery(Inpatient)2 10% 20% 40%
Specialty Surgery'-CENTERS OF EXCELLENCE ONLY3 10% 20% 40%
Surgery(Outpatient including ER) 10% 20% 40%
Anesthesiology(Office) 10% 20% 40%
Anesthesiology(Inpatient) 10% 20% 40%
Anesthesiology(Outpatient including ER) 10% 20% 40%
Home Health Care(In lieu of Hospital;up to 100 days) 10% 20% 40%
Hospice 10% 20% 40%
Chiropractic Therapy Not covered Not covered Not covered
Allergy Testing 10% 20% Not covered
1AIIeLay Treatment/Serum 10% 20% Not covered
Preventative Services You Pay
Routine Physical Exam $10 copay $25 copay Not covered
Routine Vision Exam $10 copay $25 copay Not covered
Routine Hearin Exam $10 copay $25 copay Not covered
5036457_1.XLS/ECS Benefits 1
City of Bakersfield
Medical Exclusive Care Select
2010 Plan Rates
dusive Care Select Early R` ar
Retiree Only(<65,no MC) $650.53
Retiree+ 1(all<65, no MC) $1,181.88
Retiree+2(all<65, no MC) $1,701.09
usigie—ie Select Medicare Coordination Plan
RETIREE ONLY
Retiree>65 with MC parts A& B $486.42
Retiree>65 with MC part B only $719.48
RETIREE W11 DEPENDENT
One>65 with MC parts A&B $1,136.93
One>65 with MC part B only $1,369.99
Two>65 with MC parts A&B $972.81
Two>65 with MC part B only $1,438.93
RETIREE W/2 DEPENDENTS
One>65 with MC parts A&B $1,787.46
One>65 with MC part B only $2,020.52
Two>65 with MC parts A& B $1,492.02
Two>65 with MC part B only $1,958.14
Three>65 with MC parts A&B $1,459.21
Three>65 with MC part B only $2,158.39
Exclusive Care Select Post 65 Retiree Plan
Retiree Only(>65,no MC) $991.89
Retiree+1(all>65, no MC) $1,804.49
Retiree+2(>65,no MC) $2,616.10
usive Care Select Medicare Suppleme man
Retiree Only(>65 with MC) $269.20
Retiree+ 1 >65 with MC $538.38
Assumptions:
1)If enrollment changes by more than+/-10%from the assumed enrollment of 250 rates are subject to change.
2) 18 months of PPO month by month enrollment and claims are needed before rates are final.
3)No commissions are included.
4) Due to the current economic circumstances,no guarantees will be offered.
5)Rates are estimated prior to being approved by COR BOS.
SEGAL
Doc 5044331 Riverside Plan Doc 5044991 8131/2000
Exclusive Care Select
Proposed Exclusive Care Select Early Retiree Medical Plan
Design
General Information Tier 1 Tier 2 Tier 3
EC Contracted Hospitals Clinics& Blue Shield Network Out-of-Network
Physicians (CA Outside of CA)
Transplant Benefit You Pay
Heart,Liver,Pancreas,Bone Marrow,Comea,Lung,Kidney- Covered as any other condition Covered as any other Not covered
CENTERS OF EXCELLENCE ONLY' condition
Medical Supplies&Equipment Medical Supplies 10% 20% 40%
Medical Supplies(office) 10% 20% 40%
Durable Medical Equipment;annual maximum of$1,000 10% 20% 40%
Orthotic Sup lies I Not covered Not covered Not covered
Mental Health&Drug/Alcohol Treatment You Pay
Inpatient Facility semiprivate room-CENTERS OF EXCELLENCE Not covered unless a severe mental Not covered unless a Not covered
ONLY' illness;then covered like any other severe mental illness;then
benefit covered like any other
benefit
Inpatient Facility Ancillary-CENTERS OF EXCELLENCE ONLY' Not covered unless a severe mental Not covered unless a Not covered
illness;then covered like any other severe mental illness;then
benefit covered like any other
benefit
Inpatient Facility Physician Visits-CENTERS OF EXCELLENCE Not covered unless a severe mental Not covered unless a Not covered
ONLY' illness;then covered like any other severe mental illness;then
benefit covered like any other
benefit
Physician Office Visits:Psychologist/MCSW/APRN/Psychiatrist $20 copay up to 30 visits per year;unless a severe mental illness Not covered
ENTER OF EX LLEN E Y3 then covered like anv other benefit
Other
Hearing Tests-Annual maximum$1,000 once every 5 years 10% 20% Not covered
Hearing Aids-Annual maximum$1,000 once every 5 years 10% 20% Not covered
I'1 Center of Excellence coverage only for certain procedures such as:Orthopedic,Cardiac,Oncology
(2)Bariatric Surgery is excluded from coverage.
(')Centers of Excellence are designated by Exclusive Care and Blue Shield and are characterized by exemplary results in the area of specialty.
Note:Deductible does not apply to any copays and does apply to coinsurance.
Note:Deductibles and coinsurance maximums do not cross apply through Tiers.
Note:Tier 3 coverage is based on Medically Necessary Reasonable and Customary charges
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