Human Resources

Human Resources

The Human Resources Department endeavors to attract, develop and retain highly qualified faculty, staff, and administrators who are committed to fulfilling the college mission, vision, and values. Our goal is to support the well-being of the college, and its employees, by serving as a resource in providing services such as recruitment, recognition, benefits administration, employee relations, and performance management.Toward that end, Glen Oaks provides an attractive compensation and benefit package that includes:

  • Generous paid time off
  • Paid holidays
  • Competitive retirement benefits
  • Medical, dental, vision, Long-Term Disability, and life insurance

  • Reduced GOCC tuition for yourself and your dependents (up to 100%, based on status)
  • Tuition reimbursement
  • Employee Assistance Program
  • Bookstore Discounts

Employment Opportunities

Faculty Credential Requirements

It is the policy of Glen Oaks Community College that faculty shall possess at a minimum from a regionally accredited college or university:

  • a Master’s degree in the academic field to be taught. If this is not possessed, then
  • a Master’s in any academic field, with 18 graduate semester hours in the academic field to be taught. If this is not possessed, then a Master’s in any academic field with evidence of expertise in the academic field to be taught and demonstrated through publications in the field, wide critical and public acclaim, industry certifications in the field, years of experience working in the field successfully, or other evidence as defined in document: “The Higher Learning Commission Guidance on Determining Qualified Faculty”.

Minimum requirement exceptions may include non-transferable and/or occupational disciplines.

Faculty who do not currently possess the appropriate qualifications must present a written document outlining how he/she will obtain the qualification and the time frame in which he/she will do so. This plan must be approved by the Credentialing Committee.

The teaching candidate may present evidence of qualifications to the Credentialing Committee. The Credentialing Committee will include the Dean of Teaching and Learning, the Associate Dean of Extended Learning and Workforce Development, and three faculty members—one of whom should have expertise in the teaching field being reviewed.

The DLAT committee may also review and recommend submissions of evidence of expertise for any Distance Learning faculty member requesting such review/consideration as noted in the Letter of Agreement.

Updated March 25, 2013

Benefits

Medical Benefits

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Faculty

MESSA ABC

MESSA ABC
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

MESSA: ABC & ABC RX (Plan 1) – Glen Oaks Community College
Coverage Period: Beginning on or after 01/01/2018
Coverage for: Individual/Family | Plan Type: PPO
Triangle Warning IconThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. Note: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage or to get a copy of the complete terms of coverage, visit www.messa.org or call MESSA at 800-336-0013. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call MESSA at 800-336-0013 to request a copy.
Important Questions Answers Why this Matters:
In-Network Out-of-Network
What is the overall deductible? $1,350 Individual/ $2,700 Family $2,700 Individual/ $5,400 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible? Yes. Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ .
Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?
(May include a coinsurance maximum)
$2,350 Individual/ $4,700 Family $4,700 Individual/ $9,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider? Yes. For a list of network providers see www.messa.org or call MESSA at 800-336-0013. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do I need a referral to see a specialist? No. You can see the specialist you choose without a referral.

Group Number 71452, 71453-161, 162

Triangle Warning Icon

All co-payment and co-insurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
In-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness No charge 20% coinsurance None
Specialist visit No charge 20% coinsurance None
Preventive care/ screening/ immunization No charge; deductible does not apply Not Covered You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance None
Imaging (CT/PET scans, MRIs) No charge 20% coinsurance May require preauthorization.
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.messa.org
Generic or prescribed over-the-counter drugs $10 copay/prescription for retail 34-day supply, $20 copay/prescription for 90-day supply $10 copay/prescription for retail 34-day supply, $20 copay/prescription for 90-day supply plus an additional 25% of BCBSM approved amount for the drug Preventive drugs covered in full. Mail order drugs are not covered out-of-network.
Preferred brand-name drugs $40 copay/prescription for retail 34-day supply, $80 copay/prescription for 90-day supply $40 copay/prescription for retail 34-day supply, $80 copay/prescription for 90-day supply plus an additional 25% of BCBSM approved amount for the drug
Non-Preferred brand-name drugs $40 copay/prescription for retail 34-day supply, $80 copay/prescription for 90-day supply $40 copay/prescription for retail 34-day supply, $80 copay/prescription for 90-day supply plus an additional 25% of BCBSM approved amount for the drug
If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance None
Physician/surgeon fees No charge 20% coinsurance None
If you need immediate medical attention Emergency room care No charge No charge None
Emergency medical transportation No charge No charge Mileage limits apply.
Urgent care No charge 20% coinsurance None
If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance Preauthorization may be required.
Physician/surgeon fee No charge 20% coinsurance None
If you need mental health, behavioral health, or substance use disorder services Outpatient services No charge 20% coinsurance None
Inpatient services No charge 20% coinsurance Preauthorization is required.
If you are pregnant Office visits No charge; deductible does not apply 20% coinsurance Maternity care may include services described elsewhere in the SBC (i.e. tests) and cost share may apply. Cost sharing does not apply to certain maternity services considered to be preventive.
Childbirth/delivery professional services No charge 20% coinsurance None
Childbirth/delivery facility services No charge 20% coinsurance None
If you need help recovering or have other special health needs Home health care No charge No charge Preauthorization is required.
Rehabilitation services No charge 20% coinsurance Physical, Occupational, Speech therapy is limited to a combined maximum of 60 visits per member, per calendar year.
Habilitation services No charge 20% coinsurance Applied behavioral analysis (ABA) treatment for Autism – when rendered by an approved board-certified analyst – is covered through age 18, subject to preauthorization.
Skilled nursing care No charge No charge Preauthorization is required. Limited to a maximum of 120 days per member, per calendar year.
Durable medical equipment No charge No charge Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required.
Hospice services No charge No charge Preauthorization is required. Unlimited visits.
If your child needs dental or eye care Children’s eye exam Not Covered Not Covered None
Children’s glasses Not Covered Not Covered None
Children’s dental checkup Not Covered Not Covered None

 

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan documents for more information and a list of any other excluded services.)


  • Cosmetic surgery
  • Dental care (Adult)
  • Long-term care
  • Routine eye care (Adult)
  • Routine foot care
  • Weight Loss programs

 

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan documents.)


  • Acupuncture
  • Bariatric surgery
  • Chiropractic care
  • Coverage provided outside the United States.
    See www.messa.org
  • Hearing Aids
  • Infertility treatment
  • Non-Emergency care when traveling outside the U.S.
  • Private-duty nursing
  • If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered.

 

Your Rights to Continue Coverage:

There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x61565 or www.cciio.cms.gov or by calling 1-800-324-6172. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:

There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: MESSA by calling 800-336-0013.

Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) Department of Insurance and Financial Services, P. O. Box 30220, Lansing, MI 48909-7720 or http://www.michigan.gov/difs or difs-HICAP@michigan.gov

Does this plan provide Minimum Essential Coverage?

Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards?

Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
(IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.)

Language Access Services:

If you, or someone you’re helping, needs assistance, you have the right to get help and information in your language at no cost. To talk to an interpreter, call MESSA’s Member Service Center at 800.336.0013 or TTY 888.445.5614.

 

~To see examples of how this plan might cover costs for a sample medical situation, see the next section~

 

About these Coverage Examples:

Triangle Warning IconThis is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments, and coinsurance) and excluded services under this plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

 

Peg is Having a Baby
(9 months of in participating prenatal care and a hospital delivery)
• The plan’s overall deductible $1,350
Specialist copayment 0%
• Hospital (facility) coinsurance 0%
• Other coinsurance 0%

This EXAMPLE event includes services like:

  • Specialist office visits (prenatal care)
  • Childbirth/Delivery Professional Services
  • Childbirth/Delivery Facility Services
  • Diagnostic tests (ultrasounds and blood work)
  • Specialist visit (anesthesia)
Total Example Cost $12,700

In this example, Peg would pay:

Cost Sharing
Deductibles $1,350
Co-payments $80
Co-insurance $0
What isn’t covered
Limits or exclusions $0
The total Peg would pay $1,430
Managing Joe’s type 2 Diabetes
(a year of routine in participating care of a well controlled condition)
• The plan’s overall deductible $1,350
Specialist copayment 0%
• Hospital (facility) coinsurance 0%
• Other coinsurance 0%

This EXAMPLE event includes services like:

  • Primary care physician office visits (including disease education)
  • Diagnostic tests (blood work)
  • Prescription drugs
  • Durable medical equipment (glucose meter)
Total Example Cost $7,400

In this example, Joe would pay:

Cost Sharing
Deductibles $1,350
Co-payments $870
Co-insurance $0
What isn’t covered
Limits or exclusions $0
The total Joe would pay $2,220
Mia’s Simple Fracture
(in participating emergency room visit and follow up care)
• The plan’s overall deductible $1,350
Specialist copayment 0%
• Hospital (facility) coinsurance 0%
• Other coinsurance 0%

This EXAMPLE event includes services like:

  • Emergency room care (including medical supplies)
  • Diagnostic test (x-ray)
  • Durable medical equipment (crutches)
  • Rehabilitation services (physical therapy)
Total Example Cost $1,900

In this example, Mia would pay:

Cost Sharing
Deductibles $1,350
Co-payments $0
Co-insurance $0
What isn’t covered
Limits or exclusions $0
The total Mia would pay
$1,350

The plan would be responsible for the other costs of these EXAMPLE covered services.

 

Important Disclosure
MESSA and Blue Cross Blue Shield of Michigan (BCBSM) comply with federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. MESSA and BCBSM provide free auxiliary aids and services to people with disabilities to communicate effectively with us, including qualified sign language interpreters. If you need assistance, call MESSA’s Member Service Center at 800.336.0013 or TTY 888.445.5614.

If you need help filing a grievance, MESSA’s general counsel is available to help you. If you believe that MESSA or BCBSM failed to provide services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person, or by mail, phone, fax or email: General Counsel, MESSA, P.O. Box 2560, East Lansing, MI 48826‐2560, 800.292.4910, TTY: 888.445.5613, fax: 517.203.2909 or CivilRights‐GeneralCounsel@messa.org.

You can also file a civil rights complaint with the Office for Civil Rights on the web at OCRComplaint@hhs.gov, or by mail, phone or email: U.S. Department of Health & Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201, 800.368.1019, TTD: 800.537.7697, or OCRComplaint@hhs.gov.

*For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.

MESSA Choices SBC

MESSA Choices SBC
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

MESSA: Choices & Saver RX – Glen Oaks Community College

Coverage Period: Beginning on or after 01/01/2015
Coverage for: Individual/Family | Plan Type: PPO
Triangle Warning IconThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. Note: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage or to get a copy of the complete terms of coverage, visit www.messa.org or call MESSA at 800-336-0013. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call MESSA at 800-336-0013 to request a copy.
Important Questions Answers Why this Matters:
In-Network Out-of-Network
What is the overall deductible? $300 Individual/ $600 Family $600 Individual/ $1,200 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible? Yes. Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ .
Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?
(May include a coinsurance maximum)
$1,300 Individual/ $2,600 Family $2,600 Individual/ $5,200 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider? Yes. For a list of network providers see www.messa.org or call MESSA at 800-336-0013. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do I need a referral to see a specialist? No. You can see the specialist you choose without a referral.

Group Number 71452, 71538-148

Triangle Warning Icon

All co-payment and co-insurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
In-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $20 copay/office visit 20% coinsurance Copay is waived if seen on same date of injury.
Specialist visit $20 copay/visit 20% coinsurance None
Preventive care/ screening/ immunization No charge; deductible does not apply Not Covered You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance None
Imaging (CT/PET scans, MRIs) No charge 20% coinsurance May require preauthorization.
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.messa.org
Generic or prescribed over-the-counter drugs $10 copay/prescription for retail 34-day supply, $20 copay/prescription for 90-day supply; deductible does not apply $10 copay/prescription for retail 34-day supply, $20 copay/prescription for 90-day supply plus an additional 25% of BCBSM approved amount for the drug; deductible does not apply Preventive drugs covered in full. Your prescription drug coverage has a separate out-of-pocket limit of $1,000/$2,000. Mail order drugs are not covered out-of-network.
Preferred brand-name drugs $40 copay/prescription for retail 34-day supply, $80 copay/prescription for 90-day supply; deductible does not apply $40 copay/prescription for retail 34-day supply, $80 copay/prescription for 90-day supply plus an additional 25% of BCBSM approved amount for the drug; deductible does not apply
Non-Preferred brand-name drugs $40 copay/prescription for retail 34-day supply, $80 copay/prescription for 90-day supply; deductible does not apply $40 copay/prescription for retail 34-day supply, $80 copay/prescription for 90-day supply plus an additional 25% of BCBSM approved amount for the drug; deductible does not apply
If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance None
Physician/surgeon fees No charge 20% coinsurance None
If you need immediate medical attention Emergency room care $50 copay/visit $50 copay/visit Copay waived if admitted or accidental injury.
Emergency medical transportation No charge No charge Mileage limits apply.
Urgent care $25 copay/visit 20% coinsurance None
If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance Preauthorization may be required.
Physician/surgeon fee No charge 20% coinsurance None
If you need mental health, behavioral health, or substance use disorder services Outpatient services $20 copay/visit 20% coinsurance None
Inpatient services No charge 20% coinsurance Preauthorization is required.
If you are pregnant Office visits No charge; deductible does not apply 20% coinsurance Maternity care may include services described elsewhere in the SBC (i.e. tests) and cost share may apply. Cost sharing does not apply to certain maternity services considered to be preventive.
Childbirth/delivery professional services No charge 20% coinsurance None
Childbirth/delivery facility services No charge 20% coinsurance None
If you need help recovering or have other special health needs Home health care No charge No charge Preauthorization is required.
Rehabilitation services No charge 20% coinsurance Physical, Occupational, Speech therapy is limited to a combined maximum of 60 visits per member, per calendar year.
Habilitation services No charge 20% coinsurance Applied behavioral analysis (ABA) treatment for Autism – when rendered by an approved board-certified analyst – is covered through age 18, subject to preauthorization.
Skilled nursing care No charge No charge Preauthorization is required. Limited to a maximum of 120 days per member, per calendar year.
Durable medical equipment No charge No charge Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required.
Hospice services No charge No charge Preauthorization is required. Unlimited visits.
If your child needs dental or eye care Children’s eye exam Not Covered Not Covered None
Children’s glasses Not Covered Not Covered None
Children’s dental checkup Not Covered Not Covered None

 

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan documents for more information and a list of any other excluded services.)


  • Cosmetic surgery
  • Dental care (Adult)
  • Long-term care
  • Routine eye care (Adult)
  • Routine foot care
  • Weight Loss programs

 

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan documents.)


  • Acupuncture
  • Bariatric surgery
  • Chiropractic care
  • Coverage provided outside the United States.
    See www.messa.org
  • Hearing Aids
  • Infertility treatment
  • Non-Emergency care when travelling outside the U.S.
  • Private-duty nursing
  • If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered.

 

Your Rights to Continue Coverage:

There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x61565 or www.cciio.cms.gov or by calling 1-800-324-6172. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:

There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: MESSA by calling 800-336-0013.

Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) Department of Insurance and Financial Services, P. O. Box 30220, Lansing, MI 48909-7720 or http://www.michigan.gov/difs or difs-HICAP@michigan.gov

Does this plan provide Minimum Essential Coverage?

Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards?

Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
(IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.)

Language Access Services:

If you, or someone you’re helping, needs assistance, you have the right to get help and information in your language at no cost. To talk to an interpreter, call MESSA’s Member Service Center at 800.336.0013 or TTY 888.445.5614.

 

~To see examples of how this plan might cover costs for a sample medical situation, see the next section~

 

About these Coverage Examples:
Triangle Warning IconThis is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments, and coinsurance) and excluded services under this plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

 

Peg is Having a Baby
(9 months of in participating pre natal care and a hospital delivery)
• The plan’s overall deductible $500
Specialist copayment $20
• Hospital (facility) coinsurance 0%
• Other coinsurance 0%

This EXAMPLE event includes services like:

  • Specialist office visits (prenatal care)
  • Childbirth/Delivery Professional Services
  • Childbirth/Delivery Facility Services
  • Diagnostic tests (ultrasounds and blood work)
  • Specialist visit (anesthesia)
Total Example Cost $12,700

In this example, Peg would pay:

Cost Sharing
Deductibles $3,00
Co-payments $120
Co-insurance $0
What isn’t covered
Limits or exclusions $0
The total Peg would pay $420
Managing Joe’s type 2 Diabetes
(a year of routine in participating care of a well controlled condition)
• The plan’s overall deductible $300
Specialist copayment $20
• Hospital (facility) coinsurance 0%
• Other coinsurance 0%

This EXAMPLE event includes services like:

  • Primary care physician office visits (including disease education)
  • Diagnostic tests (blood work)
  • Prescription drugs
  • Durable medical equipment (glucose meter)
Total Example Cost $7,400

In this example, Joe would pay:

Cost Sharing
Deductibles $300
Co-payments $990
Co-insurance $0
What isn’t covered
Limits or exclusions $0
The total Joe would pay
$1,290
Mia’s Simple Fracture
(in participating emergency room visit and follow up care)
• The plan’s overall deductible $300
Specialist copayment $20
• Hospital (facility) coinsurance 0%
• Other coinsurance 0%

This EXAMPLE event includes services like:

  • Emergency room care (including medical supplies)
  • Diagnostic test (x-ray)
  • Durable medical equipment (crutches)
  • Rehabilitation services (physical therapy)
Total Example Cost $1,900

In this example, Mia would pay:

Cost Sharing
Deductibles $300
Co-payments $190
Co-insurance $0
What isn’t covered
Limits or exclusions $0
The total Mia would pay
$490

The plan would be responsible for the other costs of these EXAMPLE covered services.

 

Important Disclosure
MESSA and Blue Cross Blue Shield of Michigan (BCBSM) comply with federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. MESSA and BCBSM provide free auxiliary aids and services to people with disabilities to communicate effectively with us, including qualified sign language interpreters. If you need assistance, call MESSA’s Member Service Center at 800.336.0013 or TTY 888.445.5614.

If you need help filing a grievance, MESSA’s general counsel is available to help you. If you believe that MESSA or BCBSM failed to provide services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person, or by mail, phone, fax or email: General Counsel, MESSA, P.O. Box 2560, East Lansing, MI 48826‐2560, 800.292.4910, TTY: 888.445.5613, fax: 517.203.2909 or CivilRights‐GeneralCounsel@messa.org.

You can also file a civil rights complaint with the Office for Civil Rights on the web at OCRComplaint@hhs.gov, or by mail, phone or email: U.S. Department of Health & Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201, 800.368.1019, TTD: 800.537.7697, or OCRComplaint@hhs.gov.

 

*For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.

GOSSE/Administration

Priority Health – 250/500

Priority Health 250-500
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Priority Health: POS 100 – Glen Oaks Community College
Coverage Period: 01/01/2018 – 12/31/2018
Coverage for: Subscriber/Dependent | Plan Type: POS
Triangle Warning IconThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. Note: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage or to get a copy of the complete terms of coverage, visit us at PriorityHealth.com or call 1-800-446-5674. For general definitions of common terms, such as allowed amount, balance billing, co-insurance, co-payment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-800-446-5674 to request a copy.
Important Questions Answers Why this Matters
What is the overall deductible? For participating providers $250 person / $500 family
For non-participating providers $500 person / $1,000 family
The deductible for each benefit level is calculated separately. Amounts you pay toward the deductible do not count toward any co-insurance maximums.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible? Yes, the preferred benefits deductible doesn’t apply to preventive care, certain services subject to flat dollar co-pays and prescription drugs. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ .
Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan? Yes. For participating providers $7,150 person / $14,300 family
For non-participating providers $14,300 person / $28,600 family
Your plan also has a co-insurance maximum.
For participating providers $0 person / $0 family
For non-participating providers $2,500 person / $5,000 family
The co-insurance maximum limits the total amount of co-insurance you will pay for certain covered services during a coverage period. The co-insurance maximum is included in the out-of-pocket limit. The out-of- pocket limit and co-insurance maximum for each benefit level is calculated separately.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit? Premiums, balance-billed charges, health care this plan doesn’t cover, services that exceed an annual day/visit limit, and any co-pays and co-insurance you pay for any non-essential health benefit. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Does this plan use a participating of providers? Yes. See PriorityHealth.com
or call 1-800-446-5674 for list of participating providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do I need a referral to see a specialist? No, you don’t need a referral in order to receive the preferred benefit for services provided by a participating specialist. Yes, you do need a referral in order to receive the preferred benefit for services provided by a non-participating specialist. You can see the in-participating specialist you choose without a referral. This plan will pay some or all of the costs to see an out-of-network specialist for covered services but only if you have a referral before you see the specialist.

 

Triangle Warning Icon

All co-payment and co-insurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)
If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $20 co-pay/ visit 20% co-insurance/ visit

Preferred benefit level deductible does not apply to services subject to flat dollar co-pays.

Prescription drug co-pay may also apply when selected injectable drugs are provided.

Prescription drugs for infertility treatment covered only with prescription drug addendum.

Retail health clinic services are covered at reasonable and customary charges.

Specialist visit $35 co-pay/ visit 20% co-insurance/ visit
Other practitioner office visit

•$75 co-pay/ visit for evaluation/ management services only at retail health clinics

•50% co-insurance/ visit for family planning/ infertility services

•50% co-insurance for Temporomandibular Joint Function (TMJ) treatment and Orthognathic surgery

•Evaluation/management services only at retail health clinics covered at the preferred benefit level

•Family planning/ infertility services not covered

•50% co-insurance for Temporomandibular Joint Function (TMJ) treatment and Orthognathic surgery

Preventive care/screening/immunization No charge 20% co-insurance/ visit

Preventive care services are those listed in Priority Health’s Preventive Health Care Guidelines, including women’s preventive health care services.

Preferred benefit level deductible does not apply.

You may have to pay for services that aren’t preventive.

Ask your provider if the services needed are preventive. Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work) No charge 20% co-insurance ———–none———–
Imaging (CT/PET scans, MRIs) $150 co-pay 20% co-insurance

Prior Approval required for certain radiology examinations.

Preferred benefits co-pay waived if performed while confined in a hospital as an inpatient.

Maximum of 10 co-pays per individual per contract year for imaging services.

Preferred benefit level deductible does not apply.

 

Common Medical Events Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at https://www.priorityhealth.com/prog/pharmacy/pharmacy.cgi

Generic drugs $10 co-pay/ retail prescription
$20 co-pay/ mail order prescription
Not covered

Costs shown in the “Your Cost” columns apply to drugs on the approved drug list when obtained from a Participating Provider.

Covers up to a 31-day supply (retail prescription); Covers up to a 90 day supply (mail order prescription)

Up to a 90-day supply of medication (excluding Specialty Drugs) may be obtained at one time for three applicable Copayments at a retail Participating Pharmacy.

50% co-insurance/ prescription for infertility drugs.

Deductible does not apply.

Preferred brand drugs $40 co-pay/ retail prescription
$80 co-pay/ mail order prescription
Not covered
Non-preferred brand drugs $80 co-pay/ retail prescription
$160 co-pay/ mail order prescription
Not covered
Preferred specialty drugs $40 co-pay/ retail prescription Not covered Deductible does not apply.
Non-Preferred specialty drugs $80 co-pay/ retail prescription Not covered
If you have outpatient surgery Facility fee (e.g., ambulatory
surgery center)
No charge 20% co-insurance/ visit

Including outpatient care, observation care and ambulatory surgery center care. Prior approval may be required.

Prior approval is required for bariatric surgery.

Coverage is limited to one bariatric surgery per lifetime.

Unless medically necessary, a second bariatric surgery is not Covered, even if the first procedure occurred prior to joining this plan.

Physician/surgeon fees No charge 20% co-insurance/ visit
If you need immediate medical attention Emergency room services $150 co-pay/ visit Covered at the preferred benefit level

Co-pay waived if you become confined in a Hospital as an inpatient.

Preferred benefit level deductible does not apply.

Emergency medical
transportation
$150 co-pay Covered at the preferred benefit level Preferred benefit level deductible does not apply.
Urgent care $75 co-pay/ visit 20% co-insurance/ visit

Urgent Care services received from a Non-Participating Provider who is located outside of our Service Area are Covered at the Preferred Benefit level.

Preferred benefit level deductible does not apply.

 

Common Medical Events Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)
If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% co-insurance/ visit

Prior Approval is required at least 5 working days in advance, except in emergencies or for Hospital stays for a mother and her Newborn of up to 48 hours following a vaginal delivery and 96 hours following a cesarean section.

Notification must be provided for all admissions following emergency room care.

Prior approval is required for bariatric surgery.

Coverage is limited to one bariatric surgery per lifetime. Unless medically necessary, a second bariatric surgery is not Covered, even if the first procedure occurred prior to joining this plan.

Physician/surgeon fee No charge 20% co-insurance/ visit
If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health
outpatient services
$20 co-pay/ visit 20% co-insurance/ visit

No charge for first three visits with participating provider within 90 days of discharge from a participating hospital for mental health inpatient care.

Including medication management visits.

Preferred benefit level deductible does not apply.

Mental/Behavioral health
inpatient services
No charge 20% co-insurance/ visit

Including partial hospitalization.

Except in an emergency, prior approval required.

Residential Treatment is subject to the skilled nursing care benefits described below.

Substance use disorder
outpatient services
$20 co-pay/ visit 20% co-insurance/ visit

Prior Approval required for intensive outpatient treatment.

Including medication management visits.

Preferred benefit level deductible does not apply.

Substance use disorder
inpatient services
No charge 20% co-insurance/ visit

Including partial hospitalization.

Except in an emergency, prior approval required.

Residential Treatment is subject to the skilled nursing care benefits described below.

If you are pregnant Routine prenatal and
postnatal care
No charge 20% co-insurance/ visit

Routine prenatal and postnatal visits are covered under your Preventive Health Care Services benefit.

Appropriate office visit charge (PCP or specialist) may apply for physician office services or home visits and consultations for complications of pregnancy.

Delivery and all inpatient
services
No charge 20% co-insurance/ visit ———–none———–

 

Common Medical Events Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)
If you need help recovering or have other special health needs Home health care No charge 20% co-insurance/ visit

Including hospice care services; excluding rehabilitation and habilitation services.

Prior approval required except for hospice care services in the home.

Rehabilitation services not for the treatment of Autism Spectrum Disorder $20 co-pay/ visit 50% co-insurance/ visit

Physical and occupational therapy (Including osteopathic and chiropractic manipulation) limited to a combined 50 visits per contract year.

Speech therapy limited to a combined 50 visits per contract year.

Cardiac rehabilitation & pulmonary rehabilitation limited to a
combined 50 visits per contract year.

Preferred benefit level deductible does not apply.

Habilitation services for treatment of Autism Spectrum Disorder only

•$20 co-pay/ visit for Physical, Occupational and Speech Therapy

•No charge for Applied Behavior Analysis (ABA) services

50% co-insurance/ visit Prior Approval required for Applied Behavior Analysis (ABA).
Services are Covered for children and adolescents under age 19 only.Multiple charges may apply during one day of service.Preferred benefit level deductible does not apply to flat dollar copays.
Habilitation services not for the treatment of Autism Spectrum Disorder Not covered Not covered Not covered
Skilled nursing care No charge 20% co-insurance/ visit

Services received in a skilled nursing care facility, subacute facility, behavioral health Residential Treatment facility, inpatient rehabilitation care facility or hospice care facility are limited to a combined 120 days per contract year.

Prior approval required.

Durable medical equipment (DME) No charge 50% co-insurance

Including rental, purchase or repair.

Prior Approval required for equipment over $1,000, all rentals and all shoe inserts.

Prosthetics & orthotics No charge 50% co-insurance
Hospice service No charge 20% co-insurance/ visit

This benefit applies to hospice services provided in the home only.

Any hospice services provided in a facility will be subject to the appropriate facility benefit.

If your child needs dental or eye care Child eye exam Not covered Not covered Not covered
Child glasses Not covered Not covered Not covered
Child dental check-up Not covered Not covered Not covered

 

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan documents for more information and a list of any other excluded services.)


  • Acupuncture
  • Cosmetic surgery
  • Dental care (Adult & Child)
  • Habilitation services not for the treatment of Autism Spectrum Disorder
  • Hearing aids
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Private-duty nursing
  • Routine eye care (Adult & Child)
  • Routine foot care

 

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan documents.)


  • Bariatric surgery
  • Chiropractic care
  • Emergency services provided outside the U.S.
  • Infertility treatment – diagnostic, counseling and planning services for the underlying cause of infertility
  • Weight loss programs

 

Your Rights to Continue Coverage:

There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or difs-HICAP@michigan.gov; the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x61565 or www.cciio.cms.gov; or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:

There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Priority Health at 1-800-446-5674 or www.priorityhealth.com; the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or the Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or difs-HICAP@michigan.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) at 1-877-999-6442 or difs-HICAP@michigan.gov.

Does this plan provide Minimum Essential Coverage?

Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards?

Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-800-446-5674.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-446-5674.
Chinese (中文): 如果需要中文的帮助,请拨打这个号码1-800-446-5674.
Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-446-5674.

~To see examples of how this plan might cover costs for a sample medical situation, see the next section~

 

About these Coverage Examples:
Triangle Warning IconThis is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, co-payments, and co-insurance) and excluded services under this plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

 

Peg is Having a Baby
(9 months of in participating pre natal care and a hospital delivery)
• The plan’s overall deductible $1000
Specialist copayment $50
• Hospital (facility) coinsurance 20%
• Other coinsurance 20%

This EXAMPLE event includes services like:

  • Specialist office visits (prenatal care)
  • Childbirth/Delivery Professional Services
  • Childbirth/Delivery Facility Services
  • Diagnostic tests (ultrasounds and blood work)
  • Specialist visit (anesthesia)
Total Example Cost $12,800

In this example, Peg would pay:

Cost Sharing
Deductibles $1,000
Co-payments $130
Co-insurance $2,480
What isn’t covered
Limits or exclusions $60
The total Peg would pay $3,670
Managing Joe’s Type 2 Diabetes
(a year of routine in participating care of a well controlled condition)
• The plan’s overall deductible $1000
Specialist copayment $50
• Hospital (facility) coinsurance 20%
• Other coinsurance 20%

This EXAMPLE event includes services like:

  • Primary care physician office visits (including disease education)
  • Diagnostic tests (blood work)
  • Prescription drugs
  • Durable medical equipment (glucose meter)
Total Example Cost $7,400

In this example, Joe would pay:

Cost Sharing
Deductibles $971
Co-payments $1,495
Co-insurance $891
What isn’t covered
Limits or exclusions $55
The total Joe would pay
$3,412
Mia’s Simple Fracture
(in participating emergency room visit and follow up care)
• The plan’s overall deductible $1000
Specialist copayment $50
• Hospital (facility) coinsurance 20%
• Other coinsurance 20%

This EXAMPLE event includes services like:

  • Emergency room care (including medical supplies)
  • Diagnostic test (x-ray)
  • Durable medical equipment (crutches)
  • Rehabilitation services (physical therapy)
Total Example Cost $1,900

In this example, Mia would pay:

Cost Sharing
Deductibles $581
Co-payments $440
Co-insurance $143
What isn’t covered
Limits or exclusions $0
The total Mia would pay
$1,101

The plan would be responsible for the other costs of these EXAMPLE covered services.

 

*For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.

Priority Health – 1350/2700 HSA

Priority Health 1350-2700
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Priority Health: POS/HSA High – Glen Oaks Community College
Coverage Period: 01/01/2018 – 12/31/2018
Coverage for: Subscriber/Dependent |Plan Type: POS
Triangle Warning IconThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. Note: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage or to get a copy of the complete terms of coverage, visit us at PriorityHealth.com or call 1-800-446-5674. For general definitions of common terms, such as allowed amount, balance billing, co-insurance, co-payment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-800-446-5674 to request a copy.
Important Questions Answers Why this Matters
What is the overall deductible? For participating providers $1,350 person / $2,700 family
For non-participating providers $3,000 person / $6,000 family
The deductible for each benefit level is calculated separately.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, the overall family deductible must be met before the plan begins to pay.
Are there services covered before you meet your deductible? Yes, the preferred benefits deductible doesn’t apply to preventive care. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ .
Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan? Yes. For participating providers $2,000 person / $4,000 family
For non-participating providers $4,000 person / $8,000 family
The out-of- pocket limit for each benefit level is calculated separately.
The maximum preferred out-of-pocket limit for any one individual within the family is $4,000.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met.
What is not included in the out-of-pocket limit? Premiums, balance-billed charges, health care this plan doesn’t cover, services that exceed an annual day/visit limit, and any co-pays and co-insurance you pay for any non-essential health benefit. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Does this plan use a participating of providers? Yes. See PriorityHealth.com
or call 1-800-446-5674 for list of participating providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do I need a referral to see a specialist?

No, you don’t need a referral in order to receive the preferred benefit for services provided by a participating specialist.

Yes, you do need a referral in order to receive the preferred benefit for services provided by a non-participating specialist.

You can see the in-network specialist you choose without a referral.

This plan will pay some or all of the costs to see an out-of-network specialist for covered services but only if you have a referral before you see the specialist.

 

Triangle Warning Icon

All co-payment and co-insurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)
If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness No charge 20% co-insurance/ visit

Prescription drug co-pay may also apply when selected injectable drugs are provided.

Prescription drugs for infertility treatment covered only with prescription drug addendum.

Retail health clinic services are covered at reasonable and customary charges.

Specialist visit No charge 20% co-insurance/ visit
Other practitioner office visit

•No charge for evaluation/ management services only at retail health clinics

•50% co-insurance/ visit for family planning/ infertility services

•50% co-insurance for Temporomandibular Joint Function (TMJ) treatment and Orthognathic surgery

•Evaluation/management services only at retail health clinics covered at the preferred benefit level

•Family planning/ infertility services not covered

•50% co-insurance for Temporomandibular Joint Function (TMJ) treatment and Orthognathic surgery

Preventive care/screening/immunization No charge 20% co-insurance/ visit

Preventive care services are those listed in Priority Health’s Preventive Health Care Guidelines, including women’s preventive health care services. Preferred benefit level deductible does not apply.

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work) No charge 20% co-insurance ———–none———–
Imaging (CT/PET scans, MRIs) No charge 20% co-insurance Prior Approval required for certain radiology examinations.

 

Common Medical Events Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at https://www.priorityhealth.com/prog/pharmacy/pharmacy.cgi

Generic drugs $10 co-pay/ retail prescription
$20 co-pay/ mail order prescription
Not covered

Costs shown in the “Your Cost” columns apply to drugs on the approved drug list when obtained from a Participating Provider.

Covers up to a 31-day supply (retail prescription); Covers up to a 90 day supply (mail order prescription)

Up to a 90-day supply of medication (excluding Specialty Drugs) may be obtained at one time for three applicable Copayments at a retail Participating Pharmacy.

50% co-insurance/ prescription for infertility drugs.

Preferred brand drugs $40 co-pay/ retail prescription
$80 co-pay/ mail order prescription
Not covered
Non-preferred brand drugs $80 co-pay/ retail prescription
$160 co-pay/ mail order prescription
Not covered
Preferred specialty drugs $40 co-pay/ retail prescription Not covered ———–none———–
Non-Preferred specialty drugs $80 co-pay/ retail prescription Not covered
If you have outpatient surgery Facility fee (e.g., ambulatory
surgery center)
No charge 20% co-insurance/ visit

Including outpatient care, observation care and ambulatory surgery center care. Prior approval may be required.

Prior approval is required for bariatric surgery.

Coverage is limited to one bariatric surgery per lifetime.

Unless medically necessary, a second bariatric surgery is not Covered, even if the first procedure occurred prior to joining this plan.

Physician/surgeon fees No charge 20% co-insurance/ visit
If you need immediate medical attention Emergency room services No charge Covered at the preferred benefit level ———–none———–
Emergency medical
transportation
No charge Covered at the preferred benefit level ———–none———–
Urgent care No charge 20% co-insurance/ visit Urgent Care services received from a Non-Participating Provider who is located outside of our Service Area are Covered at the Preferred Benefit level.

 

Common Medical Events Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)
If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% co-insurance/ visit

Prior Approval is required at least 5 working days in advance, except in emergencies or for Hospital stays for a mother and her Newborn of up to 48 hours following a vaginal delivery and 96 hours following a cesarean section.

Notification must be provided for all admissions following emergency room care.

Prior approval is required for bariatric surgery.

Coverage is limited to one bariatric surgery per lifetime. Unless medically necessary, a second bariatric surgery is not Covered, even if the first procedure occurred prior to joining this plan.

Physician/surgeon fee No charge 20% co-insurance/ visit
If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services No charge 20% co-insurance/ visit

No charge for first three visits with participating provider within 90 days of discharge from a participating hospital for mental health inpatient care.

Including medication management visits.

Mental/Behavioral health
inpatient services
No charge 20% co-insurance/ visit

Including partial hospitalization.

Except in an emergency, prior approval required.

Residential Treatment is subject to the skilled nursing care benefits described below.

Substance use disorder
outpatient services
No charge 20% co-insurance/ visit

Prior Approval required for intensive outpatient treatment.

Including medication management visits.

Substance use disorder
inpatient services
No charge 20% co-insurance/ visit

Including partial hospitalization.

Except in an emergency, prior approval required.

Residential Treatment is subject to the skilled nursing care benefits described below.

If you are pregnant Routine prenatal and
postnatal care
No charge 20% co-insurance/ visit

Routine prenatal and postnatal visits are covered under your Preventive Health Care Services benefit.

Appropriate office visit charge (PCP or specialist) may apply for physician office services or home visits and consultations for complications of pregnancy.

Delivery and all inpatient
services
No charge 20% co-insurance/ visit ———–none———–

 

Common Medical Events Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)
If you need help recovering or have other special health needs Home health care No charge 20% co-insurance/ visit

Including hospice care services; excluding rehabilitation and habilitation services.

Prior approval required except for hospice care services in the home.

Rehabilitation services not for the treatment of Autism Spectrum Disorder No charge 20% co-insurance/ visit

Physical and occupational therapy (Including osteopathic and chiropractic manipulation) limited to a combined 50 visits per contract year.

Speech therapy limited to a combined 50 visits per contract year.

Cardiac rehabilitation & pulmonary rehabilitation limited to a
combined 50 visits per contract year.

Habilitation services for treatment of Autism Spectrum Disorder only No charge 20% co-insurance/ visit Prior Approval required for Applied Behavior Analysis (ABA).
Covered services include Physical, Occupational, Speech Therapy and Applied Behavior Analysis (ABA). Services are Covered for children and adolescents under age 19 only. Multiple charges may apply during one day of service.
Habilitation services not for the treatment of Autism Spectrum Disorder Not covered Not covered Not covered
Skilled nursing care No charge 20% co-insurance/ visit

Services received in a skilled nursing care facility, subacute facility, behavioral health Residential Treatment facility, inpatient rehabilitation care facility or hospice care facility are limited to a combined 90 days per contract year.

Prior approval required.

Durable medical equipment (DME) No charge 50% co-insurance/ visit

Including rental, purchase or repair.

Prior Approval required for equipment over $1,000, all rentals and all shoe inserts.

Prosthetics & orthotics No charge 50% co-insurance/ visit
Hospice service No charge 20% co-insurance/ visit

This benefit applies to hospice services provided in the home only.

Any hospice services provided in a facility will be subject to the appropriate facility benefit.

If your child needs dental or eye care Child eye exam Not covered Not covered Not covered
Child glasses Not covered Not covered Not covered
Child dental check-up Not covered Not covered Not covered

 

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan documents for more information and a list of any other excluded services.)


  • Acupuncture
  • Cosmetic surgery
  • Dental care (Adult & Child)
  • Habilitation services not for the treatment of Autism Spectrum Disorder
  • Hearing aids
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Private-duty nursing
  • Routine eye care (Adult & Child)
  • Routine foot care

 

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan documents.)


  • Bariatric surgery
  • Chiropractic care
  • Emergency services provided outside the U.S.
  • Infertility treatment – diagnostic, counseling and planning services for the underlying cause of infertility
  • Weight loss programs

 

Your Rights to Continue Coverage:

There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or difs-HICAP@michigan.gov; the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x61565 or www.cciio.cms.gov; or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:

There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Priority Health at 1-800-446-5674 or www.priorityhealth.com; the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or the Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or difs-HICAP@michigan.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) at 1-877-999-6442 or difs-HICAP@michigan.gov.

Does this plan provide Minimum Essential Coverage?

Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards?

Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-800-446-5674.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-446-5674.
Chinese (中文): 如果需要中文的帮助,请拨打这个号码1-800-446-5674.
Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-446-5674.

~To see examples of how this plan might cover costs for a sample medical situation, see the next section~

 

About these Coverage Examples:
Triangle Warning IconThis is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, co-payments, and co-insurance) and excluded services under this plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

 

Peg is Having a Baby
(9 months of in participating pre natal care and a hospital delivery)
• The plan’s overall deductible $3000
Specialist copayment 20%
• Hospital (facility) coinsurance 20%
• Other coinsurance 20%

This EXAMPLE event includes services like:

  • Specialist office visits (prenatal care)
  • Childbirth/Delivery Professional Services
  • Childbirth/Delivery Facility Services
  • Diagnostic tests (ultrasounds and blood work)
  • Specialist visit (anesthesia)
Total Example Cost $12,800

In this example, Peg would pay:

Cost Sharing
Deductibles $3,000
Co-payments $60
Co-insurance $2,520
What isn’t covered
Limits or exclusions $60
The total Peg would pay $5,640
Managing Joe’s type 2 Diabetes
(a year of routine in participating care of a well controlled condition)
• The plan’s overall deductible $3000
Specialist copayment 20%
• Hospital (facility) coinsurance 20%
• Other coinsurance 20%

This EXAMPLE event includes services like:

  • Primary care physician office visits (including disease education)
  • Diagnostic tests (blood work)
  • Prescription drugs
  • Durable medical equipment (glucose meter)
Total Example Cost $7,400

In this example, Joe would pay:

Cost Sharing
Deductibles $1,823
Co-payments $1,115
Co-insurance $1,104
What isn’t covered
Limits or exclusions $55
The total Joe would pay
$4,096
Mia’s Simple Fracture
(in participating emergency room visit and follow up care)
• The plan’s overall deductible $3000
Specialist copayment 20%
• Hospital (facility) coinsurance 20%
• Other coinsurance 20%

This EXAMPLE event includes services like:

  • Emergency room care (including medical supplies)
  • Diagnostic test (x-ray)
  • Durable medical equipment (crutches)
  • Rehabilitation services (physical therapy)
Total Example Cost $1,900

In this example, Mia would pay:

Cost Sharing
Deductibles $1,504
Co-payments $0
Co-insurance $396
What isn’t covered
Limits or exclusions $0
The total Mia would pay
$1,900

The plan would be responsible for the other costs of these EXAMPLE covered services.

 

*For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.

Priority Health - 2000/4000

Priority Health 2000-4000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Priority Health: POS/HSA High – Glen Oaks Community College
Coverage Period: 01/01/2018 – 12/31/2018
Coverage for: Subscriber/Dependent | Plan Type: POS
Triangle Warning IconThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. Note: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage or to get a copy of the complete terms of coverage, visit us at PriorityHealth.com or call 1-800-446-5674. For general definitions of common terms, such as allowed amount, balance billing, co-insurance, co-payment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-800-446-5674 to request a copy.
Important Questions Answers Why this Matters
What is the overall deductible? For participating providers $2,000 person / $4,000 family
For non-participating providers $3,500 person / $7,000 family
The deductible for each benefit level is calculated separately.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, the overall family deductible must be met before the plan begins to pay.
Are there services covered before you meet your deductible? Yes, the preferred benefits deductible doesn’t apply to preventive care. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ .
Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan? Yes. For participating providers $4,000 person / $8,000 family
For non-participating providers $5,500 person / $11,000 family
The out-of- pocket limit for each benefit level is calculated separately.
The maximum preferred out-of-pocket limit for any one individual within the family is $7,150.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met.
What is not included in the out-of-pocket limit? Premiums, balance-billed charges, health care this plan doesn’t cover, services that exceed an annual day/visit limit, and any co-pays and co-insurance you pay for any non-essential health benefit. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Does this plan use a participating of providers? Yes. See PriorityHealth.com
or call 1-800-446-5674 for list of participating providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do I need a referral to see a specialist?

No, you don’t need a referral in order to receive the preferred benefit for services provided by a participating specialist.

Yes, you do need a referral in order to receive the preferred benefit for services provided by a non-participating specialist.

You can see the in-network specialist you choose without a referral.

This plan will pay some or all of the costs to see an out-of-network specialist for covered services but only if you have a referral before you see the specialist.

 

Triangle Warning Icon

All co-payment and co-insurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)
If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness No charge 20% co-insurance/ visit

Prescription drug co-pay may also apply when selected injectable drugs are provided.

Prescription drugs for infertility treatment covered only with prescription drug addendum.

Retail health clinic services are covered at reasonable and customary charges.

Specialist visit No charge 20% co-insurance/ visit
Other practitioner office visit

•No charge for evaluation/ management services only at retail health clinics

•50% co-insurance/ visit for family planning/ infertility services

•50% co-insurance for Temporomandibular Joint Function (TMJ) treatment and Orthognathic surgery

•Evaluation/management services only at retail health clinics covered at the preferred benefit level

•Family planning/ infertility services not covered

•50% co-insurance for Temporomandibular Joint Function (TMJ) treatment and Orthognathic surgery

Preventive care/screening/immunization No charge 20% co-insurance/ visit

Preventive care services are those listed in Priority Health’s Preventive Health Care Guidelines, including women’s preventive health care services. Preferred benefit level deductible does not apply.

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work) No charge 20% co-insurance ———–none———–
Imaging (CT/PET scans, MRIs) No charge 20% co-insurance Prior Approval required for certain radiology examinations.

 

Common Medical Events Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at https://www.priorityhealth.com/prog/pharmacy/pharmacy.cgi

Generic drugs $10 co-pay/ retail prescription
$20 co-pay/ mail order prescription
Not covered

Costs shown in the “Your Cost” columns apply to drugs on the approved drug list when obtained from a Participating Provider.

Covers up to a 31-day supply (retail prescription); Covers up to a 90 day supply (mail order prescription)

Up to a 90-day supply of medication (excluding Specialty Drugs) may be obtained at one time for three applicable Copayments at a retail Participating Pharmacy.

50% co-insurance/ prescription for infertility drugs.

Preferred brand drugs $40 co-pay/ retail prescription
$80 co-pay/ mail order prescription
Not covered
Non-preferred brand drugs $80 co-pay/ retail prescription
$160 co-pay/ mail order prescription
Not covered
Preferred specialty drugs $40 co-pay/ retail prescription Not covered ———–none———–
Non-Preferred specialty drugs $80 co-pay/ retail prescription Not covered
If you have outpatient surgery Facility fee (e.g., ambulatory
surgery center)
No charge 20% co-insurance/ visit

Including outpatient care, observation care and ambulatory surgery center care. Prior approval may be required.

Prior approval is required for bariatric surgery.

Coverage is limited to one bariatric surgery per lifetime.

Unless medically necessary, a second bariatric surgery is not Covered, even if the first procedure occurred prior to joining this plan.

Physician/surgeon fees No charge 20% co-insurance/ visit
If you need immediate medical attention Emergency room services No charge Covered at the preferred benefit level ———–none———–
Emergency medical
transportation
No charge Covered at the preferred benefit level ———–none———–
Urgent care No charge 20% co-insurance/ visit Urgent Care services received from a Non-Participating Provider who is located outside of our Service Area are Covered at the Preferred Benefit level.

 

Common Medical Events Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)
If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% co-insurance/ visit

Prior Approval is required at least 5 working days in advance, except in emergencies or for Hospital stays for a mother and her Newborn of up to 48 hours following a vaginal delivery and 96 hours following a cesarean section.

Notification must be provided for all admissions following emergency room care.

Prior approval is required for bariatric surgery.

Coverage is limited to one bariatric surgery per lifetime. Unless medically necessary, a second bariatric surgery is not Covered, even if the first procedure occurred prior to joining this plan.

Physician/surgeon fee No charge 20% co-insurance/ visit
If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services No charge 20% co-insurance/ visit

No charge for first three visits with participating provider within 90 days of discharge from a participating hospital for mental health inpatient care.

Including medication management visits.

Mental/Behavioral health
inpatient services
No charge 20% co-insurance/ visit

Including partial hospitalization.

Except in an emergency, prior approval required.

Residential Treatment is subject to the skilled nursing care benefits described below.

Substance use disorder
outpatient services
No charge 20% co-insurance/ visit

Prior Approval required for intensive outpatient treatment.

Including medication management visits.

Substance use disorder
inpatient services
No charge 20% co-insurance/ visit

Including partial hospitalization.

Except in an emergency, prior approval required.

Residential Treatment is subject to the skilled nursing care benefits described below.

If you are pregnant Routine prenatal and
postnatal care
No charge 20% co-insurance/ visit

Routine prenatal and postnatal visits are covered under your Preventive Health Care Services benefit.

Appropriate office visit charge (PCP or specialist) may apply for physician office services or home visits and consultations for complications of pregnancy.

Delivery and all inpatient
services
No charge 20% co-insurance/ visit ———–none———–

 

Common Medical Events Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information
Participating Provider
(You will pay the least)
Non Participating Provider
(You will pay the most)
If you need help recovering or have other special health needs Home health care No charge 20% co-insurance/ visit

Including hospice care services; excluding rehabilitation and habilitation services.

Prior approval required except for hospice care services in the home.

Rehabilitation services not for the treatment of Autism Spectrum Disorder No charge 20% co-insurance/ visit

Physical and occupational therapy (Including osteopathic and chiropractic manipulation) limited to a combined 50 visits per contract year.

Speech therapy limited to a combined 50 visits per contract year.

Cardiac rehabilitation & pulmonary rehabilitation limited to a
combined 50 visits per contract year.

Habilitation services for treatment of Autism Spectrum Disorder only No charge 20% co-insurance/ visit Prior Approval required for Applied Behavior Analysis (ABA).
Covered services include Physical, Occupational, Speech Therapy and Applied Behavior Analysis (ABA). Services are Covered for children and adolescents under age 19 only. Multiple charges may apply during one day of service.
Habilitation services not for the treatment of Autism Spectrum Disorder Not covered Not covered Not covered
Skilled nursing care No charge 20% co-insurance/ visit

Services received in a skilled nursing care facility, subacute facility, behavioral health Residential Treatment facility, inpatient rehabilitation care facility or hospice care facility are limited to a combined 90 days per contract year.

Prior approval required.

Durable medical equipment (DME) No charge 50% co-insurance/ visit

Including rental, purchase or repair.

Prior Approval required for equipment over $1,000, all rentals and all shoe inserts.

Prosthetics & orthotics No charge 50% co-insurance/ visit
Hospice service No charge 20% co-insurance/ visit

This benefit applies to hospice services provided in the home only.

Any hospice services provided in a facility will be subject to the appropriate facility benefit.

If your child needs dental or eye care Child eye exam Not covered Not covered Not covered
Child glasses Not covered Not covered Not covered
Child dental check-up Not covered Not covered Not covered

 

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan documents for more information and a list of any other excluded services.)


  • Acupuncture
  • Cosmetic surgery
  • Dental care (Adult & Child)
  • Habilitation services not for the treatment of Autism Spectrum Disorder
  • Hearing aids
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Private-duty nursing
  • Routine eye care (Adult & Child)
  • Routine foot care

 

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan documents.)


  • Bariatric surgery
  • Chiropractic care
  • Emergency services provided outside the U.S.
  • Infertility treatment – diagnostic, counseling and planning services for the underlying cause of infertility
  • Weight loss programs

 

Your Rights to Continue Coverage:

There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or difs-HICAP@michigan.gov; the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x61565 or www.cciio.cms.gov; or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:

There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Priority Health at 1-800-446-5674 or www.priorityhealth.com; the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or the Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or difs-HICAP@michigan.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) at 1-877-999-6442 or difs-HICAP@michigan.gov.

Does this plan provide Minimum Essential Coverage?

Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards?

Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-800-446-5674.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-446-5674.
Chinese (中文): 如果需要中文的帮助,请拨打这个号码1-800-446-5674.
Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-446-5674.

~To see examples of how this plan might cover costs for a sample medical situation, see the next section~

 

About these Coverage Examples:
Triangle Warning IconThis is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, co-payments, and co-insurance) and excluded services under this plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

 

Peg is Having a Baby
(9 months of in participating pre natal care and a hospital delivery)
• The plan’s overall deductible $3000
Specialist copayment 20%
• Hospital (facility) coinsurance 20%
• Other coinsurance 20%

This EXAMPLE event includes services like:

  • Specialist office visits (prenatal care)
  • Childbirth/Delivery Professional Services
  • Childbirth/Delivery Facility Services
  • Diagnostic tests (ultrasounds and blood work)
  • Specialist visit (anesthesia)
Total Example Cost $12,800

In this example, Peg would pay:

Cost Sharing
Deductibles $3,000
Co-payments $60
Co-insurance $2,520
What isn’t covered
Limits or exclusions $60
The total Peg would pay $5,640
Managing Joe’s type 2 Diabetes
(a year of routine in participating care of a well controlled condition)
• The plan’s overall deductible $3000
Specialist copayment 20%
• Hospital (facility) coinsurance 20%
• Other coinsurance 20%

This EXAMPLE event includes services like:

  • Primary care physician office visits (including disease education)
  • Diagnostic tests (blood work)
  • Prescription drugs
  • Durable medical equipment (glucose meter)
Total Example Cost $7,400

In this example, Joe would pay:

Cost Sharing
Deductibles $1,823
Co-payments $1,115
Co-insurance $1,104
What isn’t covered
Limits or exclusions $55
The total Joe would pay
$4,096
Mia’s Simple Fracture
(in participating emergency room visit and follow up care)
• The plan’s overall deductible $3000
Specialist copayment 20%
• Hospital (facility) coinsurance 20%
• Other coinsurance 20%

This EXAMPLE event includes services like:

  • Emergency room care (including medical supplies)
  • Diagnostic test (x-ray)
  • Durable medical equipment (crutches)
  • Rehabilitation services (physical therapy)
Total Example Cost $1,900

In this example, Mia would pay:

Cost Sharing
Deductibles $1,504
Co-payments $0
Co-insurance $396
What isn’t covered
Limits or exclusions $0
The total Mia would pay
$1,900

The plan would be responsible for the other costs of these EXAMPLE covered services.

 

*For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.

Dental Benefits

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GOSSE/Administration

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Vision Benefits

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GOSSE/Administration

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Prescription Benefits

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MESSA RX Saver Plan

Flexible Spending Account

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Summary Plan Description

Retirement Benefits

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Approved Investment Providers for New and Existing Salary Deferrals under the Glen Oaks Community College 403(B) Plan can be found by visiting the Glen Oaks TSA Consulting Group webpage.

403(b) supplemental retirement contributions are processed by TIAA-CREF.

403(b) Plan

Policies & Procedures

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Contact the Human Resources Department

Jamie Bennett-Yesh
Director of Human Resources
Candy Bohacz
Human Resources Coordinator

HR Hours

Academic Year:
Mon – Fri, 8:00am – 4:00pm

Summer Hours:
Mon – Thu, 7:00am – 5:00pm