Comparison of Medical Plans
-
For
CCCD Faculty & Staff
| Plan Outline | DHS | Kaiser | Pacificare |
| FACILITIES | Any | Kaiser Facilities | Contracted Facilities & Physicians |
| ANNUAL DEDUCTIBLE | $200/Person - Max $350/Family.* | None | None |
| PHYSICIAN VISITS/IN-HOSPITAL | 75% - 90%**/*** | 100% | 100% |
| IN-PATIENT HOSPITALIZATION | 75% - 90% of Semi-Private Room Rate**/*** | 100% Semi-Private (In or Out of Area) | 100% Semi-Private (In or Out of Area) |
| MATERNITY | 75% - 90%** In-Patient: Normal Delivery/48 Hr Min Stay; C-Section/96 Hr Min Stay (EE/Spouse only). Covers In-Patient Nursery Charges for newborns; however, Out-Patient well baby charges NOT covered. | $5/Visit Co-Pay - 100% Hospitalization.
Nursery & Well Baby charges covered. |
$3/Initial Visit Co-Pay - 100% Hospitalization.
Nursery & Well Baby charges covered @ 100%. |
| FAMILY PLANNING | 75% - 90%**/*** - Sterilization/Elective Abortions (EE/Spouse only). Infertility Services Not Covered. | 100% for Tubal, Vasectomy, Interruption of pregnancy & Infertility Services | 100% with Co-Pays: Tubal $100.; Vasectomy $50.; Vol Interruption of Pregnancy $125. Infertility Services Covered at 50% |
| OFFICE VISITS | 75% - 90%** | $5/Visit Co-Pay | $3/Visit Co-Pay |
| EMERGENCY ROOM SERVICES | 75% - 90%** | $35 Emerg Rm Co-Pay | $35 Emerg Rm Co-Pay |
| CHIROPRACTIC/PHYS. THERAPY | 75% - 90%** (See Employee Benefits Handbook) | Physical Therapy Only - $5/Visit Co-Pay | Physical Therapy Only - $3/Visit Co-Pay |
| PRESCRIPTIONS/OUT-PATIENT | $5 Generic or $12 Brand Name Co-Pays for 30 Day Supply @ Pharmacy. $3 Generic or $6 Brand Name Co-Pays for 90 Day Supply via Mail Order. | $5 Co-Pay - 100 Day Supply/Plan Pharmacies | $2 Co-Pay/30 Day Supply/Plan Pharmacies Mail Order Available. |
| LAB & X-RAY/DIAGNOSTIC | 75% - 90%** (100% for Pre-Admission Tests Within 7 Days of Hospital Confinement) | 100% | 100% |
| SURGERY | 75% - 90% **/**** | 100% | 100% |
| ACCIDENTAL INJURY | 100% up to $1000/Accident (within 1st 60 Days) -
Deductible Waived; Ded. Applies Thereafter. |
$35 Emerg Room Co-Pay (In or Out of Area)
$5/ Visit Co-Pay in Doctor's Office |
$35 Emerg Rm Co-Pay (In or Out of Area)
$3/ Visit Co-Pay in Doctor's Office |
| 2ND SURG OPINION CONSULTS | 100% (Voluntary or Required)/Deductible Waived | $5/Visit - Kaiser Authorized Dr only | $3/Visit With Primary Care Dr Authorization |
| MENTAL HEALTH/IN-PATIENT | 75% - 90%**/***
30 Days Per Calendar Year/Per Person |
100% 45 Days per Year | 100% - 30 Days/Yr per Member, Available through Supplemental Benefits. |
| MENTAL HEALTH/OUT-PATIENT | 50%
60 Visits Per Calendar Year/Per Person |
$5/Visit Co-Pay | $35/Visit Co-Pay - 20 Visits per Year - AND/OR 30 Visits through Supplemental Benefits with $3 Co-Pay. |
| SUBSTANCE ABUSE/IN-PATIENT | 75% - 90%**/***
$50,000 Lifetime Maximum |
100%-Acute Care/Detox & Recov Servs. $100 Co-Pay Transitional Residential Recovery Services. | 100% Detoxification Only. Under Supplemental - Incls. All Levels of Care, with Combined In/Out-Patient Max of $25,000/Cal Yr; $35,000/Lifetime. |
| SUBSTANCE ABUSE/OUT-PATIENT | 50% Except 90% at PPO Facilities. $50,000 Lifetime Maximum. See Employee Benefits Handbook. | $5/Visit Co-Pay | 100% Detoxification Only. Under Supplemental - Incls. All Levels of Care, with Combined In/Out-Patient Max of $25,000/Cal Yr; $35,000/Lifetime. |
| PREVENTIVE SERVICES | Not Covered (Except Mammograms/Drs Referral Only) | Covered | Covered |
| PRE-EXISTING CONDITIONS | EE - 6 Month Wait; Deps - One Year Wait ***** (No Pre-existing on Maternity/Newborn/Adoption) |
No Wait | No Wait |
| STOP-LOSS/PLAN MAXIMUMS | 75% - 90%** to 1st $2000 of Elig. Expenses/Cal Yr After Ded; 100% Thereafter (100% of URC for Non-PPO). Maximum Lifetime Benefits $1,000,000/Person. | $1500 Total Co-Pays
Per Member Per Year
$3000 Total Co-Pays Per Family Per Year Lifetime Maximum - Unlimited |
$800 Total Co-Pays Per Member Per Year
$2400 Total Co-Pays Per Family Per Year Lifetime Maximum - Unlimited |
*
$100 Deductible Per Person When Retired & Medicare is Primary Payor.
** 75% of URC for Non-PPO
Providers/90% for PPO Providers.
***
Addl. Deds. of $400 - For Non-PPO Hospital; $200 Without Pre-authorization for
Hospital Admit.
(See Employee Benefits Handbook).
**** Benefits Reduced to 70% for In-Patient
Elective Surgery without required 2nd Opinion.
***** Waiting Period May be Reduced With Proof of Prior
Creditable Health Coverage.
Waiting Period Waived during Open Enrollment.
NOTE: All Non-PPO Services are Subject to Usual, Reasonable, and Customary (URC) Guidelines. (Rev. 10/01/02)