Free Sample Group Health Care Plan Policy
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Sample Group Health Care Plan Policy


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Group Health Care Plan

Eligibility

Employees are eligible to enroll after  months of employment.  This -month period also serves as the waiting period and coverage is effective immediately upon enrollment.

Hospitalization

·         Eligible expenses include charges for up to 365 days of care per illness in a semi-private room.

·         Emergency room for accidental injuries or emergencies.

·         Emergency room, laboratory and x-rays are subject to a co-pay unless admitted.

·         Pre-admission provisions require all non-emergency inpatient stays be approved prior to admission.  Employees must receive approval in order to avoid payment of a deductible and co-pays for any inpatient days not considered medically necessary.

·         Medical/surgical services.

Charges for office visits at participating providers for children, chemotherapy, hemodialysis, radiation therapy are 100% covered at no cost to employees and eligible dependents.  OTHER VISITS CAN BE INCLUDED.  Other office visits are subject to a co-pay.  Charges at nonparticipating providers are reimbursed at  percent once the deductible is paid.  If an employee reaches the annual out-of-pocket maximum of eligible medical expenses, the plan will pay 100 percent of any additional eligible expenses incurred in the same calendar year (The deductible is not included in the out-of-pocket maximum).

·         Paid in full benefits are available for mental health, substance abuse, and home care services and equipment required at home. Pre-certification and use of participating providers is required.

Prescription Drugs

·         Mandatory Generic Substitution Requirement.

·         Participants pay a co-pay for each prescription filled through participating pharmacies.

·         Prior approval is required for certain drugs.

Dental Insurance

Benefits are paid based on the dental fee schedule of allowable charges and are subject to a  annual deductible (maximum  per family).  Coverage is effective  months from date of hire.  Employer ABC provides this Plan at no cost to employees.

Dependent Coverage

Eligible dependents are automatically entitled to the same coverage as the employee under the health and dental plans.  Eligible dependents include:

·         Legal spouse; partner (same or opposite sex).

·         Children under age 19.

·         Children up to age 25 inclusive who are enrolled as full-time students at an accredited post-secondary institution.

·         Children over the age of 25 who are dependent on the employee due to physical or mental infirmary.

·         Children include natural children, legally adopted children, and step-children. Children who reside permanently in the household, and who are dependent on the employee are also eligible.

Procedure

Employees should contact HR for the required enrollment/change forms for any of these plans.

A change of health insurance can be made .  Changes may be subject to waiting periods, or qualifying periods, according to the plan provisions.

Disclaimer

While every attempt has been made to ensure the accuracy of the above summary, the actual Plan text will prevail in the event of any discrepancy as this policy does not constitute a legal document.


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