Page 12 - Your New Medical Plans with Centivo

Medical Plan Comparison Chart

MBA Centivo
Plus MBA HSA High MBA HSA Low

IN-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

Network Centivo Network Cigna PPO Network N/A Cigna PPO Network N/A
Activation / PCP selection required Yes No No No No
Yes (except for OB/GYN
PCP referrals to specialists required No No No No
Plan features and behavioral health)
Deductible (individual / family) $500/$1,000 $3,000/$6,000 $6,000/$12,000 $4,000/$8,000 $8,000/$16,000

Out-of-Pocket Maximum (individual / family) $5,000/$10,000 $6,900/$13,800 $13,800/$27,600 $6,900/$13,800 $13,800/$27,600
Employer HSA contribution (employee only / employee + 1 / family) N/A $500/$750/$1,000 $500/$750/$1,000
Preventive care Preventive care (annual physical, immunizations, and screenings)* FREE FREE Deductible + 40% coins FREE Deductible + 50% coins
Deductible then: Deductible then:
• $30 copay for Tier 1/ • $30 copay for Tier 1/
Office visit (primary care)* $10 copay Deductible + 40% coins Deductible + 50% coins
Cigna Care Designated Cigna Care Designated
• $60 copay for Tier 2 • $60 copay for Tier 2
Deductible then: Deductible then:
Office visits Office visit (specialist)* $60 copay • $60 copay for Tier 1/ Deductible + 40% coins • $60 copay for Tier 1/ Deductible + 50% coins
Cigna Care Designated Cigna Care Designated
• $120 copay for Tier 2 • $120 copay for Tier 2
Behavioral health - individual therapy (no referral required) $10 copay Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
Therapeutic services (physical, occupational, speech therapy) $60 copay Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
Lab work Deductible + 20% coins Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
Diagnostic procedures Basic imaging (such as X-rays) Deductible + 20% coins Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
Advanced imaging (such as MRIs and PET scans) Deductible + 20% coins Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
Surgeries - professional services (inpatient or outpatient) (includes services from Deductible + 20% coins Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
all healthcare professionals such as surgeons, anesthesiologists, nurses, etc.)

Hospital and outpatient facilities Surgeries - facility charges (inpatient or outpatient) $500 copay, then Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
deductible + 20% coins
$500 copay, then
Hospital stays Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
deductible + 20% coins
Deductible then: Deductible then:
• $30 copay for Tier 1/ • $30 copay for Tier 1/
Office visits $10 copay Deductible + 40% coins Deductible + 50% coins
Cigna Care Designated Cigna Care Designated
• $60 copay for Tier 2 • $60 copay for Tier 2
Pregnancy expenses
Childbirth/delivery professional services Deductible + 20% coins Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
$500 copay, then
Childbirth/delivery facility services Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
deductible + 20% coins
Urgent care visits (no referral required) $500 copay** Deductible + 20% coins Deductible + 40% coins Deductible + 30% coins Deductible + 50% coins
Emergency care Emergency room $500 copay Deductible + 20% coins Deductible + 20% coins Deductible + 30% coins Deductible + 30% coins
Ambulance Deductible + 20% coins Deductible + 20% coins*** Deductible + 20% coins*** Deductible + 30% coins*** Deductible + 30% coins***

Defining Deductible Out-of-pocket maximum Copay Coinsurance * If you have any lab work, testing,
or procedures done during your visit,
additional costs may apply.
key terms: A deductible is the To protect you in the event of significant A copay is a fixed dollar After you meet your deductible for the year, ** If you are traveling outside of
medical expenses, all three plan options offer an
you will be responsible for a certain percentage
amount that you will pay
portion you must pay
out-of-pocket before annual out-of-pocket maximum (including the for a healthcare service of the costs. This is known as coinsurance. For your network area, you have up to 3
covered urgent care visits per year.
the plan pays for your deductible and any copays or coinsurance paid). or visit. example, if the coinsurance amount is 30%, that *** There will be a higher coinsurance
healthcare expenses. This is the most you will pay for any covered means you will owe 30% of the cost after you applied for non-emergency
healthcare expenses during the plan year. have reached your deductible. ambulance utilization.