Attachment B - Schedule of Benefits Revised 4.14.22.pdf

ARBenefits January 1, 2021

SCHEDULE OF BENEFITS

ASE/PSE Premium Plan (Medicare Primary Plan)

This Schedule of Benefits describes benefits available to members enrolled in the ASE/PSE Premium (Medicare Primary Plan) who are eligible for Medicare coverage. Once a member becomes eligible for Medicare coverage, the member’s entire family will automatically be moved to the ARBenefits ASE/PSE Premium Plan if they are currently enrolled in the Classic Plan or Basic Plan.

The ARBenefits ASE/PSE Premium Plan (Medicare Primary Plan) is an employer sponsored health benefit plan that supplements most benefits provided by Medicare.

In order for a particular Health Intervention to qualify for coverage under the Plan, the following criteria must be met:

(1) The health intervention must conform to specific limitations stated in the Plan.

(2) The health intervention must not be specifically excluded under the terms of the Plan.

(3) At the time of the intervention, the Covered Person must meet the Plan’s eligibility standards.

(4) You must follow the Plan’s procedures for filing claims.

MEDICAL BENEFITS AND SPECIFIC LIMITATIONS

This health benefit plan provides coverage that supplements most benefits provided by Medicare. This Section describes medical services, drugs, supplies, tests, and equipment for which coverage is provided under the Plan, provided all terms, conditions, exclusions, and limitations of the Plan, including the four coverage criteria, are satisfied.

What does ARBenefits cover for Medicare Primary Retirees?

Medicare Does Not Pay ARBenefits Retiree Plan Covers

Part A Hospital Services

Inpatient hospital deductible each benefit period ARBenefits pays the deductible

Copayment per day for days 61-90 in a hospital ARBenefits pays the copayment per day

Copayment per day for days 91-150

(Lifetime Reserve)

ARBenefits pays the copayment per day

100% of Medicare - Allowable expenses for additional 365 days after Medicare hospital benefits stop completely

ARBenefits pays

Medicare Does Not Pay ARBenefits Retiree Plan Covers

ARBenefits January 1, 2021

Part A Hospital Services, continued

Calendar year blood deductible (First 3 Pints of Blood) If deductible is not met by the replacement of blood

ARBenefits pays

Copayment per day for days 21-100 in a Skilled Nursing Facility

ARBenefits pays the copayment per day

Part B Physician and Medical Services

Part B deductible ARBenefits pays the deductible.

Normally 20% of Medicare-approved amount (Part B Coinsurance) and 20% of Medicare-approved charges for Durable Medical Equipment (After Part B Deductible Is Met)

ARBenefits pays 20% of the Medicare-approved amount, unless the benefit excluded.

Medicare Part B excess charges 100%

(This benefit would apply when you receive services from a physician that does not accept Medicare assignment.)

Coverage will be determined based on the level of coverage outlined in the SPD for active and non- Medicare members. Services paid at 100% will be no charge. Plan will pay 80% for Medicare Part B excess charges not paid by Medicare, but will be paid according to the deductible, copay, and coinsurance when applicable.