Page 48 - 2022 MLB Umpire Benefit Guide Flipbook 1

MLB League-Wide Insurance Program
Plan and Summary Plan Description

annual $12,700 individual and $25,400 family out-of-pocket limit for out-of-network covered
services. The out-of-pocket limit, under this benefit option, refersto the specified dollar amount of
coinsurance and deductible you incur for covered services and covered medications. When you
reach the out-of-pocket limit, the program begins to pay 100% of all covered expenses with the
exception of 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 is the most you pay for in-network covered services during the policy
year. When you or your covered family members reach this individual or family dollar amount, the
program begins to pay 100% of all in-networkcovered expenses, includingcovered prescription drag
expenses (described below), and no additional coinsurance, copayments or deductibles will be
incurred for in-network covered services in that benefit period. There is no total maximum out-of-

pocket for out-of-network benefits. The program also includes a prescription drag program that
coverscertain prescriptionsfilled atin-network pharmacies. Prescriptionsfilled at anout-of-network
pharmacy are not covered. After satisfying the annual in-network deductible described above, the
program covers 70% of the cost of covered prescription drags. Please refer to the benefits booklet
for more information.
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Grandfathered PPO Option This program generally provides100% of reasonable and customary
physician and hospital costsfor in-networkcovered expenseswith noannual deductible and minimal
copayments for certain services. The program also provides 80% of all reasonable and customary
physician and hospital costs for out-of-network expenses after satisfaction of a $500 individual and
$1,000 family deductible. There is an annual $ 1 ,000 individual and $2,000 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 incurred for covered services in a benefit period.
When you or yourfamily members reach an out-of-pocketlimit, the program begins to pay100% of
all covered expenses (with the exception of applicable copayments, deductibles, prescription drug
expenses, amounts in excess of the plan allowance). The program also includes a prescription drug
program requiring the use of network pharmacies, with variouscopaymentsdependingupon the type
of drag (i.e., generic, brand formulary, or brand non-formulary) and whetherit ispurchased ata retail
pharmacy or via mail order. Please refer to the benefits booklet for more information.

Please note:

The Plan and Highmark Blue Cross Blue Shield believe this coverage is a “grandfathered
health plan” under the Patient Protection and Affordable Care Act(“ACA”). As permitted
by the ACA, a grandfathered health plan can preservecertain basichealth coverage that was
already in effect when that law was enacted. Being a grandfathered health plan means that
your policy may not include certain consumer protections of the ACA that apply to other
plans,for example, the requirement for the provision of preventive healthservices without
any cost sharing. However, grandfathered health plans must comply with certain other
consumer protections in the ACA, for example, the elimination of lifetime limits on
benefits.

Questions regarding which protections apply and which protections do not apply to a
grandfathered health plan and what might cause a plan to changefrom grandfathered health

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