Download Employee Medical Plan Premium Rates

Employee Medical Plan
Premium Rates
Coverage
Each employer may choose to cover all of its
employees or only its hourly field construction
employees.
Hourly Field Construction Employees
All hourly field construction employees
must be covered by the Plan unless they are
separately covered by collectively bargained
plans.
Hourly field construction employees become
eligible the first day of the second month
following 130 - 150 hours of work within a calendar
month. All other employees become eligible the
first day of the month following one full month
of work.
Contributions must be paid for all hours
worked by hourly field construction employees
as soon as they begin employment, beginning
with the first hour worked.
All Other Employees
If an employee who is not an hourly field
construction employee can show verification of
other coverage, he or she need not be covered
by the Plan.
Minimum of 10 Enrolled Employees is required
to participate in the Trust.
Disclaimer
1. The coverage and eligibility descriptions listed
here are partial descriptions. Please refer to the
plan booklet.
Monthly/Salary
130 Hours
140 Hours
150 Hours
Employees
Field Employees Field Employees Field Employees
Health Plan of Nevada HMO Medical - Northern Nevada
Employee
$356.16
Employee and spouse
$712.32
Employee and child(ren)
$676.71
Employee and family
$1,139.72
$2.74
$5.48
$5.21
$8.77
$2.55
$5.09
$4.84
$8.15
$2.38
$4.75
$4.52
$7.60
Sierra Health and Life PPO Medical - Northern Nevada
Employee
$391.56
Employee and spouse
$783.12
Employee and child(ren)
$743.97
Employee and family
$1,253.00
$3.02
$6.03
$5.73
$9.64
$2.80
$5.60
$5.32
$8.95
$2.62
$5.23
$4.96
$8.36
Health Plan of Nevada HMO Medical - Southern Nevada
Employee
$268.24
Employee and spouse
$536.48
Employee and child(ren)
$509.66
Employee and family
$858.35
$2.07
$4.13
$3.93
$6.61
$1.92
$3.84
$3.65
$6.14
$1.79
$3.58
$3.40
$5.73
Sierra Health and Life PPO Medical - Southern Nevada
Employee
$294.89
Employee and spouse
$589.78
Employee and child(ren)
$560.28
Employee and family
$943.64
$2.27
$4.54
$4.31
$7.26
$2.11
$4.22
$4.01
$6.75
$1.97
$3.94
$3.74
$6.30
Sierra Health and Life - PPO Dental
Employee
Employee and spouse
Employee and child(ren)
Employee and family
$0.20
$0.40
$0.38
$0.64
$0.19
$0.37
$0.35
$0.59
$0.18
$0.35
$0.33
$0.55
$25.70
$51.39
$48.82
$82.22
Coverage
Coverage
Lifetime Maximum
Deductible-Calendar
Year (2per family)
Out-of-Pocket MaximumCalendar Year
Physician Services
Office
Preventive Care
Well Baby Care (0-2 yr.)
Hospital Services
Lab and X-ray
Inpatient
Outpatient
ER Visit
Prescription Drug
Generic
Brand Name
Non-Formulary
Substance Abuse/Chemical
Dependency
Inpatient
Outpatient
Mental Illness
Facility-based Care-Inpatient
Outpatient Consultation
Health Plan of Nevada (HMO)
Sierra Health and Life (PPO)
In-Network
Out-of-Network
Unlimited
None
Unlimited
$500 per Member per Year
$1,000 per Family per Year
$3,000 per Member per Year
$6,000 per Family per Year
$1,000 per Member per Year
$2,000 per Family per Year
$6,000 per Member per Year
$12,000 per Family per Year
$15/$30 Copay
100%
100%
$35 Copay (Deductible Waived)
100%
100%
40% (After Deductible)
40% (After Deductible)
40% (After Deductible)
$300 Copay per Admit
20% (After Deductible)
40% (After Deductible)
$15 Copay
$15 Copay
100%
$35 Copay (Deductible Waived)
40% (After Deductible)
40% (After Deductible)
$75 Copay
(Waived if Admitted)
$150 Copay (Deductible Waived)
$150 Copay (Deductible Waived)
$25 Copay
$50 Copay
$75 Copay
$25 Copay
$50 Copay
$75 Copay
$300 Copay per Admit
Unlimited Days
20% (After Deductible)
40% (After Deductible)
$15 Group / $30 Individual
Unlimited Visits
$35 Copay (Deductible Waived)
40% (After Deductible)
$300 Copay per Admit
Unlimited Days
20% (After Deductible)
40% (After Deductible)
$15 Group / $30 Individual
Unlimited Visits
$35 Copay (Deductible Waived)
40% (After Deductible)
None
Applicable Copay Plus 30%
Disclaimer
Benefits shown are applicable only to eligible (covered) charges. This summary
is for comparison purposes only. All benefits are subject to policy terms and
conditions. These are partial descriptions of Plan benefits and limits to benefits.
Refer to the Schedule of Benefits and Evidence of Coverage for more specific
information.
Health Plan of Nevada, Inc.
HMO C15 Medical Plan (HCR)
Lifetime Maximum
Unlimited
Covered Services
Member Pays
Medical Services
Primary Care Physician Visit
Specialist Visit
Preventive Health Services
Hospital Services - Elective Procedures
Inpatient
Outpatient
Physician Surgical Services
Inpatient Hospital
Outpatient Facility
Physician’s Office (in addition to office visit copayment)
• Primary Care Physician
• Specialist
Anesthesia
Urgent Care Facility
Within the Service Area
Outside the Service Area
Emergency Services
Emergency Room Visit
Hospital Admission
Ground Ambulance
Diagnostic Services
Routine Laboratory
Routine X-ray
$15 per visit
$30 per visit
No charge
$300 per admission
$50 per admission
$50 per surgery
$25 per surgery
$15 per visit
$30 per visit
$100 per surgery
$20 per visit
$40 per visit
$75 per visit; waived if admitted
$300 per admission
$50 per trip
$15 per visit
$15 per visit
This is a summary of Covered Services. Please refer to the HPN Evidence of Coverage, Disclosure Summary, Attachment A Benefit
Schedule Form No. HPNmasBS2011-HCR, Endorsement Form No. HPN-GRP-HCR-ENDORSE(2011), and any other applicable Riders
for additional information, limitations and exclusions of coverage. Copies of these documents are available upon request. Plan documents
govern in resolving any benefit questions or payments.
(11/11-PDf)
21NVHPN11972
PD-4584
Health Plan of Nevada, Inc.
Plan Médico HMO C15 (HCR)
Máximo de Por Vide
Servicios cubiertos
Servicios Médicos
Visita al Médico de Atención Primaria
Visita a Especialista
Servicios de salud preventiva
Servicios Hospitalarios - Procedimientos Electivos
Con Internación
Ambulatorios
Servicios Quirúrgicos efectuados por Médico
Hospital con Internación
Centro Ambulatorio
Consultorio del Médico (además del copago de la visita en consultorio)
• Médico de Atención Primaria
• Especialista
Anestesia
Centro de Cuidados Urgentes
Dentro del Área de Servicio
Fuera del Área de Servicio
Servicios de Emergencia
Visita de Sala de Emergencias
Admisión en Hospital
Ambulancia Terrestre
Servicios de Diagnóstico
Análisis de Laboratorio de Rutina
Radiografías de Rutina
Ilimitado
El Miembro paga
$15 por visita
$30 por visita
Sin cargo
$300 por admisión
$50 por admisión
$50 por cirugía
$25 por cirugía
$15 por visita
$30 por visita
$100 por cirugía
$20 por visita
$40 por visita
$75 por visita; anulado si hay internación
$300 por admisión
$50 por viaje
$15 por visita
$15 por visita
Éste es un resumen de los Servicios Cubiertos. Si desea más información, consulte el Convenio de Cobertura HPN, el
Resumen de Divulgación de Información, la Lista de Beneficios en el Anexo A formulario núm. HPNmasBS2011-HCR, El formulario
núm HPN-GRP-HCR-ENDORSE(2011), y todas las cláusulas adicionales pertinentes, así como las limitaciones y exclusiones. Se
pueden solicitar copias de estos documentos. Los documentos del plan regirán en la resolución de preguntas sobre beneficios o pagos.
Sierra Health and Life Insurance Company, Inc.
Sierra 2010 Plan 500-1000-35-80/60-X (HCR)
Plan Provider
Benefits
Non-Plan Provider
Benefits
Lifetime MaximumUnlimitedUnlimited
Calendar Year Deductible (CYD)
$500 of EME* per Insured
$1,000 of EME per Insured
separate Plan and Non-Plan Provider
$1,000 of EME per Family
$2,000 of EME per Family
Calendar Year Coinsurance Maximum (after CYD)
$3,000 of EME per Insured
$6,000 of EME per Insured
separate Plan and Non-Plan Provider
$6,000 of EME per Family
$12,000 of EME per Family
Covered Services
Insured Pays
Physician Services
Non-Specialist Office Visit
Specialist Office Visit
$35 per visit
$35 per visit
Physician Surgical Services
Inpatient Facility
Outpatient Facility
Physician's Office
Anesthesia
After CYD, Insured pays
40% of EME plus all
charges in excess of EME
No charge
Preventive Health Services
Hospital Services
Inpatient
Outpatient
Insured Pays
After CYD, Insured pays 20%
of EME
After CYD, Insured pays 20%
of EME
$50 per visit
Urgent Care Facility
Emergency Services
Emergency Room Facility
Emergency Room Physician
$150 per visit
After CYD, Insured pays 20% of EME
$150 per visit
After CYD, Insured pays 20% of EME
plus all charges in excess of EME
Ground Ambulance
After CYD, Insured pays 20% of EME
After CYD, Insured pays 40% of EME
plus all charges in excess of EME
(Insured is responsible for all amounts exceeding any
applicable maximum benefit and amounts exceeding
the Plan's EME payment to Non-Plan Providers. Such
amounts do not accumulate to the Calendar Year
Coinsurance Maximum.)
Diagnostic Services
Routine Laboratory
Routine X-ray
$35 per visit
$35 per visit
After CYD, Insured pays
40% of EME plus all
charges in excess of EME
*EME (Eligible Medical Expenses) means the maximum amount the Plan will pay for a Covered Service in accordance with the Plan
Reimbursement Schedule. The Plan Provider and Non-Plan Provider Calendar Year Coinsurance Maximums are separate and do not
accumulate to one another. Non-Plan Provider charges in excess of EME may be substantial and do not accrue toward the Calendar Year
Coinsurance maximum. This plan includes additional benefits, exclusions and limitations which are shown in the SHL Certificate of
Coverage, Attachment A Benefit Schedule Form No. SHL-Sierra2010-masBS-July2011-HCR, Endorsement Form No. SHL-GRP-HCRENDORSE(2011), and any other applicable Riders and the Disclosure Summary. Copies of these documents are available upon request. Plan
documents govern in resolving any benefit questions or payments.
41NVSHL10573
PD-4000 (09/10)
Sierra Health and Life Insurance Company, Inc.
Sierra 2010 Plan 500-1000-35-80/60-X (HCR)
Beneficios para Proveedor
Perteneciente al Plan
Beneficios para Proveedor
no Perteneciente al Plan
Máximo de Por Vide
Ilimitado
Ilimitado
Deducible por Año Calendario (CYD)
$500 del EME* por Asegurado
$1,000 del EME por Asegurado
proveedores y no proveedores del Plan separados
$1,000 del EME por Familia
$2,000 del EME por Familia
Coaseguro Máximo por Año Calendario (incluye el CYD) $3,000 del EME por Asegurado
$6,000 del EME por Asegurado
proveedores y no proveedores del Plan separados
$6,000 del EME por Familia
$12,000 del EME por Familia
Servicios cubiertos
Servicios del Médico
Consulta en consultorio de médico no especialista
Consulta en consultorio de médico especialista
Servicios de salud preventiva
Servicios de Hospital
Paciente internado
Paciente externo
Servicios Médicos Quirúrgicos
Instalación para pacientes internados
Instalación para pacientes externos
Consultorio medico
Anestesia
Centro de Atención Urgente
Servicios de Emergencia
Sala de emergencias
Médico de sala de emergencias
Ambulancia terrestre
(El asegurado es responsable de todas las cantidades
que exceden la cantidad de beneficio máximo aplicable
y las cantidades que exceden el pago del EME del plan
a proveedores que no son del plan. Dichas cantidades
no se aplican como parte del coaseguro máximo por año
calendario.)
Servicios de Diagnóstico
Exámenes de laboratorio de rutina
Radiografías de rutina
El asegurado paga
$35 por consulta
$35 por consulta
Sin cargo
El asegurado paga
Después del CYD el
asegurado paga el 40% del
EME más todos los cargos
que excedan el EME
Después del CYD, el asegurado
paga el 20% del EME
Después del CYD el asegurado
paga el 20% del EME
$50 por consulta
$150 por consulta
Después del CYD el asegurado
paga el 20% del EME
$150 por consulta
Después del CYD el asegurado
paga el 20% del EME mas todos
los cargos que excedan el EME
Después del CYD el asegurado
paga el 20% del EME
Después del CYD el asegurado
paga el 40% del EME mas todos
los cargos que excedan el EME
$35 por consulta
$35 por consulta
Después del CYD el
asegurado paga el 40% del
EME más todos los cargos
que excedan el EME
*EME (Gasto Médico Elegible) significa el monto máximo que el Plan pagará por un Servicio Cubierto de acuerdo con la Lista de Reembolsos
del Plan. Los máximos del seguro compartido por año calendario para proveedores que pertenecen al Plan y que no pertenecen al Plan son
separados y no son acumulables entre sí. Los cargos que exceden el EME de proveedores que no pertenecen al Plan pueden ser considerables y
no cuentan hacia el máximo del seguro compartido por año calendario. Este Plan incluye beneficios adicionales, exclusiones y limitaciones que
se indican en el Certificado de Cobertura de SHL, en la Lista de Beneficios del Anexo A Formulario No. SHL-Sierra2010-masBS-July2011HCR, Formulario No. SHL-GRP-HCR-ENDORSE(2011), y en las Cláusulas Adicionales correspondientes y en el Resumen de Divulgación.
Se pueden solicitar copias de estos documentos. Los documentos del plan regirán en la resolución de preguntas sobre beneficios o pagos.