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<br />MEDICAL MUTUALW
<br />Medical Benefit Hiahliahts
<br />Group Name: Mayfield Village
<br />Group Number: TBD
<br />Effective Date: January 1, 2019
<br />EOL?Z(!SLtJ?28?e??59? Prior X_o_l/?1129?4
<br />Prepared sy: Andrea D. Knierim
<br />Date 5ubmitted: 111912018
<br />for 51-99 Ske Groups Option 1 - Select O tion tdumber - - Select Option Number - - Select Option Number -
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<br />Grandfathered Status of O tion Non-Grandiathered
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<br />Health Savin s Acct HSA 0 tion No
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<br />Employer Funding AmouM (SinglelFamily)
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<br /> Network Non-Network 77
<br />Single Deductible $2,000 $4.000
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<br />EmployerCoinsurencePercentage' 100% 80% , ;>= ??GI.44?4_?::??._ ...?:' '?c?? .<..,.,..} ` ,... ? 3 +,f ????t _,_ ,=r , ,., ,?.;:• .. ,,._:' a.?l?t?
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<br />le Out of Pocket Excludes Deductible
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<br />$8,000
<br />Famil Out of Pocket Excludes Deduetible 2 $0
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<br />Offca Visits Ded, then Coins Ded, then Coins
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<br />Urgant Care Office Visits Ded, then Coins Ded, lhen Coins
<br />Emargenry Use of an Emergency Room' Ded, then Coins Ded, then Coins
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<br />Inpatient Services Detl, then Coins Ded, then Cans
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<br />Outpatlent Services
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<br />Prescription Drug Henefit Free-Standing Card 6„`>.'„+?..
<br />Comments HRA administed by third party $2000single
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<br />' Some non-network services will be covered at a cofnsuranee less than what is sho
<br />` Non-Grandfathered Groups Only: For all non-HSA plans, the maximum out of poc t(MOOP) follows the tederally defined standard (calendar year 2014: 56,350 sin8le I 312,700 family; calendar year
<br />2015: $6,600 single I$1J,200 family). For all HSA plans, the maximum 1 coinsurence out of pocket (MOOP f COOP) is equal to the sum of the network deduetible and any out of pocket Ilsted above.
<br />' Emergency room visits that do not qualify as en emergency may be covered at a fesser amount, or not at all. Coverage for emergency visits and emergency services may vary.
<br />8enefits will be determined based an Medical Mutual's medical and adminislretive policies antl proeedures. This document is only a partial Iisting oT benefits. This is not a contract of insurance. No person other than an o(ficer of Medical Mutual may agree.
<br />orally or in wrlting, to change lhe benefits listed here. The conlract or certificate will contaln the complete Iisting of covered servlces.
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