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Point of Service Medical Plan (Aetna)
Resources for Living (EAP)
Harris County Dental Plans (UnitedHealthcare Dental)
Harris County Vision Care Program
Life Insurance and AD&D
Optional Term Life Insurance
Long-Term Disability Coverage
 
Point of Service Medical Plan (Aetna)Top

 

Point of Service Medical Plan - Two Plan Options

 

The Harris County medical plans are offered through Aetna and afford you the opportunity to choose any doctor or other health care provider.  Whether you utilize in-network or out-of-network benefits depends on where and with whom you receive your care.  Neither plan requires a PCP selection or referrals for specialist visits.

 

Employees are given the opportunity each January to choose between the Base Plan OR Base Plus Plan.  These plans consist of a point-of-enrollment option for employees with a “Base” level of benefits at no cost for employee only coverage.  In addition, the County will pay 50% of the incremental cost of dependent coverage.  The “Base” plan offers a high level of affordable access to basic health and preventative services as well as protection to pay for high cost hospital and surgical expenses while containing premium cost increases for both the County and employees.  While many routine services on the “Base” plan only require a copayment; some inpatient and outpatient services are subject to an annual deductible and coinsurance when utilizing a provider in-network and/or out-of-network. 

 

The second option provided to employees is a “Plus” plan that allows employees to pay a higher contribution to receive a higher level of benefits.  The County will pay 50% of the incremental cost of dependent coverage.  The “Plus” plan has no deductibles or coinsurance when utilizing in-network providers, though out-of-network providers will be subject to deductibles on both the “Base” and “Plus” plans.

 

Both plans contain the same prescription drug benefit, which will encourage cost effective utilization of these benefits and provides potential savings to both employees and the County.

 

The Resource Guides describing these benefits are available electronically at http://www.hctx.net/hrrm under the 2012 Active or Retire Resource Guide tabs.

 

 

 

BASE PLAN
In-Network

BASE PLAN
Out-of-Network

Annual Deductible
(per calendar year)

$   500 Individual
$1,500 Family

$1,000 Individual
$3,000 Family

Maximum Out-of-Pocket-includes deductible coinsurance and medical copays

(Per Individual/Family Per Calendar Year)

$4,000 Individual

$10,000 Family

$9,000 Individual
$27,000 Family

Lifetime Maximum Benefit

Unlimited except where otherwise indicated

$1,000,000

Physician's Office Copay
Primary Care
Specialist (Aexcel provider)
Specialist (non-Aexcel prov)


100% after $25 copay
100% after $40 copay
100% after $50 copay



50% after deductible

Preventive Care

100% coverage

50% after deductible

Allergy Services (includes testing, serum and injections)

100% after $40  copay

50% after deductible

Maternity Care
  Physician's Office
   (prenatal & post natal)

 
 In the Hospital
   (for mother & newborn)


$40 for first visit only


80% after deductible


50% after deductible


50% after deductible

Diagnostic Laboratory & Radiology Services

100% coverage

50% after deductible

Complex Imaging/High Tech Radiology

90% after deductible
(requires precertification)

50% after deductiible

Rehabilitation, Speech, Occupational and Physical Therapy

100% after a $25 copay,
up to 60 visits per calendar year*

50% after deductible,
up to 60 visits per calendar year*

Walk-In Clinic

100% after a $25 copay

50% after deductible

Urgent Care Facility

100% after a $50 copay

50% after deductible

Emergency Room

$300 copay; waived if confined,
80% after deductible if admitted

$300 copay; waived if confined,
50% after deductible if admitted

Outpatient Surgery

80% after deductible

50% after deductible

Inpatient Services

80% after deductible

50% after deductible

Home Health Care

90% after deductible,
up to 100 visits per calendar year*

50% after deductible,
up 100 visits per calendar year*

International care

n/a

50% after deductible

Mental Health
   Outpatient Visits
   Inpatient Services


100% after $30 copay
80% after deductible


50% after deductible
50% after deductible

Chemical Dependency
 
   Outpatient Visits
    Inpatient Services


100% after $30 copay
80% after deductible


50% after deductible
50% after deductible

 

BASE PLUS PLAN
In-Network

BASE PLUS PLAN
Out-of-Network

Annual Deductible
(per calendar year)

None

$1,000 Individual
$3,000 Family

Maximum Out-of-Pocket-includes deductible coinsurance and medical copays

(Per Individual/Family Per Calendar Year)

$4,000 Individual

$10,000 Family

$9,000 Individual
$27,000 Family

Lifetime Maximum Benefit

Unlimited except where otherwise indicated

$1,000,000

Physician's Office Copay
Primary Care
Specialist (Aexcel provider)
Specialist (non-Aexcel prov)


100% after $20 copay
100% after $30 copay
100% after $40 copay



60% after deductible

Preventive Care

100% coverage

60% after deductible

Allergy Services (includes testing, serum and injections)

100% after $40 copay

60% after deductible

Maternity Care
  Physician's Office
   (prenatal & post natal)

 
 In the Hospital
   (for mother & newborn)


$30 for first visit only


$500 per confinement copay for mother
$500 copay for each newborn


60% after deductible


60% after deductible

Diagnostic Laboratory & Radiology Services

100% coverage

60% after deductible

Complex Imaging/High Tech Radiology

100% copay
(requires precertification)

60% after deductiible

Rehabilitation, Speech, Occupational and Physical Therapy

100% after a $20 copay,
up to 60 visits per calendar year*

60% after deductible,
up to 60 visits per calendar year*

Walk-In Clinic

100% after a $20 copay

60% after deductible

Urgent Care Facility

100% after a $50 copay

60% after deductible

Emergency Room

$300 copay; waived if confined,
80% after deductible if admitted

$300 copay; waived if confined,
60% after deductible if admitted

Outpatient Surgery

100% after $300 copay for surgical procedures, 100% coverage for non-surgical

60% after deductible

Inpatient Services

$500 per confinement copay*

60% after deductible

Home Health Care

100% coverage,
up to 100 visits per calendar year*

60% after deductible,
up 100 visits per calendar year*

International care

n/a

60% after deductible

Mental Health
   Outpatient Visits
   Inpatient Services


100% after $30 copay
$500 per confinement copay*


60% after deductible
60% after deductible

Chemical Dependency
 
   Outpatient Visits
    Inpatient Services


100% after $30 copay
$500 per confinement copay*


60% after deductible
60% after deductible

* Maximums are a combined limit for in-network and out-of-network services.

PRESCRIPTION BENEFIT IN-NETWORK FOR BOTH PLANS

 

 

% You Pay

Minimum Copay

Maximum Copay

RETAIL (30 day supply)

Generic

25%

$5

$35

Brand

30%

$25

$200

Specialty

30%

$50

$200

MAIL ORDER (61-90 days supply)

Generic

25%

$10

$70

Brand

30%

$50

$200

PRESCRIPTION BENEFIT OUT-OF-NETWORK FOR BOTH PLANS

60% of the recognized charge at non-participating pharmacies

Resources for Living (EAP)Top

 

Most people think of an EAP as a place to call when they have a crisis or an urgent need for emotional or mental health support.  Resources For Living (EAP) removes the stigma that often comes with the term EAP. 

 

The focus of this program includes:

ü  Work/life balance

ü  Improved lifestyle

ü  Better physical and mental health

ü  Total well-being

 

Confidential assistance is available 24 hours a day, 7 days a week when using the Aetna Resources For Living (EAP) program.   This is a service provided as part of your benefits to you or any member of your household at no additional cost. You can turn to Resources for Living  (EAP) for help with anything that interferes with your job or personal life such as:

 

Stress management                       Family or parenting issues

Substance abuse/misuse             Work/life balance

Burnout                                               Marital/relationship problems

Child and elder care                        Anxiety

Depression                                         Anger management

Legal concerns                                 Financial issues

Coping with change                        Self-esteem

  

 

Sometimes life can become work and work can become your life. Either way, we’re here to help you balance the two.  Maybe you just need someone to talk to about a recent transition or conflict at work, or maybe you’re looking for some guidance with your personal relationships.  When you call, a trained professional will confidentially help you assess your needs and provide referrals to local counselors at your request.  We have community and professional services available, such as psychologists, marriage and family therapists and substance abuse counselors, to help you balance your work and home life.

 

Benefits of the Resources For Living:

Þ    8 counseling sessions per issue, per year

Þ    Free initial legal consultation

Þ    Discounts on continuing legal consultation services

Þ    Free initial financial consultation

 

 

ALL INFORMATION IS CONFIDENTIAL BETWEEN AETNA RESOURCES FOR LIVING (EAP) AND YOU.

 

 

Call anytime, toll free:  1-866-849-8229 or visit http://mylifevalues.com/

then enter the User ID:  EAP4HCTX

                       Password:  EAP4HCTX 

Harris County Dental Plans (UnitedHealthcare Dental)Top

 

Harris County employees have the option of choosing either a DHMO Plan or PPO Plan for their dental care.  You must choose one plan during each annual open enrollment and no plan changes can be made until the next open enrollment.

 

·   Review the plans and decide which fits your needs best: DHMO or the PPO Plan.

·   If you select the DHMO Plan, choose a participating dentist from the directory of dental providers.

·   Remember that the dependents you enrolled in the medical plan will be covered under the dental as well.  Each family member may choose a different provider.

·   If you select the PPO Plan you must file a claim for reimbursement.

 

Dental DHMO

First, you must select a dentist who is affiliated with UnitedHealthcare Dental.  A list of these dentists can be obtained from your department’s Benefits Coordinator, or online at www.yourdentalplan.com/harriscounty.  When specialty care is required, your selected general dentist will provide you with a referral prior to receiving this treatment.

 

Standard covered services with little or no copayment:

  • Examinations and x-rays
  • Two basic cleanings each year
  • Pulp vitality tests
  • Partial or denture adjustments
  • Orthodontic consultations
  • Fluoride treatment
  • Diagnostic consultations
  • Crowns recemented
  • Wellness screenings

 

Services that are NOT COVERED:

  • Services of dentists not associated with this Plan
  • Hospitalization for any dental procedure
  • Experimental procedures
  • Prescription and non-prescription drugs
  • Oral surgery to set a fracture or dislocation
  • Services for conditions already covered under Workers’ Compensation
  • Implants and implant-related products
  • Temporomandibular Joint (TMJ) Dysfunction (medical)
  • Full mouth reconstruction

 

The Evidence of Coverage including schedule of benefits, exclusions and limitations is available on the Harris County Human Resources and Risk Management page under the “Dental Plan Documents” tab. 

 

Dental PPO Plan

The second plan is a PPO Plan available through UnitedHealthcare Dental that gives you the freedom to select any dentist or specialty dentist for any appointment you schedule.  In addition, you can choose a different dentist for each member of your family.

 

If you decide the PPO Plan is right for you, there is no need to “pre-register” with a dental care provider - you can receive treatment from any dentist. When choosing a dentist, remember that if you choose to receive care from a contracted UnitedHealthcare dentist, you could save on your out-of-pocket costs. Contracted dentists have agreed to accept the negotiated fee as payment in full with no balance billing.

 

Your Costs

Payment of claims is based on a Maximum Allowable Charge (MAC). The Maximum Allowable Charge is set by UnitedHealthcare and based on negotiated rates with contracted dentists.  This MAC is the most that UnitedHealthcare will pay for a particular dental procedure under the plan.

 

The Certificate of Coverage including schedule of benefits, exclusions and limitations is available on the Harris County Human Resources and Risk Management page under the “Dental Plan Documents” tab. 

 

 


UnitedHealthcare Dental HMO*

UnitedHealthcare Dental PPO**

No calendar year maximums; no yearly deductibles

$1,750 calendar year maximum; $50 yearly individual deductible ($150 for family)

Basic care provided by network general dentists selected at enrollment. Members may change their designated dentist by contacting UnitedHealthcare Dental customer service by the 20th of the month. Requested changes will be effective the first of the following month.

You may receive care from any licensed dentist; network dentists have agreed to accept negotiated fees as payment in full with no “balanced billing”.

Each family member may select a different UnitedHealthcare Dental network general dentist (remember to include the Practice ID number when enrolling).

Non-network dentists could “balance bill”, which may result in higher out-of-pocket costs (see the Benefit Summary or determine out-of-pocket costs by using the online Treatment Cost Calculator for more information).

Covered procedures and copayments are listed on the Schedule of Benefits and may be found on  www.yourdentalplan.com/harriscounty

All claims are paid based on the percentages of the Maximum Allowable Charge (MAC).

When specialty care is required, your selected general dentist and UnitedHealthcare Dental Customer Service Representative will assist in managing your referral.

If you require specialty care, you may see any specialty care dentist you choose. When you receive care from a network dentist, you may save on your cost of care.

No waiting periods.

New enrollees: 6 month waiting period on endodontic procedures & all major services (new employees and newly added dependents of current employees).

Adult & child orthodontics is included.

Orthodontia is not a covered benefit in the PPO plan.

No claim forms are required.

Claim forms may be required when a non-network dentist is used.

*Benefits for the UnitedHealthcare Dental DHMO plans are provided by the following UnitedHealth Group company: National Pacific Dental, Inc.

**Benefits for the UnitedHealthcare Dental PPO plans are provided by UnitedHealthcare Insurance Company, located in Hartford, Connecticut

 

 

CUSTOMER SERVICE

If you have questions regarding coverage, claims, or locating a dentist in your area, please contact the dental customer service department. The department can be reached at the toll-free number listed on your dental ID card – (866) 528-6072, Monday through Friday from 7:00 a.m. to 10:00 p.m., Central Time.

Through the same toll-free number, you may also choose to use the automated voice system. This provides access to dental information 24 hours a day, 7 days a week. Among many options, this system allows you to verify benefits, check the status of a claim, or obtain a pre-treatment estimate.

 

UnitedHealthcare Dental has created a website specifically for County employees at www.yourdentalplan.com/harriscounty.  The customized Harris County website was designed to help you get the most from your dental benefits program. 

 

The DHMO Dental Plan Evidence of Coverage is available at http://www.hctx.net/cmpdocuments/63/doc/dhmo.pdf .

 

The PPO Dental Certificate of Coverage is available at http://www.hctx.net/cmpdocuments/63/doc/dentalppo.pdf .

 

 

 

Harris County Vision Care ProgramTop

 

Harris County Vision Care Program is offered through Block Vision.  Remember, vision coverage is provided automatically for you and each dependent you enroll in the medical plan.

HOW THE VISION CARE PROGRAM WORKS

Each time you need vision care, you may seek care through the Block Vision benefit plan. Select a Block Vision participating provider by calling the provider locator at (866) 265-0517, or from www.blockvision.com.  When you make your appointment, identify yourself as a Harris County Block Vision Plan member.  A vision examination is provided by a network optometrist or ophthalmologist once every twelve months.  At an in-network provider, members will receive a $130 retail allowance towards the cost of the frame. The Block Vision benefit plan provides $130 toward your contact lens evaluation and fitting fee as well and the cost of contact lenses.  A $300 Lasik benefits reimbursement is also available either in or out-of-network. 

 With the vision plan, when you use participating providers you will pay lower out-of-pocket expenses and receive a higher level of benefits.  You may also use out-of-network benefits; however, your benefit level is reduced,  you will pay for the services and you must file a claim with Block Vision for reimbursement.

COVERED SERVICES

Highlights of your vision care benefits are shown below. For the complete schedule of benefits reference the Vision Plan Benefit Certificate of Coverage.

Service/Product

In-Network

Out-of-Network

Complete Visual Exam*

$10 copay

Up to $35

Materials (when purchasing eyeglasses, lenses, frames OR contacts in lieu of eyeglasses)

$25  copay

 

Frames

 

 

 

$130 retail allowance after

$25 materials copay

Up to $70

Lenses

 

 

Single Vision Lenses**

Standard basic lens covered  at 100%

after $25 Materials copay

Up to $25

Lined Bifocal Vision Lenses**

Standard basic lens covered  at 100%

after $25 Materials copay

Up to $40

Lined Trifocal Vision Lenses**

Standard basic lens covered  at 100%

after $25 Materials copay

Up to $45

Contact Lenses

 

 

Elective

$130 retail allowance after

 $25 Materials copay

Up to $80

Necessary***

100% after $25 Materials copay

Up to $150

Laser Correction

 

 

Lasik Vision Correction****

$300  benefit

$300 retail benefit

 

*Limited to one exam and set of lenses or contacts every 12 months from the last date of service. 

 

** Standard basic lens coverage included in your $25 copay for glasses lenses or frames and lenses.  Lens cost that exceeds the basic coverage is the member’s responsibility.  Members may receive a discount of up to 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage.

 

*** Necessary contact lenses are determined at the provider’s discretion for one or more of the following conditions:  Following cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions of anisometropia; with certain conditions of keratoconus.  If your provider considers your contacts necessary, you should ask your provider to contact Block Vision concerning the reimbursement that Block vision will make before you purchase such contacts.

 

****Lasik Vision Correction: Block Vision provides each member a $300 allowance available both in and out-of-network.   Block Vision has partnered with the LCA . In-network providers may offer additional savings and financing.   Call 877-557-7609 for assistance in coordinating your care.

 

 

 

Life Insurance and AD&D Top

 

Life Insurance and Accidental Death and Dismemberment (AD&D) Insurance offered by Prudential provides protection for your family in the event of your death or accidental injury. The County currently provides a basic level of insurance to eligible employees and your covered dependents at no cost as shown below.

a. Active Employees

         

Annual Rate of Basic Earnings is:

Life*

AD&D

$25,000

$5,000

 

 

 

 

 

 

b. Dependent Life Insurance1

Classification

Life1

Spouse

$5,000

Child(ren)

$2,000

*Benefits reduce 35% at age 70 and 50% at age 75.

1Dependent Life Insurance coverage is only available for the dependents covered under your Medical Plan.  All Dependent Life Insurance terminates when the employee retires.

If you die while insured for Life Insurance, or if you have an accident while insured for AD&D Insurance, and the accident results in loss, Prudential will pay benefits according to the terms of the Group Policy after receiving proof of loss. For AD&D Insurance, loss means loss of life, hand, foot or sight which is caused solely and directly by an accident, occurs independently of all other causes, and occurs within 365 days after the accident.

                                                     

 

Optional Term Life InsuranceTop

 

You also have the opportunity to increase the level of your insurance at competitive group rates. You may purchase Optional Life Insurance for yourself equivalent to one, two or three times your basic annual salary or wage (at time of enrollment), up to $375,000. If your salary or wage changes, your Optional Life Insurance amount will change on the next anniversary of the plan. Any Pre-Tax Life Insurance provided under the County plans in excess of $50,000 is subject to taxation.

                                                     

Long-Term Disability CoverageTop

 

Long-Term Disability (LTD) Insurance is designed to provide peace of mind by providing income protection in the event you become disabled and cannot work.

Long-Term Disability (LTD) is part of your Harris County Benefit Plan. The insurance has two (2) parts: Basic LTD and Optional LTD. You are eligible for the Basic LTD insurance on the first day of the month after three (3) months of continuous employment with Harris County. For Optional LTD, you are eligible for coverage the first day of the month following twelve (12) months of continuous employment with Harris County.

The Basic LTD coverage replaces 50% of the first $10,000 of your pre-disability earnings, reduced by deductible sources of income. There is a benefit waiting period of 180 days. The maximum benefit duration is two (2) years.

The Optional LTD increases your monthly benefit to 60% of the first $10,000 of your pre-disability earnings, reduced by any deductible sources of income. This also extends the length of disability benefits from two (2) years to age 65+, if you are still medically disabled.  The minimum benefit you will receive is $200 or 10% of your LTD benefit, whichever is greater.  This Optional LTD coverage is fully contributory by the Harris County employees who elect this coverage.

Both the Basic LTD and Optional LTD insurance coverage are offered through contracts with Cigna.  Premiums deducted for the Optional LTD will be on an after-tax basis, so any disability benefits you receive for the Optional LTD coverage will not be subject to taxation.

Disability insurance provides income replacement when you experience a covered illness, injury or pregnancy.  The coverage can help with financial obligations, such as mortgage or rent payments that continue even when you can’t work – expenses that health insurance does not cover.

If you enroll in the Optional LTD Plan within the first 31 days after you are eligible to enroll, you just complete an enrollment form. If you wait and want to enroll after the first 31 days, you must complete and submit proof of good health or an Evidence of Insurability (EOI) form to Cigna.  The late application must be reviewed and approved before any coverage is effective. Additional pre-existing conditions apply to current Harris County employees enrolling in the plan and new hires first choosing to enroll in the plan. This pre-existing limitation could possibly limit any disability benefit.

There are additional exclusions and limitations that apply to your LTD coverage. If you have any questions about the Harris County LTD Plan, please contact Cigna at (800) 362-4462 or log on to http://www.cigna.com/.

Benefits information is included in the Harris County Resource Guides (electronically at http://www.hctx.net/hrrm) that are distributed annually during open enrollment, and at employee orientation for new hires.  Should you have any questions regarding your County benefits please call (713) 755-5117 for further assistance.

 

Revised 2/2012

 

 

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