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HomeMy WebLinkAbout10-24-22-SWSAGENDA ITEMS 2023 Employee Benefits Discussion Dave Perrault, City Administrator MEMO.PDF ATTACHMENT A.PDF ATTACHMENT B.PDF ATTACHMENT C.PDF ATTACHMENT D.PDF ATTACHMENT E.PDF ATTACHMENT F.PDF COUNCIL/STAFF COMMENTS ADJOURN Mayor: David Grant Councilmembers: Brenda Holden Fran Holmes Steve Scott David Radziej Special City Council Work Session Agenda Monday, October 24, 2022 Immediately Following Economic Development Authority City Hall Address: 1245 W Highway 96 Arden Hills MN 55112 Phone: 651 -792 -7800 Website : www.cityofardenhills.org City Vision Arden Hills is a strong community that values its unique environmental setting, strong residential neighborhoods, vital business community, well -maintained infrastructure, fiscal soundness, and our long -standing tradition as a desirable City in which to live, work, and play. CALL TO ORDER 1. 1.A. Documents: 2. Page 1 of 2 AGENDA ITEM – 1A MEMORANDUM DATE: October 24, 2022 TO: Honorable Mayor and City Councilmembers FROM: Dave Perrault, City Administrator SUBJECT: Employee Benefit Discussion Budgeted Amount: Actual Amount: Funding Source: N/A N/A N/A For Council Consideration The City Council should consider providing direction on 2023 Employee Benefits selection. Background The City received notice regarding its benefit increases for 2023, the City’s current carrier PEIP is anticipating a 50 percent increase in its premiums (note, the union’s insurance is expecting a 6 or 7 percent increase). Following this news, the City requested its benefit consultant obtain quotes for other options in 2023. Below is a current break down of what the City pays and what the employee pays. Note, the below table does not reflect Union rates as they are on a different plan, per their contract they receive the same amounts as non-union employees. Their current premium is $1,345 and the City pays $1,216, leaving the union employee responsible for $130. Staff will need Council feedback on this to alert carriers of the decision and work the numbers into the draft budget. Page 2 of 2 The City received three quotes for insurance renewal with the least expensive being Health Partners; staff is also including an option to move all of staff onto the union’s plan. Below is a summary of the potential cost impacts associated with the different options (these cost impacts also include Dental Insurance which has a 4.1% increase). Attached are the breakdown of costs and contributions for each of the proposed options. To determine City contribution amounts for the “PEIP Renewal” option, staff used the breakdown we currently have in place. It should be noted that under the PEIP renewal option, the City share of the non-union premium is high enough that the union employees would not have an employee share. For the Health Partners option, it is similar in that single employees are covered for health and dental at 100% and families pay a flat fee of either $300 or $364 depending on the dental option they choose. For the 49er’s plan option, a proposed flat rate of $250 across the board for each employee. Lastly, if Health Partners is the option selected, another cost savings measure would be to allow employees that have coverage via a spouse, the option to waive City coverage. This would save the City the cost of the premium for that particular employee; it should be noted that other cities that offer this option may pay the employee a monthly lump sum (i.e. $300). The savings to the City is the difference between the lump sum and what the premium would have been. Budget Impact Any of the options presented will have a budget increase for 2023, the current draft budget for 2023 had a 6.5 percent increase over 2022 for health insurance and a 3.0 percent increase for dental insurance. Once direction is given, staff can work the numbers into the budget for discussion in November. Attachment Attachment A: Existing PEIP Information Attachment B: PEIP Renewal Information Attachment C: Health Partners with HSA Contribution Information Attachment D: Union (49er’s) Plan Information Attachment E: Health Partners Explanation of Benefits Attachment F: PEIP Explanation of Benefits Plan Type Monthly Basis Annual Difference to PEIP $ Increase Over 2022 % Increase Over 2022 PEIP Renewal 31,833 381,993 0 91,307 31% Health Partners 28,226 338,715 (43,278) 48,029 17% 49'ers Plan 31,592 379,104 (2,889) 88,418 30% 2022 PEIP 24,224 290,686.08 Summary of City Cost Non‐Union v. UnionCoverage Type Medical Premium Dental Premium Total Premium City Portion Premium Health Savings Cont. Total City Contribtuion Employee PremiumNon‐Union Single 710                               51                              760                         733                                        ‐                                      733                                          27                                     Non‐Union Single 557                               51                              608                         608                                       125                                     733                                           ‐                                    Non‐Union Single 787                               51                              838                         733                                        ‐                                      733                                          105                                   Non‐Union Family 1,441                            51                              1,492                      1,091                                    125                                     1,216                                       401                                   Non‐Union Family 1,441                            150                            1,591                      1,091                                    125                                     1,216                                       500                                   Non‐Union Single 710                               51                              760                         733                                        ‐                                      733                                          27                                     Non‐Union Single 557                               51                              608                         608                                       125                                     733                                           ‐                                    Non‐Union Single 557                               51                              608                         608                                       125                                     733                                           ‐                                    Non‐Union Family 2,055                            150                            2,205                      1,216                                     ‐                                      1,216                                       990                                   Non‐Union Single 557                               51                              608                         608                                        ‐                                      608                                           ‐                                    Non‐Union Family 1,441                            51                              1,492                      1,091                                    125                                     1,216                                       401                                   Non‐Union Single 557                               51                              608                         608                                       125                                     733                                           ‐                                    Non‐Union Single 787                               51                              838                         733                                        ‐                                      733                                          105                                   Non‐Union Family 1,441                            105                            1,547                      1,091                                    125                                     1,216                                       456                                   Non‐Union Single 557                               51                              608                         608                                       125                                     733                                           ‐                                    Union Family 1,345                             ‐                             1,345                      1,216                                     ‐                                      1,216                                       129                                   Union Family 1,345                             ‐                             1,345                      1,216                                     ‐                                      1,216                                       129                                   Union Family 1,345                             ‐                             1,345                      1,216                                     ‐                                      1,216                                       129                                   Union Family 1,345                             ‐                             1,345                      1,216                                     ‐                                      1,216                                       129                                   Union Family 1,345                             ‐                             1,345                      1,216                                     ‐                                      1,216                                       129                                   Union Family 1,345                             ‐                             1,345                      1,216                                     ‐                                      1,216                                       129                                   Union Family 1,345                             ‐                             1,345                      1,216                                     ‐                                      1,216                                       129                                   Union Family 1,345                             ‐                             1,345                      1,216                                     ‐                                      1,216                                       129                                   Union Family 1,527                             ‐                             1,527                      1,216                                     ‐                                      1,216                                       311                                   Total N/A26,446                         1,012                         27,457                   23,099                                  1,125                                  24,224                                    4,359                                PEIP Existing Non‐Union v. Union Coverage Type Medical Premium Dental Premium Total Premium City Portion Premium Health Savings Cont. Total City Contribtuion Employee PremiumNon‐Union Single 1,052                        53                          1,105                  1,001                               ‐                                1,001                                104                              Non‐Union Single 824                           53                          876                     876                                  125                               1,001                                 ‐                               Non‐Union Single 1,168                        53                          1,221                  1,001                               ‐                                1,001                                220                              Non‐Union Family 2,149                        53                          2,202                  1,626                              125                               1,751                                575                              Non‐Union Family 2,149                        156                        2,305                  1,626                              125                               1,751                                679                              Non‐Union Single 1,052                        53                          1,105                  1,001                               ‐                                1,001                                104                              Non‐Union Single 824                           53                          876                     876                                  125                               1,001                                 ‐                               Non‐Union Single 824                           53                          876                     876                                  125                               1,001                                 ‐                               Non‐Union Family 3,071                        156                        3,227                  1,751                               ‐                                1,751                                1,475                           Non‐Union Single 824                           53                          876                     876                                   ‐                                876                                      ‐                               Non‐Union Family 2,149                        53                          2,202                  1,626                              125                               1,751                                575                              Non‐Union Single 824                           53                          876                     876                                  125                               1,001                                 ‐                               Non‐Union Single 1,168                        53                          1,221                  1,001                               ‐                                1,001                                219                              Non‐Union Family 2,149                        156                        2,305                  1,626                              125                               1,751                                679                              Non‐Union Single 824                           53                          876                     876                                  125                               1,001                                 ‐                               Union Family 1,445                         ‐                         1,445                  1,445                               ‐                                1,445                                 ‐                               Union Family 1,445                         ‐                         1,445                  1,445                               ‐                                1,445                                 ‐                               Union Family 1,445                         ‐                         1,445                  1,445                               ‐                                1,445                                 ‐                               Union Family 1,445                         ‐                         1,445                  1,445                               ‐                                1,445                                 ‐                               Union Family 1,445                         ‐                         1,445                  1,445                               ‐                                1,445                                 ‐                               Union Family 1,445                         ‐                         1,445                  1,445                               ‐                                1,445                                 ‐                               Union Family 1,445                         ‐                         1,445                  1,445                               ‐                                1,445                                 ‐                               Union Family 1,445                         ‐                         1,445                  1,445                               ‐                                1,445                                 ‐                               Union Family 1,627                         ‐                         1,627                  1,627                               ‐                                1,627                                 ‐                               Total N/A 34,237                     1,100                     35,337               30,708                            1,125                            31,833                              4,629                           PEIP Renewal  Non‐Union v. Union Coverage Type Medical Premium Dental Premium Total Premium City Premium Health Savings Cont. Total City Contribtuion Employee PremiumNon‐Union Single 410                           53                           463                     463                   125                                588                                    Non‐Union Single 952                           53                           1,005                  1,005                125                                1,130                                 Non‐Union Single 910                           53                           963                     963                   125                                1,088                                 Non‐Union Family 1,410                        53                           1,462                  1,162                125                                1,287                                 300                               Non‐Union Family 2,091                        117                        2,208                  1,844                125                                1,969                                 364                               Non‐Union Single 541                           53                           594                     594                   125                                719                                    Non‐Union Single 995                           53                           1,048                  1,048                125                                1,173                                 Non‐Union Single 502                           53                           555                     555                   125                                680                                    Non‐Union Family 1,864                        117                        1,981                  1,617                125                                1,742                                 364                               Non‐Union Single 696                           53                           749                     749                   125                                874                                    Non‐Union Family 1,335                        53                           1,388                  1,088                125                                1,213                                 300                               Non‐Union Single 1,173                        53                           1,226                  1,226                125                                1,351                                 Non‐Union Single 1,063                        53                           1,115                  1,115                125                                1,240                                 Non‐Union Family 1,004                        117                        1,121                  757                   125                                882                                    364                               Non‐Union Single 502                           53                           555                     555                   125                                680                                    Union Family 1,445                         ‐                         1,445                  1,270                 ‐                                 1,270                                 175                               Union Family 1,445                         ‐                         1,445                  1,270                 ‐                                 1,270                                 175                               Union Family 1,445                         ‐                         1,445                  1,270                 ‐                                 1,270                                 175                               Union Family 1,445                         ‐                         1,445                  1,270                 ‐                                 1,270                                 175                               Union Family 1,445                         ‐                         1,445                  1,270                 ‐                                 1,270                                 175                               Union Family 1,445                         ‐                         1,445                  1,270                 ‐                                 1,270                                 175                               Union Family 1,445                         ‐                         1,445                  1,270                 ‐                                 1,270                                 175                               Union Family 1,445                         ‐                         1,445                  1,270                 ‐                                 1,270                                 175                               Union Family 1,627                         ‐                         1,627                  1,452                 ‐                                 1,452                                 175                               Total N/A 28,635                     983                        29,618                26,351              1,875                             28,226                               3,267                           HP Renewal with Health Savings Contribution  Non‐Union v. Union Coverage Type Medical Premium City Premium Employee PremiumNon‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Non‐Union Family 1,627                        1,377                250Union Family 1,445                        1,195                250Union Family 1,445                        1,195                250Union Family 1,445                        1,195                250Union Family 1,445                        1,195                250Union Family 1,445                        1,195                250Union Family 1,445                        1,195                250Union Family 1,445                        1,195                250Union Family 1,445                        1,195                250Union Family 1,627                        1,377                250Total N/A 37,592                      31,592              6,000                            49er's Plan  Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services HealthPartners:$2400-100% HSA Gold SE Open Access Coverage for: Single/Family | Plan Type: PPO 1 of 6 PSBC-SL313-230101-E 79888MN0250142-00 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-883-2177 or visit us at www.healthpartners.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment , deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc -glossary or call 1-800-883-2177 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? In-network: $2,400 Individual/ $4,800 Family Out-of -network: $10,000 Individual/ $20,000 Family Generally, you must pay all of the costs from providers up to the deductible, amount before this plan begins to pay. If you have other family members on the plan, the overall family deductible must be met before the plan begins to pay. Are there services covered before you meet your deductible? Yes,some preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible. amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive s ervices without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? There are no other specific deductibles. You don't have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-network medical/pharmacy: $2,400 Individual/$4,800 Family Out-of -network medical/pharmacy: $30,000 Individual/$60,000 Family The out -of -pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out -of -pocket limit must be met. Coverage beginning on or after 1/1/2023 2 of 6 Important Questions Answers Why This Matters: What is not included in the out-of-pocket limit? Premium, balance-billed charges (unless balanced billing is prohibited), and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out -of -pocket limit . Will you pay less if you use a network provider? Yes. See www.healthpartners.com/openaccess or call 1-800-883-2177 for a list of in- network providers . This plan uses a provider network . You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out -of -network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out -of - network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No You can see the in-network specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, and Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness Primary Office Visit: 0% coins urance Convenience Care: 0% coinsurance Virtuwell: 0% coinsurance Primary Office Visit: 50% coinsurance Convenience Care: 50% coinsurance None Specialist visit 0% coinsurance 50% coinsurance None Preventive care/screening/ immunization No charge 50% coinsurance You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x -ray, blood work) 0% coinsurance 50% coinsurance None Imaging (CT/PET scans, MRIs) 0% coinsurance 50% coinsurance None 3 of 6 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, and Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at healthpartners.com/preferredrx Generic drugs Formulary: 0% coinsurance Non-formulary: Not covered Formulary: 50% coinsurance at retail, mail not covered Non-formulary: Not covered at retail, mail not covered 31 day supply retail / 93 day supply mail order. Non-formulary drugs are not covered unless an exception is granted. Formulary insulin covered with no member cost - sharing after a $25 benefit cap per prescription per month. Any amounts paid or reimbursed by a third party, including but not limited to: point of service rebates, manufacturer coupons, manufacturer debit cards or other forms of direct reimbursement to an insured for a product or service, will not apply towards deductible and/or out -of -pocket maximum. USPSTF A and B recommended preventive drugs obtained with a prescription, including OTC drugs, are covered with no member cost sharing. Formulary brand drugs 0% coinsurance 50% coinsurance at retail, mail not covered Non-formulary brand drugs Not covered Not covered at retail, mail not covered Specialty drugs 0% coinsurance Not covered Specialty drugs are limited to drugs on the specialty drug list and must be obtained from a designated vendor. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance 50% coinsurance None Physician/surgeon fees 0% coinsurance 50% coinsurance None If you need immediate medical attention Emergency room care 0% coinsurance 0% coinsurance Out-of -network services apply to the in-network deductible. Emergency medical transportation 0% coinsurance 0% coinsurance Out-of -network services apply to the in-network deductible. Urgent care 0% coinsurance 0% coinsurance Out-of -Network services apply to the in-network deductible. If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance 50% coinsurance None Physician/surgeon fees 0% coinsurance 50% coinsurance None Outpatient services 0% coinsurance 50% coinsurance None 4 of 6 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, and Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need mental health, behavioral health, or substance abuse needs Inpatient services 0% coinsurance 50% coinsurance None If you are pregnant Office visits No charge 50% coinsurance Depending on the type of services, a copayment, coinsurance, or deductible may apply. Childbirth/delivery professional services 0% coinsurance 50% coinsurance None Childbirth/delivery facility services 0% coinsurance 50% coinsurance None If you need help recovering or have other special health needs Home health care 0% coinsurance 50% coinsurance 120 visits per calendar year Rehabilitation services 0% coinsurance 50% coinsurance None Habilitation services 0% coinsurance 50% coinsurance None Skilled nursing care 0% coinsurance 50% coinsurance 120 days per calendar year Durable medical equipment 0% coinsurance 50% coinsurance None Hospice services 0% coinsurance 50% coinsurance Respite care is limited to 5 days per episode and respite care and continuous care combined are limited to 30 days per episode . If your child needs dental or eye care Children’s eye exam No charge 50% coinsurance None Children’s glasses 0% coinsurance Not covered Limited to one pair of eyeglasses (lenses and frames) or one pair of contact lenses per calendar year. Children’s dental check -up No charge 50% coinsurance None 5 of 6 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Long-term care • Routine foot care • Bariatric surgery • Non-emergency care when traveling outside the U.S. • Weight loss programs • Cosmetic surgery with the exception of port wine stain removal and reconstructive surgery • Non-formulary drugs without a formulary exception • • Infertility treatment • Private-duty nursing • Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care • Hearing aids • • Dental care (Children) • Routine eye care (Adult) • Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Your plan at 1-800-883-2177, the Department of Labor’s Employee Benefits Security Administration at 1 -866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform or MN Dept of Health at 651-201-5100 / 1-800-657-3916.Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.mnsure.org or call 1-855-366-7873. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Your plan at 1-800-883-2177, the Department of Labor’s Employee Benefits Security Administration at 1 -866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform or MN Dept of Health at 651-201-5100 / 1-800-657-3916. Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plan, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1 -866-398-9119. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-883-2177. Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-883-2177. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1 -800-883-2177. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– 6 of 6 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles , copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans . Please note these coverage examples are based on self -only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $2,400 ◼ The plan’s overall deductible $2,400 ◼ The plan’s overall deductible $2,400 ◼ Specialist coinsurance 0% ◼ Specialist coinsurance 0% ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% ◼ Other coinsurance 0% ◼ Other coinsurance 0% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $2,400 Deductibles $2,400 Deductibles $2,400 Copayments $0 Copayments $0 Copayments $0 Coinsurance $0 Coinsurance $0 Coinsurance $0 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $70 Limits or exclusions $20 Limits or exclusions $0 The total Peg would pay is $2,470 The total Joe would pay is $2,420 The total Mia would pay is $2,400 09/21 Minnesota Public Employees Insurance Program (PEIP) Advantage Health Plan 2022 - 2023 Benefits Schedule - HSA Compatible Benefit Provision Cost Level 1 – You Pay Cost Level 2 – You Pay Cost Level 3 – You Pay Cost Level 4 – You Pay A. Preventive Care Services • Routine medical exams, cancer screening • Child health preventive services, routine immunizations • Prenatal and postnatal care and exams • Adult immunizations • Routine eye and hearing exams Nothing Nothing Nothing Nothing B. Annual First Dollar Deductible * Combined Medical/Pharmacy (single coverage) Combined Medical/Pharmacy (family coverage) $1,500 $2,000 $3,000 $4,000 $2,800 per family member $3,000 per family $3,200 per family member $4,000 per family $4,800 per family member $6,000 per family $6,400 per family member $8,000 per family C. Office visits for Illness/Injury, for Outpatient Physical, Occupational or Speech Therapy, and Urgent Care • Outpatient visits in a physician’s office • Chiropractic services • Outpatient mental health and chemical dependency • Urgent Care clinic visits (in & out of network) $45 copay per visit annual deductible applies $55 copay per visit annual deductible applies $105 copay per visit annual deductible applies $130 copay per visit annual deductible applies D. Network Convenience Clinics & Online Care $0 copay annual deductible applies $0 copay annual deductible applies $0 copay annual deductible applies $0 copay annual deductible applies E. Emergency Care (in or out of network) • Emergency care received in a hospital emergency room $250 copay annual deductible applies $300 copay annual deductible applies $350 copay annual deductible applies $600 copay annual deductible applies F. Inpatient Hospital Copay $400 copay annual deductible applies $650 copay annual deductible applies $1,500 copay annual deductible applies 50% coinsurance annual deductible applies G. Outpatient Surgery Copay $250 copay annual deductible applies $400 copay annual deductible applies $800 copay annual deductible applies 50% coinsurance annual deductible applies H. Hospice and Skilled Nursing Facility Nothing after annual deductible Nothing after annual deductible Nothing after annual deductible Nothing after annual deductible I. Prosthetics and Durable Medical Equipment 20% coinsurance annual deductible applies 25% coinsurance annual deductible applies 30% coinsurance annual deductible applies 50% coinsurance annual deductible applies J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments) 20% coinsurance annual deductible applies 25% coinsurance annual deductible applies 30% coinsurance annual deductible applies 50% coinsurance annual deductible applies K. MRI/CT Scans 20% coinsurance annual deductible applies 25% coinsurance annual deductible applies 30% coinsurance annual deductible applies 50% coinsurance annual deductible applies L. Other expenses not covered in A – K above, including but not limited to: • Ambulance • Home Health Care • Outpatient Hospital Services (non-surgical) • Radiation/chemotherapy • Dialysis • Day treatment for mental health and chemical dependency • Other diagnostic or treatment related outpatient services 20% coinsurance annual deductible applies 25% coinsurance annual deductible applies 30% coinsurance annual deductible applies 50% coinsurance annual deductible applies M. Prescription Drugs 30-day supply of Tier 1, Tier 2, or Tier 3 prescription drugs, including insulin; or a 3-cycle supply of oral contraceptives. $30 tier one $50 tier two $75 tier three annual deductible applies $30 tier one $50 tier two $75 tier three annual deductible applies $30 tier one $50 tier two $75 tier three annual deductible applies $30 tier one $50 tier two $75 tier three annual deductible applies N. Plan Maximum Out-of-Pocket Expense** (including prescription drugs) Single Coverage Family Coverage $3,000 $3,000 $4,000 $5,000 $5,000 per family member $6,000 per family $5,000 per family member $6,000 per family $6,900 per family member $8,000 per family $6,900 per family member $10,000 per family Emergency care or urgent care at a hospital emergency room or urgent care center out of the plan’s service area or out of net work is covered as described in sections C and E above. This chart applies only to in-network coverage. Point of Service coverage is available only to members whose permanent residence is both outside the State of Minne sota and the Advantage Plan’s service area. This category includes employees temporarily residing outside Minnesota on temporary as signment or paid leave [including sabbatical leaves] and college students. It is also available to dependent children and spo uses permanently residing outside the service area. Members pay a $1,500 single or $3,000 family deductible (separate and distinct from the deductibles listed in section B above) and 30% coinsurance that will apply to the out-of-pocket maximums described in section N above. Members pay the drug copayment described at section M above to the out -of-pocket maximum described at section N. This benefit must be requested. The PEIP Advantage Plans offer a standard set of benefits regardless of the selected carrier. There are some differences in t he way each carrier administers the benefits, including the transplant benefits, in the referral and diagnosis coding patterns of primary care clinics, and in the definition of Allowed Amount. *The family Deductible is the maximum amount that a family has to pay in deductible expenses in any one calendar year. The family Deductible is not the amount of expenses a family must incur before any family member can receive benefits. Individual family members only need to satisfy their individua l deductible once to be eligible for benefits. Once the family Deductible has been met, deductible expenses for the family ar e waived for the balance of the year. **The family Out-of-Pocket Maximum is the maximum amount that a family has to pay in any one calendar year. The per-family member embedded Out-of-Pocket Maximum is the maximum amount that a family has to pay in any one calendar year on behalf of any individual family member.