| Benefits |
Current Retiree |
Current Mental Health Benefits |
Holman Federal Parity Compliant Plan |
Mental Health Substance Abuse |
| In-Network |
Out-of-Network |
|
In- Network |
Out-of- Network |
|
| In-Network |
Out-of-Network |
|
| Outpatient |
$15 per visit for PCP, $25 per visit for Specialists |
30% copay of Eligible Expenses |
|
$35 visit |
30% of UCR, $75 UCR/visit, 30 visits/year |
|
$25 per visit for Specialists |
30% copay of Eligible Expenses |
|
| Subacute-60 days/calendar year |
| 10% copay of Eligible Expenses |
30% copay of Eligible Expenses |
|
|
| 10% copay of Eligible Expenses |
30% copay of Eligible Expenses |
|
| Inpatient |
10% copay of Eligible Expenses |
30% copay of Eligible Expenses |
|
20% copay
|
30% of UCR, $250 deductible per admission |
|
10% copay of Eligible Expenses |
30% copay of Eligible Expenses |
|
| Emergency Room |
|
$100 copay/day, waived if admitted |
|
|
| Deductible |
| $250/person not to exceed $500 for all covered persons in a family |
$500/person not to exceed $1,500 for all covered persons in a family |
|
|
| $250/person not to exceed $500 for all covered persons in a family |
$500/person not to exceed $1,500 for all covered person is a family |
|
| Annual Maximum |
Subacute 100 days per year
|
|
| 50 outpatient visits/year, 45 subacute and inpatient days/year combined mental health, in and out of network combined. 60 subacuate and inpatient days/year combined substance abuse, in and out of network. |
|
Subacute 60 days per year combined (in and out of network) |
|
| Lifetime Maximum |
$20,000 maximum plan benefit per covered person (in and out of network combined) |
|
| N/A |
2 courses substance abuse treatment per lifetime |
|
$20,000 maximum plan benefit per covered person (in and out of network combined) |
|
| Out-of-Pocket Maximum |
| $1,500/person not to exceed $4,500 in a covered family |
$2,000/person not to exceed $4,000 in a covered family |
|
|
| $1,500/person not to exceed $4,500 in a covered family |
$2,000/person not to exceed $4,000 in a covered family |
|
| Ambulance |
| 10% copay of Eligible Expenses |
10% copay of Eligible Expenses |
|
|
| 10% copay of Eligible Expenses |
10% copay of Eligible Expenses |
|