E-I. Medical Benefits

A. Health Care Plan Design Effective.

Plan Design.

The Board and Union agree to provide a healthcare plan to qualifying employees that include a PPO, an HMO and HSA.

Select plan types to compare

Benefit Highlights (for eligible expenses)	HMO	PPO with HSA In-Network	PPO with HSA Out-of-Network	PPO In-Network	PPO Out-of-Network
Health Savings Account (Employer Contributions)	n/a	$600 Employee Only $1,500 Employee+1 $2,000 Family	$600 Employee Only $1,500 Employee+1 $2,000 Family	n/a	n/a
Annual Deductible (not applicable to services with co-pays)	none	$2,000 per person $4,000 per family	$4,000 per person $8,000 per family	$600 per person $1,800 per family	$1,200 per person $3,600 per family
Out-of-Pocket Maximum (including deductible)	$1,500 per person $3,000 per family	$4,000 per person $8,000 per family	$8,000 per person $16,000 per family	$2,700 per person $5,200 per family	$5,400 per person $10,800 per family
Lifetime Maximum Coverage	Unlimited	Unlimited	Unlimited	Unlimited	Unlimited
Care in Physician’s Office (general doctor office visits such as x-rays, allergy shots and chemotherapy)	100% after $30 co-pay per visit	80% after deductible	50% after deductible	$25 co-pay and 80% after deductible	50% after deductible
Preventive (preventive screening) (routine physical check-ups for adults and children, mammograms, PSA, pap smears, HPV screenings, physicals and immunizations)	100% (no co-pay) (no deductible)	100% (no co-pay) (no deductible)	50% after deductible	100% (no co-pay) (no deductible)	50% after deductible
Pre-Certification through Vendor Selected by the Board	HMO Participants are not required to obtain pre-certification through vendor selected by the Board. Referrals are handled by participants’ primary care physicians.	Pre-authorization required, failure can results in 50% additional co-insurance charge up to $1,000 plus the co-insurance that is applicable to the service. Benefits can be further reduced or denied completely if it is determined that treatment or admission is not medically necessary.	Pre-authorization required, failure can results in 50% additional co-insurance charge up to $1,000 plus the co-insurance that is applicable to the service. Benefits can be further reduced or denied completely if it is determined that treatment or admission is not medically necessary.	Pre-authorization required, failure can results in 50% additional co-insurance charge up to $1,000 plus the co-insurance that is applicable to the service. Benefits can be further reduced or denied completely if it is determined that treatment or admission is not medically necessary.	Pre-authorization required, failure can results in 50% additional co-insurance charge up to $1,000 plus the co-insurance that is applicable to the service. Benefits can be further reduced or denied completely if it is determined that treatment or admission is not medically necessary.
Inpatient Hospital Services Hospital (Semi-Private) Room and Board	100% after $265 co-pay per admission	80% after deductible	50% after deductible	$100 per admission and 80% after deductible	$100 per admission and 50% after deductible
Doctor’s Visits (including specialists, x-rays, labs, drugss, surgeon’s fees and anesthesiologistsava)	100% $0 co-pay	included in in-patient hospitalization	included in in-patient hospitalization	included in in-patient hospitalization	included in in-patient hospitalization
Outpatient Hospital Care (including surgery)	covered in full after $225 co-pay per visit	80% after deductible	50% after deductible	80% after deductible	50% after deductible
Maternity Prenatal/Postnatal Hospital Coverage (mother and newborn)	100% after $45 co-pay per visit 100% after $275 co-pay per admission	80% after deductible 80% after deductible	80% after deductible 50% after deductible	100% after $40 co-pay per visit 80% after deductible	50% after deductible 50% after deductible
Covered Emergency Care Emergency Care (if emergency) Ambulance (if emergency)	100% after $200 co-pay per visit 100% with $0 co-pay	80% after deductible 100% after deductible	80% after deductible 100% after deductible	100% after $200 co-pay per visit 100% after deductible	100% after $200 co-pay per visit 100% after deductible
Mental Health and Substance Abuse Inpatient Outpatient	100% after $275 co-pay per visit 100% after $20 co-pay²	100% after deductible 100% after deductible	80% after deductible 80% after deductible	80% after deductible 100% after $25 co-pay	50% after deductible 80% after $25 co-pay
Basic Vision Plan *Employees have the option of purchasing additional coverage by enrolling in the Enhanced Vision Plan, which is described in paragraph(B)(3) below.	Annual eye exam through network provider covered at 100% after $15 co-pay Discounts on eyewear	Annual eye exam through network provider covered at 100% after $15 co-pay Discounts on eyewear	Annual eye exam through network provider covered at 100% after $15 co-pay Discounts on eyewear	Annual eye exam through network provider covered at 100% after $15 co-pay Discounts on eyewear	Annual eye exam through network provider covered at 100% after $15 co-pay Discounts on eyewear
Therapy (physical, occupational and speech therapy for restoration of function) (services for acquisition of function not covered) (limited to 60 visits per calendar year per therapy)	100% for the number of visits which, if approved by a doctor, up to 60 visits combined for all therapies, plus $30 co-pay per visit per calendar year	100% after deductible, then $30 co-pay	80% after deductible	100% after deductible, then $30 co-pay	80% after deductible
Chiropractic Care (unlimited visits if medically necessary)	100% after $45 co-pay per visit³	100% after deductible, then $30 co-pay	80% after deductible, then $30 co-pay	100% after deductible, then $30 co-pay	80% after deductible
Care in Skilled Nursing Facility (non-custodial) (up to 60 days per year if medically necessary)	100%	80% after deductible	50% after deductible	80% after deductible	50% after deductible
Prosthetic Devices and Medical Equipment	100%	80% after deductible	50% after deductible	80% after deductible	50% after deductible

Table Notes
2	The amount of this co-pay reflects the parties’ settlement of grievance case no. 20-02-117.
3	The amount of this co-pay reflects the parties’ settlement of grievance case no. 20-12-014(amr).

B. Insurance Benefits - Other.

1. Pre-authorization.

Pre-authorization required, failure can result in 50% additional co-insurance charge up to $1,000 plus the coinsurance that is applicable to the service. Benefits for medically unnecessary procedures are subject to further reduction or denial in accordance with plan policy. The BOARD will continue to provide information about pre-authorization to its employees during the Open Enrollment period. The BOARD agrees that employees should be provided with additional information materials upon which to base health care decisions and will design a specific communication piece such as a section of the annual open enrollment materials, or other communication.

2. Chronic Care/Disease Management Program.

The parties agree to continue to maintain a chronic care/disease management program. The program shall provide individualized/customized treatment plans, education support, monitoring via nurse care coordinators, communications to employees through the internet and mail, and targeted phone calls to engage employees in preventive actions.

3. Enhanced Vision Plan.

The BOARD shall continue to offer an employee-paid vision plan providing contacts/lenses once every calendar year and frames once every calendar year. Employee premiums are as follows:

Employee: as determined by insurer, or if self-insured as determined by vendor.
Employee + 1: as determined by insurer, or if self-insured as determined by vendor.
Family: as determined by insurer, or if self-insured as determined by vendor.

In addition, there will be a $150 frame allowance every calendar year and a $175 contacts/lenses allowance every calendar year covered in network. Greater allowances may be provided at the discretion of the BOARD.

4. Pharmaceutical Benefit.

The prescription drug benefit shall continue to include the following terms:

Annual mailing providing employees with summary of Rx expenses and recommendations to save employees money such as for generic substitutions.
Retail Fill Restrictions (initial fill + 4, then employee must use mail order to avoid penalty).

6. Benefits Eligibility for New Hires.

A newly hired employee will continue to be eligible for health care benefits beginning on the first day of the month following his or her date of hire.

7. Employee Assistance Program.

An Employee Assistance Program shall continue to be maintained as part of the health care program.

C. Benefit Information.

The BOARD currently provides a guide, providing an overview of its health care plans to new employees and re-hired employees and during the annual Open Enrollment period, and the BOARD will continue to do so. The guide will be available online to allow employees to view current plan information electronically.
The BOARD benefit plans provide a toll-free hotline and an online site for members to access with questions regarding their health care plan. The hours of operation for each health care plan are 8:00 a.m. to 6:00 p.m. Additionally, the BOARD has a Benefits Customer Service team which answers calls during business hours.
As a result of the PeopleSoft conversion, the BOARD relies on a unique identification number (“UID”) for all employees. The BOARD will work with each of its vendors to ensure that employees are routinely identified by these UIDs as opposed to the employees’ Social Security numbers.

D. Anti-Fungal Drugs.

Griseofulvin is covered by the Board. All other anti-fungal drugs have the option of going through medical necessity review and may be covered after review with the exception of Penlac which is excluded from the plan and Grifulvin V and Gris-Peg which are no longer available on the market.

Drug Name	Covered
Grifulvin V	N/A
Gris-Peg	No
Griseofulvin	Yes
Lamisil	No
Sporanox	No
Penlac	No