Healthcare Plans (put name of each plan offered in separate column) 1) 2) 3) Name of plan Plan Type (EPO, HMO, PPO, POS) Does plan require you to choose primary care physician Yes Yes Yes □ □ □ (PCP)? No No No □ □ □ If so, is your current primary care physician in network? Yes Yes Yes □ □ □ No No No □ □ □ Premium (this can be monthly, annually or per pay period) $ $ $ Financial (deductable/coinsurance/annual limits) Note: Some services are covered before deductible is met Deductible: Individual $ $ $ Family $ $ $ Maximum out-of-pocket $ $ $ Individual Family $ $ $ Co-Insurance out-of-pocket (i.e. 90/10, 80/20, 70/30) – / / / Is the deductible included in the out-of-pocket? Yes No Yes No Yes No □ □ □ □ □ □ Does the plan have annual max? (for all group plans and new individual policies issued after 3/23/2010, the ACA Yes Yes Yes □ □ □ restricts and phases out annual limits; the limit for 2012 is No No No □ □ □ $1.25 million, unless the plan received a waiver) If so, what is the limit? $ $ $ Does the plan have life time max? (no plan may impose a lifetime maximum on benefits that Yes Yes Yes □ □ □ are considered essential) No No No □ □ □ If so, what is the limit? $ $ $ (Worksheet continued on next page) Preventive Care Co-Pay (For a complete list of preventive services for which there is no co-pay allowed
Healthcare Plans (put name of each plan offered in separate column) Name of plan 1) 2) 3) Plan Type (EPO, HMO, PPO, POS) Does plan require you to choose primary care physician Yes □ Yes □ Yes □ (PCP)? No □ No □ No □ If so, is your current primary care physician in network? □ □ □ Yes Yes Yes No □ No □ No □ Premium (this can be monthly, annually or per pay period) $ $ $ Financial (deductable/coinsurance/annual limits) Note: Some services are covered before deductible is met Deductible: $ $ $ Individual Family $ $ $ Maximum out-of-pocket $ $ $ Individual $ $ $ Family Co-Insurance – out-of-pocket (i.e. 90/10, 80/20, 70/30) / / / Is the deductible included in the out-of-pocket? Yes □ No □ Yes □ No □ Yes □ No □ Does the plan have annual max? (for all group plans and new individual policies issued after 3/23/2010, the ACA restricts and phases out annual limits; the limit for 2012 is $1.25 million, unless the plan received a waiver) Yes □ Yes □ Yes □ No □ No □ No □ If so, what is the limit? $ $ $ Does the plan have life time max? Yes □ Yes □ Yes □ (no plan may impose a lifetime maximum on benefits that are considered essential) No □ No □ No □ If so, what is the limit? $ $ $ (Worksheet continued on next page) Preventive Care Co-Pay (For a complete list of preventive services for which there is no co-pay allowed
IDF-Toolkit-10-3-122.docx