Page 3 - Mi Health and Hospital 2021 Renewal Booklet.2
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2021 Renewal Benefits





           BCBSM CB PPO $250 Single/$500 Family Deductible: 100% Coinsurance After Deductible.
             Annual Maximum Out of Pocket (MOOP): $1,000 Single / $2,000 Family
             (MOOP Includes Deductible, Coinsurance and flat dollar copays).


           BCBSM HSA PPO $1,400 Single Deductible / $2,800 Family Deductible:
             100% Coverage after Deductible, except prescription drug copays,$15/$30/$60. Annual Out of
             Pocket Maximum: $2,250 Single / $4,500  Family

           MHA HSA Contribution: $1,400 Single/ $2,800 Family – Deposited in January
               * Must be enrolled in HSA Qualified HDHP / Must not be on Medicare
               Total HSA Contribution Maximum for 2021: $3,600 Single / $7,200 Family


           Delta Dental (Blind) PPO: Annual Maximum - $1,500 per member
             Lifetime Ortho Maximum - $2,000, per member – No age limit
             $0 Deductible, 100% - Preventative, 75% - Basic, 50% - Major, 50% - Ortho


           EyeMed Vision: Frequency of benefit is once every 12 months
             $10 Copay for Eye Exam / $25 copay on Single Vision Lenses
             $0 copay for frames and contact lenses, $150 Allowance



           UNUM Life/AD&D:  2 x annual earnings to a maximum of $300,000, Guarantee Issue up to
             $300,000

           UNUM Voluntary Life/AD&D:  $130,000 Guaranteed Issue for Employees. $30,000 GI on
             Spouse. $10,000 on Children. *Can purchase same amount on Spouse as on Employee.




           UNUM Long Term Disability:  Elimination Period 90 days. Class 1~ 70% of monthly  income to
             a maximum monthly benefit of $11,000;  Class 2 ( Management Council) ~ 60% of monthly
             income to a maximum of $6,000


           UNUM Individual Disability Insurance: Class 2 (Management Council), 70% of monthly
             insurable income less LTD, to Guarantee Standard Issue (GSI), Monthly Maximum $12,500


           UNUM Long Term Care:  LTC  $1000 Facility Monthly Benefit, Duration 3 years. Buy up options
             available.




           BASIC Flexible Spending Account:  Current 2020,         Medical - $2750 Max – Use it or lose it. If
             enrolled in the HSA health plan, the Medical FSA is limited to Dental and Vision expenses.
             Dependent Care FSA - $5,000 Annual Maximum. 2021 Limits, To Be Determined
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