2021 City of Hutchinson Benefit Guide FINAL - 11-20-20

6 Medical Comparison The City of Hutchinson offers two plans to choose from, a traditional PPO medical plan and a Qualified High Deductible plan that can be paired with a Health Savings Account (HSA). • Meritain is our Third Party Administrator (TPA) for claims processing. Both plans are PPO plans. This means that you have a network of providers that you are encouraged to use for a deeper discount. However, if you see an out-of-network provider, you will pay higher out-of-pocket costs. Aetna Choice POS II is our network. • You are not required to designate a primary care physician (PCP) and do not have to receive a referral to see a specialist. • To locate a network provider, please visi t www.aetna.com/docfind/custom/mymeritain or call 800-343-3140 . Provider Network: Aetna Choice POS II $1,250 deductible Group #: 16569 Qualified High Deductible Health Plan (QHDHP) Group #: 16569 In-NetworkBenefits Out-of-Network Benefits In-NetworkBenefits Out-of-Network Benefits Annual Deductible Individual $1,250 $1,250 $3,000 $3,000 Family $2,500 $2,500 $6,000 $6,000 Coinsurance 80% 60% 100% after Deductible 80% after Deductible MaximumOut-of-Pocket Individual $4,000 $8,000 $3,000 $6,000 Family $8,000 $16,000 $6,000 $12,000 Physician Office Visit Primary Care $20 copay Deductible 60% Deductible/100% Deductible/80% Specialty Care $40 copay Deductible 60% Deductible/100% Deductible/80% Teladoc – see page 7 24/7/365 access $0 Copay $40 charge Preventive Care Adult Periodic Exams 100% Deductible/60% 100% Deductible/80% Well-Child Care 100% Deductible/60% 100% Deductible/80% Diagnostic Services X-ray and Lab Tests Deductible/80% unless part of office visit in physician's office and billed as part of the office visit Deductible/60% Deductible/100% Deductible/80% Complex Radiology Deductible/80% Deductible/60% Deductible/100% Deductible/80% Urgent Care Facility $50 copay Deductible/60% Deductible/100% Deductible/80% Emergency Room Facility Charges $200 copay Deductible/80% Paid at the participating provider level of benefits. Deductible/100% Paid at Participating Provider level of benefits. Non-Emergency Medical Conditions NOT covered Inpatient Facility Charges Deductible/80% Deductible/60% Deductible/100% Deductible/80% Outpatient Facility and Surgical Charges Deductible/80% Deductible/60% Deductible/100% Deductible/80%