Schedule C - Plan Design Final.docx
DOCX document 25 KB Posted
- Attached to
- Vision Insurance Plan Administration for CSC
- Solicitation number
- RFP-171-180000001030-4
- Issued by
- Grand Traverse County, Lansing City, Michigan
About this file
This is a Schedule C Plan Design document for RFP No. 180000001030, detailing vision insurance coverage for State of Michigan (SOM) employees and retirees. The document outlines a comprehensive vision insurance plan that includes coverage for routine eye exams, eyeglass lenses, frames, contact lenses, VDT/CRT computer glasses, and safety eyewear.
The plan structure includes specific coverage levels for participating and non-participating providers, with defined co-pays and reimbursement maximums. Key coverage elements include 100% coverage minus a $5 co-pay for routine eye exams through participating providers, a $100 frame allowance with a $7.50 co-pay, and coverage for various lens types including single vision, bifocal, and trifocal lenses. The plan allows for new lenses every 24 months or 12 months with prescription changes, and includes specific allowances for medically necessary contact lenses up to $210 and cosmetic contact lenses up to $130. The document also lists 22 specific exclusions from coverage, including designer frames, experimental procedures, and various lens enhancements such as UV coating and anti-reflective treatments.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Schedule A - Final.docx | DOCX document | |
| Schedule E - HIPAA 834 File Layouts Final.pdf | ||
| RFP 180000001030 Questions and Answers Final.docx | DOCX document | |
| Schedule F - Provider Cost Claims Data Final.XLSX | XLSX spreadsheet | |
| Schedule J Safeguard Requirements of Confidential Data Final.docx | DOCX document | |
| Schedule D - GeoAccess Data Final_Rev 2-28-18.xlsx | XLSX spreadsheet | |
| Standard Contract Terms Final.docx | DOCX document | |
| Vision RPF Q&A #28.xlsx | XLSX spreadsheet | |
| Vision RPF Q&A #33.xlsx | XLSX spreadsheet | |
| Proposal Instructions and Vendor Questions Worksheet Final.docx | DOCX document | |
| Schedule B - Pricing Matrix Final.xlsx | XLSX spreadsheet | |
| Schedule G - Provider Location Data for Disruption Analysis Final_Rev 2-28-18.xlsx | XLSX spreadsheet | |
| Schedule H - Sample Claims Report and Invoice Format Final.xlsx | XLSX spreadsheet | |
| Schedule I - SLA Reporting Format Final.pdf |
Show all 14
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Text version
RFP No. 180000001030 Schedule C SOM Employee and Retiree Vision Insurance Plan Design
| Vision Testing Exam |
| Participating Providers |
| Non-participating Providers |
| Routine eye exam |
| 100% of Third Party Administrator (TPA) approved amount minus $5.00 co-pay. |
| Reimbursement up to $34 minus $5.00 co-pay (member responsible for any difference). |
Once every 12 months
| Eyeglass lenses (Glass, plastic, or prism up to 60 mm) |
| Participating Providers |
| Non-participating Providers |
| Replacement schedule |
| Members may obtain one pair of corrective lenses once every 24 months or once every 12 months if prescription has changed. Members may obtain either eyeglasses or contact lenses but not both. |
| Single vision |
| 100% of TPA approved amount |
minus $7.50 co-pay Reimbursement up to a maximum of $17 minus $7.50 co-pay (member responsible for any cost exceeding the difference).
Bifocal (includes blended) 100% of TPA approved amount minus $7.50 co-pay Reimbursement up to a maximum of $30 minus $7.50 co-pay (member responsible for any cost exceeding the difference).
| Trifocal |
| 100% of TPA approved amount |
minus $7.50 co-pay Reimbursement up to a maximum of $43 minus $7.50 co-pay (member responsible for any cost exceeding the difference).
| Special lenses |
| 100% of TPA approved amount |
minus $7.50 co-pay Not covered
Progressive lenses (standard)
Member is responsible for difference if premium or custom progressive lens is selected.
| 100% of TPA approved amount minus $7.50 co-pay |
| Reimbursement up to a maximum of $30 minus $7.50 co-pay (member responsible for any cost exceeding the difference). |
| Rose Tint #1 and #2 or Photochromatic Tint |
| 100% of TPA approved amount minus $7.50 co-pay |
| Not covered |
| Frames |
| Participating Providers |
| Non-participating Providers |
| Eyeglass frames |
| $100 allowance is applied toward frames (member responsible for any cost exceeding the allowance) minus $7.50 co-pay (one co-pay applies to both frames and lenses). |
| Up to $38.25 Allowance (member responsible for any cost exceeding the allowance) minus $7.50 co-pay (one co-pay applies to both frames and lenses). |
Once every 24 months or once every 12 months if prescription has changed.
| Contact Lenses |
| Participating Providers |
| Non-Participating Providers |
| Medically necessary |
| 100% of the TPA approved amount |
Includes contact lens fitting and suitability exam minus $7.50 co-pay.
Maximum of $210 allowance per pair minus $7.50 co-pay (member responsible for any cost exceeding the allowance).
Cosmetic Not medically necessary Up to $130 allowance (member responsible for any cost exceeding the allowance) Includes contact lens fitting and suitability exam.
No co-pay Maximum of $100 allowance (member responsible for any cost exceeding the allowance).
No co-pay
| VDT/CRT or Computer Glasses* |
| Participating Providers |
| Non-participating Providers |
| Per pair of glasses |
| Once every 24 months or once every 12 months if prescription has changed. Only covered if prescription is in addition to, and different from, prescribed everyday eyewear. |
| Eye exam |
| Initial eye exam covered if within12 months of routine eye exam and is not subject to co-pay. Subsequent evaluation included with routine eye exam. |
| VDT/CRT or Computer Glasses* |
| Participating Providers |
| Non-participating Providers |
| Single vision, plastic |
| 100% of TPA approved amount |
| Up to $17 allowance (member responsible for any cost exceeding the allowance). |
Bifocal (includes blended)
| 100% of TPA approved amount |
| Up to $30 allowance (member responsible for any cost exceeding the allowance). |
| Trifocal |
| 100% of TPA approved amount |
| Up to $43 allowance (member responsible for any cost exceeding the allowance). |
Progressive lens (standard) Member is responsible for difference if premium or custom progressive lens is selected.
| 100% of TPA approved amount |
| Up to $30 allowance (member responsible for any cost exceeding the allowance). |
| Special lenses |
| 100% of TPA approved amount |
| Not covered |
| Rose Tint #1 to #2 |
| 100% of TPA approved amount |
| Not covered |
| Eyeglass frames |
| $100 allowance (member responsible for any cost exceeding the allowance). |
| Up to $38.25 allowance (member responsible for any cost exceeding the allowance). |
| Safety Eye-wear* |
| Participating Providers |
| Non-participating Providers |
| Replacement schedule |
| Members may obtain one pair of corrective lenses once every 24 months or once every 12 months if prescription has changed. |
| Single vision |
| 100% of TPA approved amount |
| Not covered |
Bifocal (includes blended)
| 100% of TPA approved amount |
| Not covered |
| Trifocal |
| 100% of TPA approved amount |
| Not covered |
| Special lenses |
| 100% of TPA approved amount |
| Not covered |
| Safety Eye-wear* |
| Participating Providers |
| Non-participating Providers |
Progressive lenses (standard) Member is responsible for difference if premium or custom progressive lens is selected.
| 100% of TPA approved amount |
| Not covered |
| Eyeglass frames |
| Up to $65 allowance (member responsible for any cost exceeding the allowance). |
Not covered
Rose Tint #1 and #2
100% of TPA approved amount
Not covered
*Departmental employer must certify business need; not applicable to dependents or retirees.
Exclusions:
1. Additional office visits associated with contact lens pathology
1. Aphakic lenses when the patient lacks a natural lens
1. Charges for completion of forms
1. Conditions requiring treatment as a result of employment or war
1. Contact lens modification, polishing or cleaning
1. Cost of designer frames or frames that exceed allowable payments
1. Drugs or medications other than for vision testing examinations
1. Experimental
1. Lens tinting darker that rose tint #2
1. Medical/surgical treatment and lenses and/or frames required as a result of medical and/or surgical treatment
1. Oversized lenses (over 60 mm)
1. Plano lenses (lenses with refractive correction of less than ± .50 diopter)
1. Polycarbonate lenses
1. Refitting of contact lenses after the initial (90-day) fitting period
1. Replacement of lost or broken lenses or frames
1. Scratch guard
1. Services and/or materials not indicated on this schedule as covered plan benefits
1. Services associated with CRT or Orthokeratology
1. Services before/after beginning/termination date of coverage
1. Services not recommended by an Ophthalmologist or Optometrist
1. Special procedures such as vision training or subnormal vision aids
1. Anti-reflective lenses or non-prescription sunglasses
1. Two pair of glasses instead of bifocals
1. UV coating
2018 MCSC Vision RFP, Schedule C Page 5 of 5
File details come from the government source that posted it. Updated .