MEDICAL INSURANCE
McKibbon Hospitality offers medical coverage through United Healthcare (UHC). You have four plan options to choose from. To find participating providers go to www.myuhc.com and click on “Find a Doctor”, then follow the prompts to complete the search within the “Choice Plus” network. The chart below provides a brief overview of the medical plans offered.
BUY-UP PLAN #1
BUY-UP PLAN #2
HDHP H.S.A. PLAN
BASE PLAN
IN-NETWORK
Choice Plus
Choice Plus
DEDUCTIBLE (your first dollar cost for covered in-network claims) Deductible (Individual / Family) $6,600 / $13,200
$2,500 / $5,000
$4,500 / $9,000
$3,500 / $7,000
COINSURANCE (your responsibility on claims costs once you’vemet the deductible) 20% 20% OUT OF POCKET MAXIMUM (once met all in-network covered services are covered by the plan) MaximumOut-of-Pocket (Individual / Family) $7,130 / $14,260 $6,350 / $12,700
20%
20%
$5,000 / $10,000
$5,000 / $6,850
Maximum Includes
Deductible, Coinsurance, Prescription Costs & Copays
PREVENTIVE CARE Wellness, Immunizations, Mammography, Colonoscopy, etc.
Covered 100%, no cost to you
Covered 100%, no cost to you
OFFICE VISITS Referral Required
No
No $49
Virtual Visits
$10 Copay
$10 Copay
$10 Copay
Office Visits (Illness/Injury)
Covered 80% after deductible
$50 Copay
$45 Copay
$35 Copay
Covered 80% after deductible
Specialist Visits
$75 Copay
$60 Copay
$60 Copay
HOSPITAL SERVICES Inpatient Hospital
Covered 80% after deductible Covered 80% after deductible Covered 80% after deductible Covered 80% after deductible
Covered 80% after deductible
Covered 80% after deductible Covered 80% after deductible
Outpatient Surgery
Covered 80% after deductible
Covered 80% after deductible Covered 80% after deductible
Emergency Room
$500 Copay
$500 Copay
$500 Copay
Urgent Care
$75 Copay
$75 Copay
$75 Copay
DIAGNOSTIC TESTING Lab & X-Ray Advanced Imaging (MRI, CAT, PET, etc.)
Covered 80% after deductible
Covered 100%
Covered 100%
Covered 100%
Covered 80% after deductible
Covered 80% after deductible
Covered 80% after deductible Covered 80% after deductible
PRESCRIPTIONS
Your medical deductible applies first then, $10 / $35 / $60 Yes
Retail (30 day supply) Tier 1 / 2 / 3 / 4
$20 / $50 / $100 / $200
$20 / $50 / $100 / $200
$20 / $50 / $100 / $200
Medicare (Part D) Creditable
Yes
Yes
Yes
OUT-OF-NETWORK 1
Refer to plan summary for details . Copies can be found within forms library on the Benefits Portal.
$114.56 $293.38 $263.23 $365.10
Employee Only
$ 81.65
$121.92
$161.40
Employee + Spouse
$216.50
$312.23
$350.96
Employee + Child(ren)
$197.50
$280.15
$298.32
Employee + Family
$236.57
$388.55
$447.15
4 This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage. Reminder: You are not able to drop coverage outside of open enrollment unless you experience a qualified life event (QLE). Examples of QLEs are provided on page 3 of this guide. If you later decide the cost of the plan is too expensive, you will not be able to drop the coverage or change plans as this is not a QLE. Please note these rules and restriction are set and regulated by the IRS, not McKibbon Hospitality. 1 Charges are subject to balance billing
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