Benefits Summaries & Orientation

Medical

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, household member and any children who are less than age twenty-six (26), or until age 27 (for GVSU Standard PPO Plan, HDHP/HSA and Dental), if the child is currently a full-time student in an accredited school. Your cost will depend upon the plan you select and the coverage you choose. 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.
    • A newborn child, adopted, or child placed for adoption will be covered if enrolled within the thirty-one (31) day period following birth, adoption, or adoption placement.
    • If coverage for a dependent (including new borns, adopted children, or children placed for adoption) is applied for more than thirty-one (31) days following the date that dependent becomes eligible for coverage, the dependent may only be able to enroll during the open enrollment/election period.
  • 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

The Personalized Benefits Program offers three different medical plans from which you may choose plus a "No Coverage" option for those who prefer to use another non-GVSU medical benefit plan. Grand Valley's medical plans provide coverage for hospital and surgical expenses, emergency medical care, laboratory and x-ray fees, prescription drugs, preventive health care, out-patient surgery, physicians office visits, secondary surgical opinions, mental health care, substance abuse treatment, and alternatives to in-hospital care. 

Medical coverage is effective upon employment. Eligible family members may be covered for a charge.  An annual cash credit is available to those who waive their medical coverage.

University paid coverage terminates on the final day of employment. However, you will be given the option to continue the plan at your cost for a designated period of time. 

The medical plan you select will remain in effect unless you have a major change in family status.
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.

The University will partially reimburse the cost of medical insurance for eligible retirees and their spouse. The amount reimbursed is determined by the retiree's years of service to the University. For additional information concerning Retirees Benefits, download the Retirement Benefits Summary.

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. Under "traditional" coordination of benefits, the secondary plan generally pays whatever the primary plan does not. The GVSU Standard PPO Plan -- and the HMOs, if approved procedures are maintained -- follow traditional coordination of benefits rules.

GVSU's Standard PPO Plan follows a "non-duplicating" method for the coordination of benefits, which applies whenever the Standard PPO Plan is the secondary plan for a claim. In such cases, the Standard PPO Plan will pay only the difference between what the primary plan pays and the amount the Standard PPO Plan would have paid if it had been the primary plan.

GVSU High Deductible Health Plan with HSA 

Priority Health administers the GVSU High Deductible Health Plan with HSA. This plan encourages you to use the Priority Health PPO network which is the primary network or, if traveling outside of the network, PHCS which is a secondary national network. Services including physician office visits, prescriptions, hospital, surgical, laboratory & x-ray fees, chemotherapy, physical therapy, etc. will be subject to an in-network annual deductible of $1,500 per person; $3,000 per family. Once the deductible has been met the plan covers 100% of eligible expenses.

Under the GVSU High Deductible Health Plan with HSA, you may go outside the Priority Health PPO network at any time. Outside the network, the plan provides coverage for 80% of eligible expenses for treatment of sickness or injury, after the annual deductible ($3,000 per person, $6,000 family maximum) is met. If your 20% annual share reaches the $2,000 out-of-pocket limit per person; $4,000 per family, the plan covers 100% of eligible expenses. The out-of-pocket limit does not include deductibles, co-pays or any amounts exceeding reasonable and customary. 

The Prescription drug benefit is a generic mandatory program. You will be given a generic equivalent for each drug if one exists. If you request a brand name drug when a generic equivalent exists, you must provide the pharmacist with a DAW (Dispense As Written) from the prescribing physician. If you request a brand name without a DAW and a generic equivalent exists, you will pay the cost differential between the generic and brand name. For more information on this plan see the Medical Plan Comparison Chart

GVSU Standard PPO Plan

Priority Health also administers the GVSU Standard PPO Plan. This plan encourages you to use the Priority Health PPO network which is the primary network or, if traveling outside of the network, PHCS which is a secondary national network. A $20 co-payment applies to Priority Health PPO network and PHCS physician's office visits. Other services including hospital, surgical, laboratory & x-ray fees, chemotherapy, physical therapy...etc. will be subject to an in-network annual deductible of $250 per person; $500 per family & then payable at 90%. If your 10% share reaches the $1,000 out-of-pocket limit per person; $2,000 per family, the plan covers 100% of eligible expenses. The out-of-pocket limit does not include deductibles, co-pays or any amounts exceeding reasonable and customary.

Under the GVSU Standard PPO Plan, you may go outside the Priority Health PPO network at any time. Outside the network, the plan provides coverage for 70% of eligible expenses for treatment of sickness or injury, after the annual deductible ($500 per person, $1000 family maximum) is met. If your 30% annual share reaches the $2,500 out-of-pocket limit per person; $5,000 per family, the plan covers 100% of eligible expenses. The out-of-pocket limit does not include deductibles, co-pays or any amounts exceeding reasonable and customary.

The Prescription drug benefit is a generic mandatory program, which requires a co-payment of $4 for generic, $20 for formulary drugs and $40 for name brand and specialty drugs. You will be given a generic equivalent for each drug if one exists. If you request a brand name drug when a generic equivalent exists, you must provide the pharmacist with a DAW (Dispense As Written) from the prescribing physician. If you request a brand name without a DAW and a generic equivalent exists, you will pay the cost differential between the generic and brand name plus the co-pay. For more information on this plan, please see the Medical Plan Comparison Chart.

Download the GVSU Standard PPO Medical Plan Summary Plan Description.

Priority Standard HMO Plan

The Priority Health Standard HMO Plan, Health Maintenance Organization (HMO), provides comprehensive care through its group of primary care physicians. Individuals covered under the plan must select a primary care physician from a directory of physicians. A current directory is available online at  www.priority-health.com . The primary care physician coordinates all of the individual's health care needs, including referral to a Priority Health Plan specialist if necessary. A $20 co-payment applies to Priority Health network physician's office visits. Other services including hospital, surgical, laboratory & x-ray fees, chemotherapy, physical therapy...etc. will be subject to the Priority Health network annual deductible of $250 per person; $500 per family & then payable at 90%. If your 10% share reaches the $1,000 out-of-pocket limit per person; $2,000 per family, the plan covers 100% of eligible expenses. The out-of-pocket limit does not include deductibles, co-pays or any amounts exceeding reasonable and customary.

The Prescription drug benefit is a generic mandatory program, which requires a co-payment of $4 for generic, $20 for formulary drugs and $40 for name brand and specialty drugs. You will be given a generic equivalent for each drug if one exists. If you request a brand name drug when a generic equivalent exists, you must provide the pharmacist with a DAW (Dispense As Written) from the prescribing physician. If you request a brand name without a DAW and a generic equivalent exists, you will pay the cost differential between the generic and brand name plus the co-pay. For more information on this plan see the Medical Plan Comparison Chart

Download the Priority Health Summary of Benefits.

No Coverage
If you have medical coverage through another non-GVSU plan, you may choose the "No Coverage" option, which enables you to opt out of all GVSU medical plans. 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.

If you and your spouse are employed by 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.

You may list each other as dependents for dental coverage, but you may not do so for medical coverage. If both you and your spouse want the optional vision coverage, only one person has to select this plan. 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 or one of your dependents become ineligible for other medical coverage during the year because of a status change, you have 30 days from the time of loss of coverage to enroll in any of the medical options available under GVSU's Personalized Benefits Program.

Choosing the Right Medical Option for You
As you make your decision about which medical plan is right for you, consider your needs and the needs of your family and your past medical expenses. Some people have few medical expenses, while others have routine or predictable expenses throughout the year. The plan you select will remain in effect until December 31. You may change your Single, Dual or Family Coverage selection if you have a major change in family status.

The following are some items to consider when determining which medical option is best for you:

-How often do you use your medical benefits? What kinds of expenses have you had in the past several years? 

-Are you expecting a child in the next year? Will your number of dependents decrease because a child is leaving home? 

-How much can you afford to pay each year in deductibles and co-payments? 

-Are your physicians affiliated with the PPO Network? 
Are you willing to change health care providers? 

compare each plan's annual deductible and out-of-pocket maximums. People who generally have few medical expenses may be willing to accept more financial responsibility when choosing a plan.

If your spouse has other coverage for you and your dependents compare both coverages carefully. Your spouse's medical benefits package may affect the plan and coverage you select.

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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