HEALTH PLAN
CHISLHB maintains a self-funded Flexible Benefit program. Coverage is available for regular full-time employees beginning the first pay period following 30 days of full-time employment. Part-time employees are eligible for employee-only medical benefits beginning the first pay period following 60 days of employment (EPO only). The hospital and active physician staff function as the network for CHISLHB’s PPO and EPO, along with First Health’s Network.
Medical Plan
Employer Provided Option
|
|
Preferred Provider Option
(Grandfathered)
|
|
BRHS/BHA
|
In Network*
|
Out of Network*
|
|
In Network
|
Out of Network*
|
Deductible (Calendar Year)
-Employee Only
-Employee + Family
|
$300
$900
|
$1,000
$2,000
|
$3,000
$6,000
|
|
$1,000
$2,000
|
$3,000
$6,000
|
Coinsurance - Employee's Coinsurance
|
10% |
20% |
40% |
|
20% |
40% |
Out of Pocket Maximum
(Deductible & Copays included)
-Employee Only
-Employee + Family |
$2,500
$5,000
|
$6,600
$13,200
|
$17,500
Unlimited
|
|
$6,600
$13,200
|
$17,500
Unlimited
|
Physician’s Office
-Primary Care Physician
-Specialist |
$30
$50
|
$30
$50
|
40%
40%
|
|
20%
20%
|
40%
40%
|
Emergency Care
BUCC |
$150 Co-pay
$50 Co-pay
|
$150 Co-pay
20%
|
$150 Co-pay
40%
|
|
$150 Co-pay
$50 Co-pay
|
$150 Co-pay
$50 Co-pay
|
Inpatient Hospital |
$300 Co-pay |
$500 Co-pay |
$1,500 Co-pay |
|
$500 Co-pay |
$1,500 Co-pay |
Outpatient Hospital/Surgery |
$300 Co-pay |
$500 Co-pay |
$1,500 Co-pay |
|
20% |
40% |
Pharmacy
-Generic
-Brand Formulary
-Brand Non-Formulary
-Specialty Medications
Maximum Out-of-Pocket
Per Script for Specialty
-Per Prescription
-Per Calendar Year |
|
$15
$50
$75
20%
$250
$2,500
|
|
|
$15
$50
$75
20%
$250
$2,500
|
|
Dental Plan
The dental program encourages preventive treatment, allowing you to achieve oral health while striving to minimize dental costs. Coverage is
provided through CHISLHB’s self-funded dental program and claims are administered by HealthFirst.
Benefits |
You Pay
|
Deductible - Waived for Preventive |
Individual - $50
Family - $150
|
Preventive Care
-Examinations and Cleanings, Routine
-Fluoride
-Oral Hygiene Instruction
-Palliatives
-Prophylaxis
-Sealants (under age 13)
-Space Maintainer (2 per year, under age 19)
-X-rays, Routine
|
0% |
Basic Care
-Anesthesia
-Endodontic
-Extractions
-Fillings
-Injection of Antibiotics
-Oral Surgery
-Periodontal
-Relining and Rebasing
-Recementing Crowns, Inlays, Onlays, Denture |
20%* |
Major Care
-Appliances
-Crowns
-Implants
-Inlays, Onlays
-Occlusal Restoration
-Prosthetics |
50%* |
Orthodontia (Children only) |
50%
|
Maximum |
Plan Pays |
Annual (Preventive/Basic/Major) |
$1,250 |
Lifetime Orthodontia |
$1,250 |
Vision Plan
Eye health is an indicator of overall health. Regular eye exams can detect diseases like glaucoma, diabetes and blindness. To ensure that you
and your family get the care you need, CHISLHB offers a comprehensive vision benefit provided by UnitedHealthcare.
Carrier/Plan Provisions
|
In-Network
|
Out-of-Network
|
Exam Every |
12 Months |
Lenses Every |
12 Months |
Frame Every |
12 Months |
Copayment |
Exam |
$10 |
|
Materials |
$25 |
|
Service |
Plan Pays |
Plan Reimburses |
Eye Exam |
100% |
$40 |
Single Vision Lenses |
100% |
$40 |
Lined Bifocal Lenses |
100% |
$60 |
Lined Trifocal Lenses |
100% |
$80 |
Lenticular Lenses |
100% |
$80 |
Frames |
Up to $130, then 30% |
Up to $45 |
Contact Lenses
-Covered in Full Selection Contacts
-Non-Selection Contacts |
4 Boxes
Up to $105
0% up to $120
|
Up to $105
Up to $105
Up to $120
|
Contact Lenses – Medically Necessary |
100% |
Up to $210 |