• Medical Coverage - Allegiance
     
     
     
     
    Allegiance  
     
     
     
     
     
    Customer Service: 855-333-1012
     
     
    Visit Allegiance Online: www.askallegiance.com/ccps
     
      
    Onsite Representative:
    Heather Stiegler
    855-333-1012 ext. 3703
     
     
     
     
    2019 Medical Plan Year: January 1, 2019 - December 31, 2019
     
     
    The District’s medical plan continues to be a Preferred Provider Organization (PPO) not an HMO. You may use a provider (physician, hospital, etc.) of your choice; however deductibles, out-of-pocket expenses, co-insurance and co-payments are higher when an out-of-network provider is used.
     
    Allegiance is the District’s Third Party Administrator (TPA) who processes all medical claims. Premiums for full-time employees are paid by The District School Board of Collier County. Premiums for your dependents or for eligible part-time employees are paid by the employee. Deductions are taken over 20 pay periods. Detailed benefits for each plan can be found in the Summary Plan Description (SPD) and Summary of Benefits and Coverage (see each Pathway below). The documents provide plan participants with information on how the medical plan operates, when an employee can begin to participate in the plan, how service and benefits are paid, covered benefits and exclusions, deductibles, co-pays and co-insurance. The “benefit year” is January 1 to December 31. To submit a claim, mail your itemized statement to the address listed on the back of your medical ID card. No claim forms are required.
     
    In-Network/Out-of-Network: An in-network provider is a physician or medical facility that is part of the group of contracted providers. Using an in-network provider offers cost-savings advantages because a covered person pays only a percentage of the scheduled fee for services provided. A covered person who goes to an out-of-network provider will pay more for the services rendered and his or her share of the cost may not apply to the out-of-pocket maximum.
     

    Pathways to Enhanced Health: The Pathways plan is a behavior-based health plan providing a covered person three different levels of coverage or “Pathways.” Under the Pathways plan, you qualify for better coverage by participating in wellness activities. These activities are designed to improve health awareness, to maintain good health and address chronic disease or serious medical conditions. Covered persons who choose not to participate in the activities will be placed in the Basic Pathway for the subsequent plan year. Covered dependents will be enrolled in the same Pathway as the employee. 

    The three Pathways of coverage are: 1) Basic Pathway - provides coverage for catastrophic Illness, 2) Custom Pathway - provides excellent coverage, 3) Enhanced Pathway - provides the most comprehensive coverage. To view more information regarding the Pathways program and how to upgrade your pathway, click here. 

     

    Benefits

    Basic Pathway

    Custom Pathway*

    Enhanced Pathway

    *New Hires and those with newly elected coverage will begin in the Custom Pathway.

    The amounts and percentages are what the employee pays.  

    Annual Deductible

    Individual 1

     In-Network

     $3,000

    $1,000

    $400

    Individual 1

    Out-of-Network

    $6,000

    $1,300

    $800

    Family 2

    In-Network

    $6,000

    $2,000

    $800

    Family 2

    Out-of-Network

    $12,000

    $2,600

     $1,600

    Maximum Out-of-Pocket 3 

    Individual

    In-Network

    $4,700

    $4,450

    $2,400

    Individual

    Out-of-Network

    $16,000

    $8,500

    $4,800

    Family

    In-Network

    $9,400

    $8,900

    $4,800

    Family

    Out-of-Network

    $32,000

    $17,000

    $9,600

    Primary Care Physician 4

    In-Network

    40% after CYD*

    $50 Copay 5

    $30 Copay 5

     Out-of-Network 

    50% after CYD*

    45% After CYD*

    40% After CYD*

    Specialist Office Visit 4

    In-Network 

    40%

    $75 Copay 5

    $50 Copay 5

    Out-of-Network 

    50% after CYD*

    45% After CYD*

    40% After CYD*

    Inpatient Facility Charges 4

    In-Network

    Deductible then 40%

    Deductible then 30%

    Deductible then 20%

    Out-of-Network

    Deductible then 50%

    Deductible then 45%

    Deductible then 40%

    Outpatient Facility Charges 4

    In-Network

    Deductible then 40%

    Deductible then 30%

    Deductible then 20%

    Out-of-Network

    Deductible then  50% 

    Deductible then  45%

    Deductible then  40%

    MRI, CT Scans, PET Scans/X-Ray 4

    In-Network

    Deductible then 40%

    Deductible then 30%

    Deductible then 20%

    Out-of-Network

    Deductible then 50%

    Deductible then 45%

    Deductible then 40%

    Prescriptions

    Deductible

    $400 

    $250

    $100

    Maximum Out- of-Pocket Individual

    $2,150

    $2,150

    $2,100

    Maximum Out- of-Pocket Family

    $4,300

    $4,300

    $4,200

    Generic

    40% 4

    30% 4

    20% 4

    Brand

    40% 4

    30% 4

    20% 4

    Brand Non-Preferred

    60% 4

    50% 4

    40% 4

     

     

     

    1. Annual individual deductible is the dollar amount the covered person must pay during the calendar year before covered expenses are payable under the health insurance plan. The out-of-network deductible is separate from the in-network deductible.
    2. Annual family deductible is the accumulative deductible which can be met by one or multiple family members. There is no limit on the number of covered dependents.
    3. The annual maximum out-of-pocket is the maximum amount of covered expenses a covered person must pay during the calendar year. The Out-of-Pocket Maximum includes amounts applied towards the Deductible and any applicable Medical Copayments. After the Out-of-Pocket Maximum is satisfied, no further Deductible is required and Copayments are waived for the remainder of the Benefit Period.
    4. Co-insurance is the percentage paid by the employee after the annual deductible is met.
    5. Co-pay/co-payment is the flat dollar amount paid for medical services by a covered person per office visit. Services for which co-payments apply are covered at 100% after the covered person pays the co-payment. Applies to in-office services not to exceed $500 per visit.
     *CYD refers to Calendar Year Deductible
     
     
     
     
     
     

    MEDICAL COVERAGE

    Effective 1/1/20

    ANNUAL

    MONTHLY 

     

    PER CHECK

    (20 checks)

    DAILY 

    EMPLOYEE ONLY

    Full-time employees:   100% paid by the District

     $9,189.00 $765.75  $459.45   $25.18

    1 CHILD ONLY

    $2,255.00

    $187.92

    $112.75

    $6.18

    2 CHILDREN ONLY

    $4,510.00

    $375.83

    $225.50

    $12.36

    3 CHILDREN ONLY

    $6,764.00

    $563.67

    $338.20

    $18.53

    DUAL SPOUSE

    (Two employees with two or more children)

    $3,552.00

    $296.00

    $177.60

    $9.73

    SPOUSE ONLY

    $6,913.00

    $576.08

    $345.65

    $18.94

    FAMILY

    $10,466.00

    $872.17

    $523.30

    $28.67

      
     
     

     

    Dependent Eligibility

    Dependent Type

    Definition

    Required Documentation

    Spouse

    An individual to whom you are legally married

    1. Marriage Certificate AND

    2. Tax Return*

    *If Tax Return is not available because you were recently married and haven't filed a tax return with your new spouse yet, proof of a current relationship (such as joint bank account, joint ownership of a residence, evidence of shared household expenses, or joint ownership of a loan or mortgage) may be substituted. Other exceptions may apply.

    Dependent Child

    Under Age 26

    Your legal child married or unmarried

    1. Birth Certificate listing the employee as parent, or

    2. Court order dictating that the employee provides health insurance for the child, if applicable, or

    3. Court issued paperwork establishing the employee as parent/guardian, if applicable.

    Dependent Child

    Age 26 to 30

     

    Extended-Coverage Child**

    1. Birth Certificate listing the employee as parent, or

    2. Court order dictating that the employee provides health insurance for the child, if applicable, or

    3. Court issued paperwork establishing the employee as parent/guardian, if applicable.

    4. Affidavit of Dependent Eligibility

    Stepchild

    Your unmarried stepchild

    1. Birth Certificate listing the employee's spouse as parent, and

    2. Marriage Certificate

    3. Divorce decree establishing employee's spouse as custodial parent, if applicable.

    4. Divorce decree establishing employee's spouse must provide health insurance, if applicable.

    *If providing your tax return, please provide your most recent federal income tax return, which will list your dependents. If you filed electronically, please provide the first page of your 1040 form and your E-file confirmation (conceal income amounts). If you did not file electronically, please provide both pages of your 1040 form (second page contains your signature and the date - conceal income amounts).

    **An Extended-Coverage Child as defined by Florida Statute 627.6562 who is twenty-six (26) years of age but less than thirty (30) years of age may continue to be an eligible Dependent if the Dependent child was covered under this Plan on the last day of the Calendar Year after the Dependent child attains twenty-six (26) years of age and meets all of the following criteria required by Florida Statute:

    1. Unmarried without Dependents of their own; and

    2. A Florida resident or a full or part-time student; and

    3. Not provided coverage under any other health plan or policy; and

    4. Not entitled to coverage under Medicare

     
     
     
     
     
    Medical ID Cards
     
    • New ID cards will NOT be issued for 2020.
    • New ID cards will only be issued to members making certain enrollment changes, such as adding or removing a dependent, or switching Pathways.
    • If you receive a new ID card, throw away your old card.
    • Always show your most recent ID card to all medical providers and pharmacies to minimize any delay in claims processing. 
     
    Emergency Room Services
     
    Charges for Emergency Room Services for non-emergency use, including the facility and professional fees, are not covered.
     
    The definition of "Emergency" under our Plan is:
     
    "Emergency" means a medical condition manifesting itself by acute symptoms which occur suddenly and unexpectedly and for which the Covered Person receives medical attention no later than 48 hours after the onset of the condition. Emergency is any medical condition for which a reasonable and prudent layperson, possessing average knowledge of health and medicine, would expect that failure to seek immediate medical attention would result in death, more severe or disabling medical condition(s), or continued severe pain without cessation in the absence of medical treatment. Emergency may include, but is not limited to, severe injury, hemorrhaging, poisoning, loss of consciousness or respiration, fractures, convulsions, injuries reasonably likely to require sutures, severe acute pain, severe burns, prolonged high fever and symptoms normally associated with heart attack or stroke.
     
    "Emergency" will specifically exclude usual out-patient treatment of childhood diseases, flu, common cold, prenatal examinations, physical examinations and minor sprains, lacerations, abrasions and minor burns, and other medical conditions usually capable of treatment at a clinic or doctor's office during regular working hours.
     
    If you are in a non-emergency situation, please consider using an Urgent Care Center or Walk-In Clinic that is In-Network. These facilities typically offer extended evening, weekend and holiday hours. You may also choose to use the MDLive benefit for more routine care. Click HERE for more information on MDLive. 
     
    For a list of In-Network Urgent Care Centers and Walk-in Clinics, click HERE. Go to PROVIDER DIRECTORY, then select COLLIER COUNTY PUBLIC SCHOOLS DIRECTORY. Scroll down to the bottom of the document