MedBasic Plan: Cost of Coverage
This section will help participants understand how they pay for medical coverage under the MedBasic plan.
Employee Contributions
SAIC and participants share in the cost of coverage. Each pay period, employee contributions are deducted from the participant's paycheck on a pre-tax basis. The employee contribution amount will vary based on the coverage level elected:
- Employee only;
- Employee plus spouse;
- Employee plus one or more children; or
- Family coverage.
Annual Deductible
The "deductible" is the initial $600 each participant must pay for medical services he or she receives each calendar year before the plan begins to pay benefits.
The annual deductible is waived for certain services provided by in-network physicians, including office visits, periodic health assessments, well-child care, lab and X-ray, routine mammograms, routine pap smears, psa/dre, home health care and hospice care. Services must be provided in physician's office as part of the office visit. Services provided by third parties are subject to annual deductible and coinsurance.
Under certain conditions, the participant is allowed to carry over eligible expenses from one year to the next. If the participant incurs expenses in October, November or December and has not yet met the annual deductible for that year, those expenses will be carried over and applied to the following year's annual deductible.
Common Accident Deductible
If two or more covered family members are injured in the same accident, only one individual deductible for all family members involved will be applied to the eligible expenses resulting from the accident. The deductible will be applied only to those accident-related medical expenses incurred during the calendar year in which the accident occurs.
Copayments and Coinsurance
"Copayments" are the fixed dollar amounts a participant pays for an eligible expense at the time a service is provided. Under the MedBasic plan, copayments are required for network office visits, prescription drugs and outpatient mental health and substance abuse treatment.
"Coinsurance" is the percentage of eligible expenses a participant pays for medical services once the participant meets the annual deductible.
Annual Out-of-Pocket Maximum
The "out-of-pocket maximum" is the amount of coinsurance payments a participant must pay each calendar year before the MedBasic plan begins paying 100% of eligible expenses up to the negotiated rate (for in-network providers) or reasonable and customary (R&C) limit (for out-of-network providers), whichever applies. This maximum is designed to protect a participant from catastrophic costs. See "Network Benefits" in the SAIC MedBasic section for more information about negotiated rates and "Out-of-Network Benefits" for more information about R&C limits.
The following expenses do not count toward a participant's annual out-of-pocket maximum:
- Payments for eligible expenses incurred in a different calendar year;
- Copayments a participant makes for eligible expenses (including those for prescription drugs);
- Annual deductibles;
- Charges that are not covered under the plan;
- Charges that are reimbursed at 50%, such as non-emergency use of the emergency room;
- Charges that exceed R&C limits; and
- Charges that exceed the maximum benefits for that year.
- Mental health and substance abuse services received through CIGNA Behavioral Health (CBH)
When a participant uses a network provider, his or her annual out-of-pocket maximum is $2,500. When a participant uses an out-of-network provider, his or her annual out-of-pocket maximum is $7,500.
Please note: Annual out-of-pocket maximums are combined for network and out-of-network providers.
Lifetime Maximum
The "lifetime maximum" is the maximum medical benefit payable for a covered participant throughout his or her lifetime. Once the lifetime benefit maximum is reached, no additional benefits will be paid.
The lifetime maximum benefit is $2 million per covered participant whether he or she sees network providers or out-of-network providers. The lifetime maximum benefit is combined for all self-insured medical plans offered by SAIC.
Please note: SAIC's self-insured plans do provide a $1,000 annual lifetime restoration, once the lifetime maximum is reached.
