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Health
Insurance
Schedule
of Benefits |
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| This Schedule is a brief
summary of benefits under this plan and is for your convenience and is
not a complete list. Please review this entire Summary Plan
Description to determine your complete benefits. All Benefits are subject to the following deductibles, coinsurance and maximums unless otherwise stated: |
| Individual Deductible | $750 per person per calendar year. |
| Family or Two-Party Deductible | $1,500 per family or $1250 two-party per calendar year. |
| Coinsurance Percentage | The plan pays 70% (60% "Out-of-Network") of the first $5,000 per individual or $10,000 per family of eligible expenses per calendar year after satisfying the deductible, then 100% thereafter to the end of the calendar year. |
| Mental Health Services (including Drug Dependency and Alcoholism Benefit) | Subject to deductible and
coinsurance.
Outpatient mental health charges, including drug dependency and alcoholism, are limited to 26 visits per calendar year. Inpatient mental health charges are paid as usual and customary up to 30 days per calendar year. Inpatient services for alcoholism or drug dependency are limited to 30 days during any six month period. Lifetime maximum of 90 days per person for alcoholism or drug dependency treatment. Note: Two days of partial hospitalization (minimum 6 hours to maximum of 12 hours) will count as one day of confinement. Pre certification, as outlined in Article 111, is required for inpatient and partial hospitalization Mental Health Services. |
| Annual Physical Examination
(Limited Wellness Benefit) |
$100 per calendar year per covered person. Not subject to deductible or coinsurance. See Section 4.04 for the details of eligible benefits under this provision. |
| Outpatient Surgery | Precertification needed. Subject to deductible and coinsurance. |
| Pregnancy Care | Subject to deductible and coinsurance. |
| Convalescent Care Benefit | Subject to deductible, then paid at 50% up to a maximum of 90 days per calendar year. |
| Private Duty Nursing Care | Subject to deductible and coinsurance. Up to 40 visits per calendar year or a maximum payment of $7,500 per calendar year, whichever is less. |
OPTIONAL ITEMS THAT SAVE YOU MONEY
| Preferred Provider Networks: | |
| Providers | Various discounts applied to eligible claims submitted by participating providers. Pre-Approval is needed for hospitalization, call O-Hara at 1-800-363-4272. Network providers are listed on First Administrators web page. It is http://firstview.firstadministrators.com. (Note: you must register to enter this site). |
| Pharmacy | Electronic claim filing by participating pharmacies, no paper claims need be filed. Patient must pay pharmacy and be reimbursed by the plan. Provider information is available from employer. |
| Supplemental Accident | First $300 per accident, if claims is incurred within 90 days of accident, paid in full and not subject to deductible. |
| Pre-Surgery Testing | Paid at 100% if done as an outpatient |
| Second Surgical Opinion | Paid at 100% if second opinion is obtained prior to surgery. |
| Self-Audit Billing Credit | 25% credit for billing errors found by participants. |
GENERAL INFORMATION:
| Lifetime Maximum all Benefits | $1,000,000 except as limited herein |
| Medicare Qualifying Participants | This Plan is Primary for participants and their dependents. This Plan is a Supplement to Medicare for non-employee participants and their dependents. |
| Effective Date and Waiting Period | First day of employment with proper-enrollment, subject to the provisions of Section 2.01. |
| Dependent Child Maximum Age | To age 19, unless a full-time student, then to age 23, with an option to purchase single coverage for up to 36 months. |
| Termination of Coverage | End of month after date of termination of employment or loss of eligibility, with an option to purchase continuation of benefits. |
CONTINUATION OF BENEFITS
| A. Temporary lay-off, normal termination, reduction of hours, leave of absence and discharge for misconduct (Except for termination due to gross misconduct). | Up to eighteen months. |
| B. Disability | Up to eighteen months, unless at the time of termination or reduction of hours or within 60 days thereafter the person is totally disabled as determined by the Social Security Administration, then up to twenty-nine months. |
| C. Surviving dependents due to death or divorce | Thirty-six months or until covered by another plan, whichever is shorter. |
| D. Leave approved by School Board | Up to time limit approved by Board of Education. |
| E. Retirement | Eligible retired employees and/or participating dependents, may continue coverage to age 65, as outlined in Section 4.16. |
| F. See Section 4.15 in your health book, for other continuance options available to dependents. |
LIFE INSURANCE AND ACCIDENTAL DEATH AND DISMEMBERMENT
| All Eligible Employees | Life Insurance and Accidental Death & Dismemberment Insurance. See your separate Group Term Life Certificate of Insurance for deta |
THE CURRENT COST FOR THE PLAN IS:
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| 2-Party |
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Send
Health Insurance Questions to: 
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Communicator at 800x600, 16 bit (32,000) or higher colors. |
400 Patriot Drive Box Elder, South Dakota USA, 57719 605-923-0000 Copyright 2003 |
by The Douglas School District For questions or problems,
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