A Brief Glossary of Terms
Health care coverage plans use several terms to describe costs associated with the plans.
Deductible: the amount you are required to pay before your plan covers any major medical benefits per year.
Eligible dependent: a spouse and any unmarried children who are less than age nineteen (19). You may continue coverage for a child less than age twenty-seven (27) in the GVSU Flexible Medical Plan, Dental Plan and until age twenty-five (25) for Eyemed Vision coverage, if the child is currently a full-time student in an accredited school. Physically or mentally handicapped children may be covered regardless of their age. The term children includes your natural children, adopted children, or children placed for adoption, stepchildren who live with you, or children for whom you are the legal guardian and who live with you.
Co-payment: the amount you are required to pay each visit in sharing eligible expenses with the plan. Co-payments are usually a set amount or a percentage. The plan pays the remainder.
Annual out-of-pocket expense limit: the maximum medical expense you would have to pay per year, after which the plan pays 100% of most eligible expenses for the rest of the year. The out-of-pocket limit does not include deductibles, co-pays or any amounts exceeding reasonable and customary.
Reasonable and Customary
All of the medical plan options contain "reasonable and customary" language, which means that eligible medical expenses will be covered up to the reasonable and customary amount. A reasonable and customary ("R & C") charge will be the usual charge made by a physician or supplier of services, medicines, or supplies and will not exceed the general level of charges made by others rendering or furnishing such services, medicines, or supplies within the area in which the charge is incurred for the illness or injury being treated. The term "area" as it would apply to any particular service, medicine, or supply means a county or such greater areas as is necessary to obtain a representative cross section of the level of charges.
You will incur out-of-pocket costs only for amounts exceeding the reasonable and customary rates for services obtained outside of the appropriate network: PPO, Delta Dental and/or Eyemed Vision.
Medical Benefits Summary
Download the Medical Plan Comparison Chart.
Medical BenefitsWeyco, Inc. administers the Base PPO Medical Plan. This plan also encourages you to use the PPO network. Eligible expenses for treatment received from a PPO provider, including preventive care up to $400 per year, is covered at 100%. A $20 co-payment applies to physicians' office visits.
Under the Base Medical Plan, you also maintain the freedom to go outside the PPO network at any time. Outside the network, the plan provides coverage for 80% of eligible expenses for treatment of sickness or injury, as well as preventive health care, after the annual deductible ($300 per person, $600 family maximum) is met. If your 20% annual share reaches the $2,500 per person or $5,000 family "out-of-pocket" limit, the plan covers 100% of eligible expenses. Expenses over reasonable and customary do not count toward your "out-of-pocket" limit. However, physicians' office visits are always covered in full after the $25 co-payment is met; the deductible does not apply to office visits.
Prescription drug coverage requires a co-payment of $7 for generic equivalents, $15 for formulary drugs, and $25 for name-brand drugs. When you use the mail order program, which provides up to a 90-day prescription supply, a one month co-payment applies. Please refer to your enrollment form to determine the cost of coverage under this plan.
Download the GVSU Base PPO Medical Plan Summary Plan Description.
Human Resources must be notified within 30 days if a dependent, who is covered under your policy, becomes ineligible for any reason (e.g., divorce, marriage of child, or student status changes). Ineligible dependents will be given the option to continue the policy at their cost for a designated period of time.
Get the Qualified Events Chart for a list of Qualifying events for Mid-year Election Changes.
If you have medical coverage through another non-GVSU plan, you may choose the "No Coverage" option, which enables you to opt out of the GVSU Base PPO Medical Plan. To be eligible for the No Coverage option, you must provide proof of coverage under the other plan by completing the "Verification of Other Coverage-Medical" during enrollment.
Individuals who select the No Coverage option will receive a $750 cash credit annually, to be used for the purchase of other benefits or to be added to their paychecks as taxable income.
If you and your spouse work at GVSU as regular faculty or staff, both of you must enroll in a medical plan. If you choose "no coverage" under your medical plan, you must be covered on your spouse's plan and you will not receive the medical credit for waiving coverage.
Coordination of Benefits In Cases of Double Coverage
If you or a dependent are also covered under another non-GVSU group medical plan, one of the plans is deemed "primary," and the other, "secondary." The primary plan pays benefits first and the secondary plan provides payment after that. A plan is always primary if it covers you as the employee. If a dependent is covered under two plans, the plan of the parent whose birthday is earlier in the calendar year will be primary.
GVSU's Base PPO Medical Plan (BMP) follows a "non-duplicating" method for the coordination of benefits, which applies whenever the BMP is the secondary plan for a claim. In such cases, the BMP will pay only the difference between what the primary plan pays and the amount the BMP would have paid if it had been the primary plan.
Automobile Accident Coverage
The Base PPO Medical Plan also excludes coverage for injuries incurred in an automobile accident. "No-fault" coverage under your automobile insurance policy provides unlimited lifetime coverage for injuries incurred in an automobile accident. However, some automobile insurance companies provide a small discount if your auto insurance policy is secondary to your employer's medical plan for such injuries. Check with your auto insurance agent to make sure your auto insurance provides "full" medical coverage if you enroll in the Base PPO Medical Plan.
Women's Health and Cancer Rights Act
Notice of Breast Reconstruction Benefits
All of GVSU's medical plans provide breast reconstruction benefits. Any participant or beneficiary receiving benefits in connection with a mastectomy may elect coverage for:
-Reconstruction of the breast on which the mastectomy has been performed
-Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
-Prosthesis and treatment of physical complication at all stages of mastectomy, including lymphedemas.
Appropriate treatments will be determined by consultations between the attending physician and the patient. Plan coverage is subject to the annual deductibles and co-insurance provisions that apply to other similar medical treatments.
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