6-Attachment J - 2025 ACTIVE MEDICAL PLAN 1 SCHEDULE OF BENEFITS.PDF
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- Attached to
- 2027 Stop Loss Insurance Policy
- Solicitation number
- RFP 200-27 MRH
- Issued by
- Orange County, Texas
About this file
This document is a Schedule of Benefits for the Open Access Aetna Select Option I Plan provided by the City of Amarillo under contract number MSA-0737475, effective January 1, 2025. The schedule outlines the comprehensive medical coverage structure for the plan's participants, including detailed deductibles, copayments, coinsurance percentages, and maximum out-of-pocket limits. Individual deductibles are set at $1,500 per year with a family deductible of $3,000 per year, while maximum out-of-pocket limits are established at $5,000 for individuals and $10,000 for families, both on an annual basis. The plan covers a broad range of medical services including preventive care (provided at 100% with no deductible), emergency services, inpatient and outpatient hospital care, physician and specialist services, behavioral health treatment, maternity care, surgical services, diagnostic testing, therapies, and various other medical procedures and supplies.
The plan utilizes an 80% coinsurance model for most covered in-network services after the deductible is satisfied, with specific variations for certain service categories such as obesity surgery (50% coinsurance) and preventive care services (100% coverage). Notable coverage provisions include visit limits for specific services such as home health care (40 visits per year), spinal manipulation (20 visits per year), and skilled nursing facility care (60 days per year), as well as lifetime limits on certain procedures such as obesity surgery ($20,000 combined inpatient and outpatient) and hearing aids ($2,000 every 3 years). The plan emphasizes preventive services with comprehensive coverage for immunizations, cancer screenings, tobacco cessation counseling, obesity counseling, and family planning services, all at no cost to the member. Third Party Administrative Services are provided by Aetna Life Insurance Company, with federal No Surprises Act protections applying to out-of-network emergency services.
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Schedule of benefits
Prepared for:
Employer: City of Amarillo Contract number: MSA-0737475 Plan name: Open Access Aetna Select Option I Plan Schedule of benefits: 1A Plan effective date: January 1, 2025 Plan issue date: June 6, 2025
Third Party Administrative Services provided by Aetna Life Insurance Company
Schedule of benefits
This schedule of benefits (schedule) lists the deductibles, copayments or payment percentage, if any apply to the covered services you receive under the plan. You should review this schedule to become aware of these and any limits that apply to these services.
How your cost share works The deductibles and copayments, if any, listed in the schedule below are the amounts that you pay for covered services.
- For the covered services under your medical plan, you will be responsible for the dollar amount
- For pharmacy benefits where a percentage cost share acts like a copayment, you will be responsible for the percentage amount Payment percentage amounts, if any, listed in the schedule below are what the plan will pay for covered services.
Sometimes your cost share shows a combination of your dollar amount copayment that you will be responsible for and the payment percentage that your plan will pay.
You are responsible to pay any deductibles, copayments and remaining payment percentage, if they apply and before the plan will pay for any covered services.
This plan doesn’t cover every health care service. You pay the full amount of any health care service you get that is not a covered service.
This plan has limits for some covered services. For example, these could be visit, day or dollar limits.
They may be:
- Based on a rolling, 12 month period starting with the date of your most recent visit under this plan See the schedule for more information about limits.
Your cost share may vary if the covered service is preventive or not. Ask your physician or contact us if you have a question about what your cost share will be.
For examples of how cost share and deductible work, go to the Using your Aetna benefits section under Individuals & Families at https://www.aetna.com/
Important note:
Covered services are subject to the deductible, maximum out-of-pocket, limits, copayment or payment percentage unless otherwise stated in this schedule. The Surprise bill section in the booklet explains your protections from a surprise bill.
https://www.aetna.com/
How your deductible works The deductible is the amount you pay for covered services each year before the plan starts to pay. This is in addition to any copayment or payment percentage you pay when you get covered services from an in-network provider. This schedule shows the deductible amounts that apply to your plan. Once you have met your deductible, we will start sharing the cost when you get covered services. You will continue to pay copayments or payment percentage, if any, for covered services after you meet your deductible.
How your PCP or physician office visit cost share works You will pay the PCP cost share when you get covered services from any PCP.
How your maximum out-of-pocket works This schedule shows the maximum out-of-pocket limits that apply to your plan. Once you reach your maximum out-of-pocket limit, your plan will pay for covered services for the remainder of that year.
Contact us We are here to answer questions. See the Contact us section in your booklet.
This schedule replaces any schedule of benefits previously in use. Keep it with your booklet.
Plan features
Deductible You have to meet your deductible before this plan pays for benefits.
Deductible type In-network Individual $1,500 per year Family $3,000 per year
Maximum out-of-pocket limit Includes the deductible.
Maximum out-of-pocket type
In-network
Individual $5,000 per year Family $10,000 per year
General coverage provisions This section explains the deductible, maximum out-of-pocket limit and limitations listed in this schedule.
Deductible provisions The deductible may not apply to some covered services. You still pay the copayment or payment percentage, if any, for these covered services.
Individual deductible You pay for covered services each year before the plan begins to pay. This individual deductible applies separately to you and each covered dependent. After the amount paid reaches the individual deductible, this plan starts to pay for covered services for the rest of the year.
Family deductible You pay for covered services each year before the plan begins to pay. After the amount paid for covered services reaches this family deductible, this plan starts to pay for covered services for the rest of the year. To satisfy this family deductible for the rest of the year, the combined covered services that you and each of your covered dependents incur toward the individual deductible must reach this family deductible in a year. When this happens in a year, the individual deductibles for you and your covered dependents are met for the rest of the year.
Payment Percentage This is the percentage of the bill you pay after you meet your deductible.
Maximum out-of-pocket limit The maximum out-of-pocket limit is the most you will pay per year in copayments, payment percentage and deductible, if any, for covered services. Covered services that are subject to the maximum out-of-pocket limit include those provided under the medical plan and the outpatient prescription drug plan.
Individual maximum out-of-pocket limit This plan may have an individual and family maximum out-of-pocket limit. As to the individual maximum out-of-pocket limit, each of you must meet your maximum out-of-pocket limit separately.
After you or your covered dependents meet the individual maximum out-of-pocket limit, this plan will pay 100% of the eligible charge for covered services that would apply toward the limit for the rest of the year for that person.
Family maximum out-of-pocket limit After you or your covered dependents meet the family maximum out-of-pocket limit, this plan will pay 100% of the eligible charge for covered services that would apply toward the limit for the remainder of the year for all covered family members. The family maximum out-of-pocket limit is a cumulative maximum out-of-pocket limit for all family members.
To satisfy this maximum out-of-pocket limit for the rest of the year, the following must happen:
The family maximum out-of-pocket limit is met by a combination of family members No one person within a family will contribute more than the individual maximum out-of-pocket limit amount in a year
If the maximum out-of-pocket limit does not apply to a covered service, your cost share for that service will not count toward satisfying the maximum out-of-pocket limit amount.
Certain costs that you have do not apply toward the maximum out-of-pocket limit. These include:
All costs for non-covered services which are identified in the booklet and the schedule Costs for non-urgent use of an urgent care provider
Your financial responsibility and decisions regarding benefits We base your financial responsibility for the cost of covered services on when the service or supply is provided, not when payment is made. Benefits will be pro-rated to account for treatment or portions of stays that occur in more than one year. Decisions regarding when benefits are covered are subject to the terms and conditions of the booklet.
Prescription drug – outpatient maximum out-of-pocket limit provisions Covered services that are subject to the maximum out-of-pocket limit include covered services provided under the medical plan and the prescription drug plan.
The maximum out-of-pocket limit is the most you will pay per year in copayments, payment percentage and deductible, if any, for covered services. This plan may have an individual and family maximum out-of-pocket limit.
Covered services Acupuncture
Description In-network Acupuncture 80% per visit after deductible Ambulance services
Description In-network Emergency services 80% per trip after deductible Non-emergency services ground, air, or water ambulance
Not covered
Applied behavior analysis Description In-network
Applied behavior analysis Covered based on type of service and where it is received
Autism spectrum disorder Description In-network
Diagnosis and testing Covered based on type of service and where it is received Treatment Covered based on type of service and where it is received Occupational (OT), physical (PT) and speech (ST) therapy for autism spectrum disorder
Covered based on type of service and where it is received
Behavioral health Mental health treatment Coverage provided is the same as for any other illness
Description In-network Inpatient services-room and board including residential treatment facility
80% per admission after deductible
Other inpatient services and supplies Other residential treatment facility services and supplies
80% per admission after deductible
Description In-network Outpatient office visit to a physician or behavioral health provider
80% per visit after deductible
Physician or behavioral health provider telemedicine consultation
80% per visit after deductible
Outpatient mental health disorders telemedicine cognitive therapy consultations by a physician or behavioral health provider
Covered based on type of service and provider from which it is received
Description In-network Other outpatient services including:
Behavioral health services in the home
Partial hospitalization treatment
Intensive outpatient program
The cost share doesn’t apply to in-network peer counseling support services
80% per visit after deductible
Description In-network Telemedicine provider mental health disorders consultation
Covered based on type of service and provider from which it is received
Telemedicine cognitive therapy mental health disorders consultation by a telemedicine provider
Covered based on type of service and provider from which it is received
Substance related disorders treatment Includes detoxification, rehabilitation and residential treatment facility Coverage provided is the same as for any other illness
Description In-network Inpatient services-room and board during a hospital stay
80% per admission after deductible
Other inpatient services and supplies during a hospital stay
80% per admission after deductible
Outpatient office visit to a physician or behavioral health provider
80% per visit after deductible
Physician or behavioral health provider telemedicine consultation
80% per visit after deductible
Outpatient telemedicine cognitive therapy consultations by a physician or behavioral health provider
Covered based on type of service and provider from which it is received
Description In-network Other outpatient services including:
Behavioral health services in the home
Partial hospitalization treatment
Intensive outpatient program
The cost share doesn’t apply to in-network peer counseling support services
80% per visit after deductible
Description In-network Telemedicine provider substance related disorders consultation
Covered based on type of service and provider from which it is received
Telemedicine cognitive therapy substance related disorders consultation by a telemedicine provider
Covered based on type of service and provider from which it is received
Clinical trials Description In-network
Experimental or investigational therapies
Routine patient costs Covered based on type of service and where it is received
Durable medical equipment (DME) Description In-network
DME 80% per item after deductible
Emergency services Description In-network Out-of-network
Emergency room 80% per visit after deductible Paid same as in-network
Non-emergency care in a hospital emergency room
80% per visit after deductible Not covered
Emergency services important note: Out-of-network providers do not have a contract with us. However, for out of network emergencies the federal No Surprises Act applies. If the provider bills you for an amount above your cost share, you are not responsible for payment of that amount. You should send the bill to the address on your ID card and we will resolve any payment issue with the provider. Make sure the member ID is on the bill. If you are admitted to the hospital for an inpatient stay right after you visit the emergency room, you will not pay your emergency room cost share if you have one. You will pay the inpatient hospital cost share, if any.
Habilitation therapy services Outpatient physical (PT), occupational (OT) therapies
Description In-network PT, OT therapies Covered based on type of service and where it is received Outpatient speech therapy (ST)
Description In-network ST therapy Covered based on type of service and where it is received
Hearing aids Description In-network
Hearing aids 80% per item after deductible Limit $2,000 every 3 years
Hearing exams Description In-network
Hearing exams Covered based on type of service and where it is received
Home health care A visit is a period of 4 hours or less
Description In-network Home health care 80% per visit after deductible
Visit limit per year 40
Home health care important note:
Intermittent visits are periodic and recurring visits that skilled nurses make to ensure your proper care. The intermittent requirement may be waived to allow for coverage for up to 12 hours with a daily maximum of 3 visits.
Hospice care Description In-network
Inpatient services -room and board
80% after deductible
Other inpatient services and supplies
80% per admission after deductible
Description In-network Outpatient services 80% per visit after deductible
Limit per lifetime unlimited
Hospice important note:
This includes part-time or infrequent nursing care by an R.N. or L.P.N. to care for you up to 8 hours a day. It also includes part-time or infrequent home health aide services to care for you up to 8 hours a day.
Hospital care Description In-network
Inpatient services -room and board
80% after deductible
Description In-network Other inpatient services and supplies
80% per admission after deductible
Infertility services Basic infertility
Description In-network Treatment of basic infertility
Maternity and related newborn care Includes complications
Description In-network Inpatient services – room and board
80% per admission after deductible
Other inpatient services and supplies
80% per admission after deductible
Services performed in physician or specialist office or a facility
80% per visit after deductible
Other services and supplies
80% per visit after deductible
Maternity and related newborn care important note:
Any cost share collected applies only to the delivery and postpartum care services provided by an OB, GYN or OB/GYN. Review the Maternity section of the booklet. It will give you more information about coverage for maternity care under this plan.
Obesity surgery Description In-network
Inpatient services – room and board
50% per admission after deductible
Other inpatient services and supplies
50% per admission after deductible
Description In-network Outpatient services 50% per visit after deductible
Limit per lifetime -inpatient and outpatient combined
$20,000
Oral and maxillofacial treatment (mouth, jaws and teeth) Description In-network
Treatment of mouth, jaws and teeth
Covered based on type of service and where it is received
Outpatient surgery Description In-network
At hospital outpatient department
80% per visit after deductible
At facility that is not a hospital
80% per visit after deductible
At the physician office Covered based on type of service and where it is received
Physician and specialist services Physician services-general or family practitioner Including surgical services
Description In-network Physician office hours (not-surgical, not preventive)
80% per visit after deductible
Physician surgical services
80% per visit after deductible
Description In-network Physician visit during inpatient stay
80% per visit after deductible
Description In-network Physician telemedicine consultation
80% per visit after deductible
Description In-network Telemedicine provider consultation
Basic medical services
Covered based on type of service and provider from which it is received
Specialist Description In-network
Specialist office hours (not surgical, not preventive)
80% per visit after deductible
Specialist surgical services
80% per visit after deductible
Description In-network Specialist telemedicine consultation
80% per visit after deductible
All other services not shown above
All other services 80% per visit after deductible
Preventive care Description In-network
Preventive care services 100% per visit, no deductible applies Breast feeding counseling and support
100% per visit, no deductible applies
Breast feeding counseling and support limit
6 visits in a group or individual setting
Visits that exceed the limit are covered under the physician services office visit Breast pump, accessories and supplies
100%, no deductible applies
Breast pump, accessories and supplies limit
Electric pump: 1 every 12 months
Manual pump: 1 per pregnancy
Pump supplies and accessories: 1 purchase per pregnancy if not eligible to purchase a new pump
Breast pump waiting period
Electric pump: 12 months to replace an existing electric pump
Counseling for alcohol or drug misuse
100% per visit, no deductible applies
Counseling for alcohol or drug misuse visit limit
5 visits/12 months
Counseling for obesity, healthy diet
100% per visit, no deductible applies
Counseling for obesity, healthy diet visit limit
Age 22 and older: 26 visits per 12 months, of which up to 10 visits may be used for healthy diet counseling.
Counseling for sexually transmitted infection
100% per visit, no deductible applies
Counseling for sexually transmitted infection visit limit
2 visits/12 months
Counseling for tobacco cessation
100% per visit, no deductible applies
Counseling for tobacco cessation visit limit
8 visits/12 months
Family planning services (female contraception counseling)
100% per visit, no deductible applies
Family planning services (female contraception counseling) limit
Contraceptive counseling limited to 2 visits/12 months in a group or individual setting
Immunizations 100%, no deductible applies Immunizations limit Subject to any age limits provided for in the comprehensive guidelines supported by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention
For details, contact your physician
Generic preventive care female contraceptives (birth control)
100% no deductible applies
Preventive care drugs and supplements
100% no deductible applies
Preventive care drugs and supplements limit
Subject to any sex, age, medical condition, family history and frequency guidelines as recommended by the USPSTF
For a current list of covered preventive care drugs and supplements or more information, see the Contact us section
Preventive care risk reducing breast cancer prescription drugs
100% no deductible applies
Preventive care risk reducing breast cancer prescription drugs limit
Subject to any sex, age, medical condition, family history and frequency guidelines as recommended by the USPSTF
For a current list of covered preventive care drugs and supplements or more information, see the Contact us section
Preventive care tobacco cessation prescription and OTC drugs
100% no deductible applies
Limit Two 90 day treatments only Routine cancer screenings
100% per visit, no deductible applies
Routine cancer screening limits
Subject to any age, family history and frequency guidelines as set forth in the most current:
Evidence-based items that have a rating of A or B in the current recommendations of the USPSTF
The comprehensive guidelines supported by the Health Resources and Services Administration
For more information contact your physician or see the Contact us section Routine lung cancer screening
100% per visit, no deductible applies
Routine lung cancer screening limit
1 screening every 12 months
Screenings that exceed this limit covered as outpatient diagnostic testing Routine physical exam 100% per visit, no deductible applies Routine physical exam limits
Subject to any age and visit limits provided for in the comprehensive guidelines supported by the American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration for children and adolescents
High risk Human Papillomavirus (HPV) DNA testing for woman age 30 and older limited to 1 every 36 months
Well woman GYN exam 100% per visit, no deductible applies Well woman GYN exam limit
Subject to any age and visit limits provided for in the comprehensive guidelines supported by the Health Resources and Services Administration
Prosthetic devices Description In-network
Prosthetic devices 80% per item after deductible
Reconstructive surgery and supplies Including breast surgery
Description In-network Surgery and supplies Covered based on type of service and where it is received
Short-term rehabilitation services A visit is equal to no more than 1 hour of therapy.
Cardiac rehabilitation
Description In-network Cardiac rehabilitation Covered based on type of service and where it is received Pulmonary Rehabilitation
Description In-network Pulmonary rehabilitation Covered based on type of service and where it is received Cognitive Rehabilitation
Description In-network Cognitive Rehabilitation Covered based on type of service and where it is received
Physical and occupational therapies Description In-network
80% per visit after deductible Speech therapy (ST)
Description In-network 80% per visit after deductible
Spinal Manipulation Description In-network
80% per visit after deductible
Visit limit per year 20
Skilled nursing facility Description In-network
Inpatient services -room and board
80% per admission after deductible
Other inpatient services and supplies
80% per admission after deductible
Day limit per year 60
Tests, images and labs – outpatient Diagnostic complex imaging services
Description In-network 80% per visit after deductible
Diagnostic lab work Description In-network
Services performed by Quest Lab
100% per visit, no deductible applies
Service performed by any other lab facility
80% per visit after deductible
Diagnostic x-ray and other radiological services Description In-network
80% per visit after deductible
Therapies Chemotherapy
Description In-network Chemotherapy services Covered based on type of service and where it is received
Gene-based, cellular and other innovative therapies (GCIT) Description In-network (GCIT-designated facility/provider) Out-of-network
(Including providers who are otherwise part of Aetna’s network but are not
GCIT-designated facilities/providers) Services and supplies Covered based on type of service and where it is received Not covered
Gene therapy products, prescription drugs
80% after deductible Not covered
Infusion therapy Outpatient services
Description In-network In physician office 80% per visit after deductible At an infusion location Covered based on type of service and where it is received In the home 80% per visit after deductible At hospital outpatient department
80% per visit after deductible
At facility that is not a hospital
80% per visit after deductible
Radiation therapy
Radiation therapy Covered based on type of service and where it is received
Respiratory therapy Description In-network
Respiratory therapy Covered based on type of service and where it is received
Transplant services Description In-network (IOE facility)
Inpatient services and supplies
80% per transplant after deductible
Physician services Covered based on type of service and where it is received
Urgent care services At a freestanding facility or provider that is not a hospital A separate urgent care cost share will apply for each visit to an urgent care facility or provider
Description In-network Urgent care facility 100% per visit, no deductible applies
Non-urgent use of an urgent care facility or provider
Not covered
Virtual primary care Telemedicine consultation
Description In-network Preventive care consultations
100% per visit, no deductible applies
All other basic medical services consultations
100% per visit, no deductible applies
Routine physical check-up limit
1 virtual visit per year
Walk-in clinic Not all preventive care services are available at a walk-in clinic. All services are available from a network physician.
Description Designated network Non-designated network Non-emergency services 100% per visit, no deductible applies 100% per visit, no deductible applies Preventive care immunizations
100% per visit, no deductible applies 100% per visit, no deductible applies
Preventive care immunization limits
Subject to any age and frequency limits provided for in the comprehensive guidelines supported by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention
For details, contact your physician
Subject to any age and frequency limits provided for in the comprehensive guidelines supported by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention
For details, contact your physician Screening and counseling services
100% per visit, no deductible applies 100% per visit, no deductible applies
Screening and counseling limits
See the Preventive care section of the schedule
See the Preventive care section of the schedule
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