Page 8 - AESC 2019 Benefits Gudie
P. 8
Medical Contributions
Important Terms 2019 Envision AESC Monthly Savings Plan Reimbursement Sharing Plan
X Deductible—the amount Contributions (HSA) Plan (HRA) (EPO)
you pay toward medical and Salary < $54,000
dental expenses each year Employee (Ee) $22 .00 $57 .00 $89 .00
before the plan begins paying Ee/Spouse $80 .00 $118 .00 $186 .00
benefits Employee + Working Spouse** $180 .00 $218 .00 $286 .00
Ee/Child(ren) $62 .00 $98 .00 $169 .00
X Copayment—a flat fee you pay Family $119 .00 $178 .00 $279 .00
for medical services; generally Family + Working Spouse ** $219 .00 $278 .00 $379 .00
applies to physicians’ office $54,000–$74,999
visits and prescription drugs; Employee (Ee) $33 .00 $72 .00 $116 .00
$152 .00
$89 .00
copayments do not apply to Ee/Spouse $189 .00 $252 .00 $243 .00
Employee + Working Spouse**
$343 .00
the deductible Ee/Child(ren) $76 .00 $125 .00 $221 .00
X Coinsurance—the percentage Family $133 .00 $228 .00 $366 .00
of the medical or dental Family + Working Spouse ** $233 .00 $328 .00 $466 .00
$75,000–$124,999
charges you pay after you Employee (Ee) $33 .00 $75 .00 $123 .00
have paid the deductible Ee/Spouse $93 .00 $158 .00 $258 .00
X Out-of-pocket limit—the Employee + Working Spouse** $193 .00 $258 .00 $358 .00
$80 .00
$130 .00
total amount an employee or Ee/Child(ren) $139 .00 $238 .00 $234 .00
$388 .00
Family
dependent pays out-of-pocket Family + Working Spouse ** $239 .00 $338 .00 $488 .00
in a given plan year; once this $125,000+
maximum has been reached Employee (Ee) $34 .00 $78 .00 $125 .00
the plan pays 100% of eligible Ee/Spouse $96 .00 $164 .00 $263 .00
expenses for the remainder of Employee + Working Spouse** $196 .00 $264 .00 $363 .00
the plan year Ee/Child(ren) $83 .00 $136 .00 $239 .00
Family $143 .00 $246 .00 $391 .00
X Premium—the amount an Family + Working Spouse ** $243 .00 $346 .00 $491 .00
employee pays for benefit
coverage * If you do not enroll in or waive medical coverage during your 30 day open enrollment
period, you will be automatically enrolled for employee only coverage in the Savings
X Network—group of doctors (HSA) plan on your 31st day of employment .
or hospitals who agree to ** Working spouse: this option applies if your spouse works and has access to medical
negotiated rates with a health coverage (dental and vision not included) at an employee-only premium of $125 or
insurance company less per month, and does not enroll in other employee coverage, AND enrolls in one
of the Envision AESC medical plans .
In-Network vs . Out-of-Network*
A network is a group of providers your plan contracts with at discounted rates . You will almost always pay less
when you receive care in-network .
If you choose to see an out-of-network provider, you may be balance billed, which means you will be responsible
for charges above BCBS’ reimbursement amount .
* The Sharing (EPO) plan only has access to in-network services . Out-of-network services are not covered by the plan .
8 2019 Benefits Enrollment
Important Terms 2019 Envision AESC Monthly Savings Plan Reimbursement Sharing Plan
X Deductible—the amount Contributions (HSA) Plan (HRA) (EPO)
you pay toward medical and Salary < $54,000
dental expenses each year Employee (Ee) $22 .00 $57 .00 $89 .00
before the plan begins paying Ee/Spouse $80 .00 $118 .00 $186 .00
benefits Employee + Working Spouse** $180 .00 $218 .00 $286 .00
Ee/Child(ren) $62 .00 $98 .00 $169 .00
X Copayment—a flat fee you pay Family $119 .00 $178 .00 $279 .00
for medical services; generally Family + Working Spouse ** $219 .00 $278 .00 $379 .00
applies to physicians’ office $54,000–$74,999
visits and prescription drugs; Employee (Ee) $33 .00 $72 .00 $116 .00
$152 .00
$89 .00
copayments do not apply to Ee/Spouse $189 .00 $252 .00 $243 .00
Employee + Working Spouse**
$343 .00
the deductible Ee/Child(ren) $76 .00 $125 .00 $221 .00
X Coinsurance—the percentage Family $133 .00 $228 .00 $366 .00
of the medical or dental Family + Working Spouse ** $233 .00 $328 .00 $466 .00
$75,000–$124,999
charges you pay after you Employee (Ee) $33 .00 $75 .00 $123 .00
have paid the deductible Ee/Spouse $93 .00 $158 .00 $258 .00
X Out-of-pocket limit—the Employee + Working Spouse** $193 .00 $258 .00 $358 .00
$80 .00
$130 .00
total amount an employee or Ee/Child(ren) $139 .00 $238 .00 $234 .00
$388 .00
Family
dependent pays out-of-pocket Family + Working Spouse ** $239 .00 $338 .00 $488 .00
in a given plan year; once this $125,000+
maximum has been reached Employee (Ee) $34 .00 $78 .00 $125 .00
the plan pays 100% of eligible Ee/Spouse $96 .00 $164 .00 $263 .00
expenses for the remainder of Employee + Working Spouse** $196 .00 $264 .00 $363 .00
the plan year Ee/Child(ren) $83 .00 $136 .00 $239 .00
Family $143 .00 $246 .00 $391 .00
X Premium—the amount an Family + Working Spouse ** $243 .00 $346 .00 $491 .00
employee pays for benefit
coverage * If you do not enroll in or waive medical coverage during your 30 day open enrollment
period, you will be automatically enrolled for employee only coverage in the Savings
X Network—group of doctors (HSA) plan on your 31st day of employment .
or hospitals who agree to ** Working spouse: this option applies if your spouse works and has access to medical
negotiated rates with a health coverage (dental and vision not included) at an employee-only premium of $125 or
insurance company less per month, and does not enroll in other employee coverage, AND enrolls in one
of the Envision AESC medical plans .
In-Network vs . Out-of-Network*
A network is a group of providers your plan contracts with at discounted rates . You will almost always pay less
when you receive care in-network .
If you choose to see an out-of-network provider, you may be balance billed, which means you will be responsible
for charges above BCBS’ reimbursement amount .
* The Sharing (EPO) plan only has access to in-network services . Out-of-network services are not covered by the plan .
8 2019 Benefits Enrollment
