4 Medical Benefits The City of Hutchinson offers two plans to choose form, a Traditional PPO medical plan and a Qualified High Deductible plan that can be paired with a Health Savings Account (HSA). • Meritain is City of Hutchinson’s 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-ofnetwork provider, you will pay higher out-of-pocket costs. • Our Network is Aetna Choice POS II • 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 visit www.aetna.com/docfind/custom/mymeritain or call 800-343-3140. • Benefit Coverage Meritain Health (TPA) $1,250 deductible 16569 Meritain Health (TPA) $3,000 Deductible HDHP 16569 In-Network Benefits Out-of-Network Benefits In-Network Benefits 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 (Plan Pays) 80% 60% 100% 80% Maximum Out-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 60% after deductible 0% after deductible 80% after deductible Specialty Care $40 copay 60% after deductible 0% after deductible 80% after deductible Preventive Care Adult Periodic Exams Covered at 100% 40% after deductible Covered at 100% 20% after deductible Well-Child Care Covered at 100% 40% after deductible Covered at 100% 20% after deductible Diagnostic Services (Member Pays) X-ray and Lab Tests 20% after deductible 40% after deductible 0% after deductible 20% after deductible Complex Radiology 20% after deductible 40% after deductible 0% after deductible 20% after deductible Urgent Care Facility $50 copay 40% after deductible 0% after deductible 20% after deductible Emergency Room Facility Charges $200 copay then 20% after deductible $200 copay then 20% after deductible 0% after deductible Subject to deductible Inpatient Facility Charges 20% after deductible 40% after deductible 0% after deductible 20% after deductible Outpatient Facility and Surgical Charges 20% after deductible 40% after deductible 0% after deductible 20% after deductible Mental Health Inpatient 20% after deductible 40% after deductible 0% after deductible 20% after deductible Outpatient $20 copay 40% after deductible 0% after deductible 20% after deductible Substance Abuse Inpatient 20% after deductible 40% after deductible 0% after deductible 20% after deductible Outpatient $20 copay 40% after deductible 0% after deductible 20% after deductible Other Services Chiropractic 20% after deductible 40% after deductible 0% after deductible 20% after deductible
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