Page 120 - 2022 Washington Nationals Flipbook

MLB LWIP & Nationals Welfare
Plans and Summary Plan Description

measurement period during which the ACA Full-Time Employee works on average a
minimum or 30 hours per week.

CESSATION OF PARTICIPATION
Coverage terminates on the last day of the month in which termination (or loss of eligibility)
occurs.

ELECTIONS AND CONTRIBUTIONS
You are required to contribute towards the cost of the coverage you elect at the rates
established each year by the Nationals.

BENEFITS
Medical Option(s) Offered:

 PPO Option 1 – 80/60 PPO

This program generally provides 80% of all reasonable and customary physician and
hospital costs for in-network covered expenses after a $300 individual and $600
family deductible. The program covers 100% of all reasonable and customary costs
for in-network routine preventative care services with no participant cost sharing, and
100% of certain in-network services after a copayment, without regard to the
deductible. The program also provides 60% payment of all reasonable and customary
physician and hospital costs for out-of-network expenses after a $600 individual and
$1,200 family deductible.

There is an annual $1,500 individual and $3,000 family out-of-pocket limit for in-
network covered services and an annual $3,000 individual and $6,000 family out-of-
pocket limit for out-of-network covered services. The out-of-pocket limit, under this
benefit option, refers to the specified dollar amount of coinsurance you incur for
covered services. When you reach the out-of-pocket limit, the program begins to pay
100% of all covered expenses with the exception of applicable copayments,
deductibles, prescription drug expenses (described below), and amounts in excess of
the plan allowance.

In addition, there is an annual $6,350 individual and $12,700 family total maximum
out-of-pocket for in-network covered services. The total maximum out-of-pocket
(“TMOOP”) is the most you and your family members pay for in-network covered
services during the policy year. Once you or any of your covered family members
reach the individual TMOOP limit, the program begins to pay 100% of all in-network
covered expenses for that individual (including covered prescription drug expenses
described below), and no additional coinsurance, copayments or deductibles will be
incurred for in-network covered services in that benefit period, even if the family
TMOOP limit has not been met. Once the family TMOOP limit is reached, the
program will pay 100% of all in-network covered expenses for you and all of your
covered family members, no matter how much each individual has accumulated in
TMOOP expenses. There is no TMOOP for out-of-network benefits.

The program also includes a prescription drug program requiring the use of network
pharmacies, with various copayments depending upon the type of drug (i.e., generic,

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