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					    Overview of
  Medical Benefits -
Managed Care Plan
                Effective 4/01/2013
                 Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                        Managed Care Plan




                 Annual Deductible
• $400.00 per person; maximum of three deductibles per
family.
• After annual deductible has been met, the Plan pays the
percentage of covered charges as shown. When the annual
out-of-pocket amount has been met, the Plan will pay 100% of
covered charges for that calendar year.
              Monterey Bay Public Employees Trust
                  Overview of Medical Benefits
                     Managed Care Plan




       Annual Out-of-Pocket Limit
   • In-P.H.A.-network: $2,250.00 per individual.
• Out-of-P.H.A.-network: $10,000.00 per individual.
            Monterey Bay Public Employees Trust
                Overview of Medical Benefits
                   Managed Care Plan




             Lifetime Maximum
•Lifetime Maximum: Lifetime per person maximum zero.
                  Monterey Bay Public Employees Trust
                      Overview of Medical Benefits
                         Managed Care Plan




                      Life Insurance
Life Insurance:      $25,000.00 term life insurance for active
participants only.
                  Monterey Bay Public Employees Trust
                      Overview of Medical Benefits
                         Managed Care Plan




Physician (Surgery, Home, Office, Hospital)
• In-P.H.A.-network: 80% of contracted rates for
surgeon/anesthetist. 70% for hospital visits and home visits.
$25.00 co-payment for office visits (deductible does not apply).
     • Out-of-P.H.A.-network: 60% of U.C.R. charges.
                 Monterey Bay Public Employees Trust
                     Overview of Medical Benefits
                        Managed Care Plan




            Specialty Referral Process
• In-P.H.A.-network: Referral to a specialist must be made by
a Primary Care Physician and approved by Network Manager – not
required for Ophthalmology, OB/GYN, or Podiatry.
• Out-of-P.H.A.-network:     60% of U.C.R. charges. (Same
referral process as for in-network.)
              Monterey Bay Public Employees Trust
                  Overview of Medical Benefits
                     Managed Care Plan




                    Anesthesia
     • In-P.H.A.-network: 80% of contracted rates.
• Out-of-P.H.A.-network: 80% of U.C.R. covered charges.
                        Monterey Bay Public Employees Trust
                            Overview of Medical Benefits
                               Managed Care Plan




                         Hospital Services (slide 1 of 4)
                         • M.B.P.E.T. Hospitals of Distinction

•  90% of contracted rates. (Natividad Medical Center, George L. Mee Memorial
Hospital, Hazel Hawkins Memorial Hospital, Salinas Valley Memorial Hospital, Watsonville
Community Hospital and Community Hospital of the Monterey Peninsula.
                       Monterey Bay Public Employees Trust
                           Overview of Medical Benefits
                              Managed Care Plan




                        Hospital Services (slide 2 of 4)
• M.B.P.E.T. Centers of Excellence: 100% of contracted rates; $250.00 daily per
diem for family expenses for each day of in-patient medically necessary care (must be
pre-approved by Executive Director). (Stanford Medical Center and other pre-
approved inpatient facilities for specialized procedures/treatments).
          Monterey Bay Public Employees Trust
              Overview of Medical Benefits
                 Managed Care Plan




      Hospital Services (slide 3 of 4)
• Non-network Hospitals: 60% of U.C.R. charges.
               Monterey Bay Public Employees Trust
                   Overview of Medical Benefits
                      Managed Care Plan




           Hospital Services (slide 4 of 4)

• Non-Contracting Hospitals: 60% of U.C.R. charges.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




              Skilled Nursing Facility
• In-P.H.A.-network: 80% of contracted rates up to 365 days
per lifetime. (Must be pre-authorized.)
             • Out-of-P.H.A.-network: None.
               Monterey Bay Public Employees Trust
                   Overview of Medical Benefits
                      Managed Care Plan




        X-Ray and Laboratory Services
• In-P.H.A.-network:   80% of contracted rates (deductible
does not apply.
 • Out-of-P.H.A.-network: 60% of U.C.R. covered charges.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




    Maternity and Interrupted Pregnancy
• In-P.H.A.-network: Covered as any other medical condition.
• Out-of-P.H.A.-network: Covered as any other medical
condition.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




                      Vasectomy
• In-P.H.A.-network: Covered as any other medical condition.
• Out-of-P.H.A.-network:     Covered as any other medical
condition.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




                  Emergency Room
• In-P.H.A.-network: 80% of contracted rates after a $200.00
co-payment.
•90% of contracted rates    in Hospitals of Distinction after a
$200.00 co-payment.
• Out-of-P.H.A.-network:    60% of U.C.R. charges, after a
$200.00 co-payment.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




               Wellness / Well Baby
• In-P.H.A.-network: 100% of contracted rates for exams
and immunizations as listed under the Affordable Health Care
Protection Act. There is no deductible or coinsurance.
             • Out-of-P.H.A.-network: None.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




                 Flu Immunizations
• In-P.H.A.-network: 100% of covered charges as listed
under the Affordable Health Care Protection Act. There is no
deductible or coinsurance.
             • Out-of-P.H.A.-network: None.
                 Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                        Managed Care Plan




      Physical Exams and Mammograms
• In-P.H.A.-network: 100% of contracted rates for
mammograms.       For routine physicals   as listed under the
Affordable Health Care Protection Act. There is no deductible or
coinsurance.
              • Out-of-P.H.A.-network: None.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




 Allergy Testing / Administration of Serum
• In-P.H.A.-network: 80% of contracted rates for testing, and
100% of covered charges for administration of serum.
• Out-of-P.H.A.-network: 70% of U.C.R. charges for testing,
and 100% of covered charges for administration of serum.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




                 Home Health Care
• In-P.H.A.-network: 80% of contracted rates up to 120 days
per disability, when home care plan is prescribed by your
physician. (Pre-authorization required.)
             • Out-of-P.H.A.-network: None.
               Monterey Bay Public Employees Trust
                   Overview of Medical Benefits
                      Managed Care Plan




                    Hospice Care
• In-P.H.A.-network:        80% of contracted rates up to
$15,000.00 lifetime maximum. Pre-certification required;
otherwise, penalties apply.
             • Out-of-P.H.A.-network: None.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




 Durable Medical Equipment / Prosthetics
• In-P.H.A.-network:       80% of contracted rates.   (Pre-
authorization required.)
             • Out-of-P.H.A.-network: None.
                 Monterey Bay Public Employees Trust
                     Overview of Medical Benefits
                        Managed Care Plan




                      Acupuncture
• In-P.H.A.-network: 80% of contracted rates to a maximum
allowance of $50.00 per visit for up to eighteen (18) visits per
calendar year.
              • Out-of-P.H.A.-network: None.
                 Monterey Bay Public Employees Trust
                     Overview of Medical Benefits
                        Managed Care Plan




                   Hearing Services
•In-P.H.A.-network: Payable under office visit benefits and/or
physician benefits. No hearing aid coverage except if
required because of surgery.
              • Out-of-P.H.A.-network: None.
                 Monterey Bay Public Employees Trust
                     Overview of Medical Benefits
                        Managed Care Plan




                         Podiatry
• In-P.H.A.-network: Payable under office visit benefits and/or
physician benefits.
• Out-of-P.H.A.-network: 60% of U.C.R. charges.
               Monterey Bay Public Employees Trust
                   Overview of Medical Benefits
                      Managed Care Plan




                Chiropractic Care
• In-C.H.P.C.-network: $10.00 co-payment per visit up to
forty-five (45) visits per calendar year.
           • Out-of-C.H.P.C.-network: None.
                 Monterey Bay Public Employees Trust
                     Overview of Medical Benefits
                        Managed Care Plan




Prescription Drugs – Retail Store (slide 1 of 3)
• Generic: $10.00 co-payment for up to a thirty (30) day supply
(co-payment waived only at CVS Pharmacy Stores);
• Formulary Brand: $30.00 co-payment for up to a thirty (30)
day supply;
• Non-Formulary Brand: $50.00 co-payment for up to a thirty
(30) day supply.
                 Monterey Bay Public Employees Trust
                     Overview of Medical Benefits
                        Managed Care Plan

  Prescription Drugs – CVS Pharmacy Stores
                         (slide 2 of 3)
• Generic: $0.00 co-payment for up to a thirty (30) day supply;
• Formulary Brand: $30.00 co-payment for up to a thirty (30)
day supply;
• Non-Formulary Brand: $50.00 co-payment for up to a thirty
(30) day supply.
 Note: Ninety (90) day supply solely at CVS Pharmacy Stores at
same co-payments as the prescription mail order program except
             there is a zero co-pay for generics.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




  Prescription Drugs - Mail Order (slide 3 of 3)
• Generic:   $20.00 co-payment for up to a ninety (90) day
supply;
• Formulary Brand: $60.00 co-payment for up to a ninety (90)
day supply;
• Non-Formulary Brand: $100.00 co-payment for up to a
ninety (90) day supply.
           Monterey Bay Public Employees Trust
               Overview of Medical Benefits
                  Managed Care Plan




Rates for active employees (effective 4/01/2013)
          • Single: $1,215.45 per month.
        • Two-Party: $1,746.50 per month.
          • Family: $2,469.95 per month.
         Monterey Bay Public Employees Trust
             Overview of Medical Benefits
                Managed Care Plan




Rates for retirees under 65       (effective 4/01/2013)

        • Single: $1,215.45 per month.
      • Two-Party: $1,746.50 per month.
        • Family: $2,469.95 per month.
         Monterey Bay Public Employees Trust
         Overview    of    Medical   Benefits
         Managed Care Plan




Rates for retirees 65 and older        (effective 4/01/2013)

          • Single: $654.49 per month.
        • Two-Party: $964.05 per month.
          • Family: $1,172.47 per month.
                Monterey Bay Public Employees Trust
                    Overview of Medical Benefits
                       Managed Care Plan




                      Disclaimer
  • This presentation provides only a general overview of the
         Medical benefits for the Managed Care Plan;
• For complete information, consult your copy of the Summary
       Plan Description or call Health Services & Benefit
     Administrators(1-831-757-1711 or 1-888-742-3380).

				
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