Health Insurance
Employees may enroll in
either the PPO or the HMO plan—premiums are the same for each. Premiums are
payroll deducted on a pre-tax basis unless a request is made during open
enrollment for after-tax status.
State Employees’ PPO Plan
The State Employees' PPO Plan uses a Preferred
Patient Care (PPC) organization and provides worldwide coverage. A
"self-insured plan," the State Employees' PPO Plan functions so that
claims it pays each year on behalf of its members determine the amount of
premiums necessary to keep the plan financially sound. Blue Cross/Blue Shield
of Florida is the servicing agent for the State Employees' PPO Plan. Its
responsibilities include health claims processing, customer service,
utilization review, and providing a preferred patient care organization for
enrollees. Health insurance premiums are payroll deducted on a pre-tax basis
unless a request is made by the employee each year during the fall open
enrollment period for after-tax status.
Blue Cross/Blue Shield of
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Biweekly |
Employee: $25.00 |
Family: $90 |
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Deductible** |
PPC: |
Non-PPC: |
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Co-Pay |
Network
Primary Care: $15/visit |
Network
Specialist: $25/visit |
Non-Network: 40 percent of allowance, plus difference |
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Coverages |
PPC coverage area: |
Non-PPC coverage area: Worldwide |
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Comment |
A six-month pre-existing
condition provision applies. For a comparison of PPC/Non-PPC co-payments
and deductibles. Please direct questions regarding specific procedures to
Blue Cross Blue Shield of Florida at 1-800-825-2583. |
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* Employees whose full-time equivalency (FTE)
is not 1.00 should contact University Benefits for exact premium amounts.
**Physician’s office visits are not subject to the calendar-year deductible.
Eligible dependents include your spouse; your
unmarried children; children placed in your home for the purpose of adoption in
accordance with Chapter 63, F. S.; stepchildren you can claim as an exemption
on your federal income tax return; any children for whom you have established
legal guardianship pursuant to Chapter 744, F.S.; foster children; or any other
unmarried children for whom you have been granted court ordered temporary or
other custody.
All such children must be unmarried and under age 19. If between age 19 and the
end of the calendar year in which the child turns age 25, the child must be
unmarried and meet the following criteria to be eligible: dependent on you for
financial support and either lives with you or is a full- or part-time student.
Eligibility may also be extended, upon approval by the plan, beyond the
limiting age for children who are disabled if the child was included as a
dependent at the time of initial enrollment of the employee. Newborn children of
an eligible child are eligible for coverage for up to 18 months after birth.
Preferred Patient Care (PPC) Network is the
trademark name for the Blue Cross and Blue Shield of Florida’s preferred
provider organization. PPC providers have agreed to charge no more than a
negotiated, pre-set allowance for all covered services. That allowance is
generally lower than the provider’s normal charge, and the provider cannot bill
you more than that amount. With a non-PPC provider, you are subject to higher
basic charges plus the difference between what that plan will pay the provider
and what the provider charges. It’s to your advantage to use PPC providers. A copy of the PPC Provider Directory for your
area can be reviewed at University Benefits or your human resources satellite
office.
A
pre-existing condition under this health insurance plan is any condition for
which you or your eligible dependents received medical advice or treatment
within six months of:
Pre-existing
conditions do not include covered services related to domestic violence,
pregnancy, or medical treatment of a newborn or newly adopted child of a
covered employee or dependent, as long as the child is enrolled in this health
insurance plan within 31 days of its birth, adoption, or placement for adoption.This plan does not pay benefits for pre-existing
conditions that would otherwise be considered a covered service until:
Participants of the State Employees' PPO Plan are covered under the Prescription Drug Program. Caremark Inc. is the state prescription drug provider.
Generic |
30 day $10 90 day $20 |
Preferred Brand |
30 day $25 90 day $50 |
Non-Preferred brand |
30 day $25 90 day $50 |
The
State Employees' PPO and the Health Investor PPO reimburse you for 100% of the
allowed amounts for specific preventive care services and immunizations. If you
use a non-network provider, preventive care expenses are subject to the
deductible and coinsurance, and you are responsible for any amounts above the
non-network maximum allowable payment. With the exception of mammograms, other
preventive care services and immunization benefits are available through the PPOs without a deductible. As a covered benefit, network
and non-network costs are associated with mammograms and deductibles do apply.
For more information on standards for preventative care, visit the DMS web center.
|
COBRA |
Individual $436.42 |
Family $986.96 |
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Retirees |
Individual
$427.86 |
Family
$967.60 |
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Medicare |
I: $227.18 |
|
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II:
$655.04 |
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III:
$454.36 |
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Each HMO is a self-administered, prepaid, direct-service health plan that provides services to people who live or work within the HMO’s service area. Health insurance premiums are payroll deducted on a pre-tax basis unless a request is made by the employee each year during the fall open enrollment period for after-tax status.
|
Biweekly |
Employee: $25.00 |
Family: $90.00 |
|
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Deductible |
None |
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Co-Pay |
PCP
Office visit: $15 |
Specialist: $25 |
Inpatient
hospital charge: $250 |
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Coverages |
Regional
coverage area. If outside of coverage area, must be life or limb threatening.
See summary below. |
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Comment |
No
pre-existing condition provision. Review our list of participating
HMOs, which
includes phone numbers and co-payment schedule. |
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* Employees whose full-time
equivalency (FTE) is not 1.00 should contact University Benefits and Retirement
for exact premium amounts.Most HMOs provide limited
or no coverage for services outside their service areas except in the case of
life or limb threatening emergencies. It is important to understand the HMO’s
policy, especially if any covered dependents do not live in the service area.
However, HMOs serving employees in more than one service area will provide
coverage to dependents residing in a different county if it is part of the
HMO’s service area.Since HMOs emphasize early
detection and treatment of illness to reduce expensive and inconvenient
hospital stays, they tend to offer a range of benefits that may include
preventive health care and additional services.
Primary Care Physician (PCP)
Some HMOs, but not all, may require participants to select a primary care
physician, or PCP, from those in the HMO’s provider network. Be sure to check
with your HMO provider first before scheduling an appointment. The PCP will
authorize all medical care including referrals to specialists and hospital
admissions. Participants will not be allowed to refer themselves to a
specialist or hospital.PCPs and other medical service
providers will vary among HMOs. Employees may contact the HMO and request a
provider list to review the contracted physicians. When selecting a plan,
employees should remember that the selection should not be made because of a
particular physician. If the physician decides to discontinue association with
the plan or the contract is not renewed, participants will need to choose a new
PCP from the provider network.
|
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PPO |
HMO |
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Biweekly |
$7.50
(individual) |
$7.50
(individual) |
|
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Deductible |
In network |
Non-network |
In network only |
|
$1,250
(individual) |
$2,500
(individual) |
$1,250 |
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Annual out-of-pocket maximum |
$3,000 (individual) |
$7,500 (individual) |
$3,000 (individual) |
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What you pay for care received after deductible: |
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Office Visits |
20% |
substantially higher costs |
20% |
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Coinsurance |
20% medical care in network |
20% medical
care |
|
|
|
20% |
substantially higher costs |
20% |
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Prescription Drugs |
- 30% generic and brand prescription drug* |
- 30% generic and brand* |
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Health Savings
Account and Limited Medical Reimbursement Account available plans for
employees electing Health Investor Plan |
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Health Savings |
Account
owned by the employee where contributions to the account can be used to pay
for additional medical expenses. The employee can make contributions to the
account on a pre-tax basis, and the state will contribute $41.66 per month
for individual coverage (or $83.33 for family coverage). The
HSA earns interest and can be carried over from one year to the next. The HSA
is also portable, meaning that the account is still owned by the employee
after termination of employment. |
*
Employees whose full-time equivalency (FTE) is not 1.00 should contact
University Benefits for exact premium amounts.
**Physician’s office visits are not subject to the calendar-year deductible.
***Employees with spouses who work for a state government agency (including the
|
Biweekly premium* |
Two full-time employees (both have 1.00 FTE) One part-time employee (.50 FTE)* and one full-time employee (1.00
FTE) |
A pre-existing condition under this health
insurance plan is any condition for which you or your eligible dependents
received medical advice or treatment within six months of:
Pre-existing conditions do
not include covered services related to domestic violence, pregnancy, or
medical treatment of a newborn or newly adopted child of a covered employee or
dependent, as long as the child is enrolled in this health insurance plan
within 31 days of its birth, adoption, or placement for adoption. This plan
does not pay benefits for pre-existing conditions that would otherwise be
considered a covered service until: