Medical insurance coverage helps you and your family access routine and preventive health care at a reasonable cost and protects against the catastrophic costs of major illness or injury.
Macalester’s medical insurance program is self-funded. This means that Macalester pays the total costs of medical claims made against its health care plans. It does not transfer the claims costs or the risk of claims to a third-party insurer. However, Macalester has retained the services of HealthPartners to provide third-party administrative services, such as access to a network of providers and claims processing.
By self-funding our health care insurance program, Macalester effectively serves as its own insurance company. Macalester does not price the medical plan to make a profit. Employees who elect to participate in the Macalester’s plans pay a portion of the cost through deductibles and coinsurance. Macalester pays the remainder of the claim costs.
Eligible employees’ paychecks are generally reduced on a pre-tax basis by the amount of their health insurance premiums. This pre-tax plan is governed by IRS regulations and, as a result, there are certain limitations on an enrollee’s ability to make changes to coverage levels during the year.
Annual enrollment in Macalester’s medical insurance plan is held on a yearly basis during late Fall, at which time employees can change their medical plan and/or the level of coverage.
Employees can choose between the HealthPartners High Deductible Health Plan (HDHP) with HSA or the HealthPartners PPO Health Plan. Both plans use the Open Access Choice PPO network and provide comprehensive coverage. Highlights of the plans include fully covered preventive health care (no deductible or co‐pay). The Open Access Choice PPO network gives you the care and service you need, at your convenience. With more than 650,000 providers, you have access to one of the country’s largest networks.
Frequently Asked Questions
Who is eligible to be covered under Macalester’s health plans?
Any regular Macalester employee scheduled to work 1007.50+ hours (0.50 full time equivalent (FTE) or higher) is eligible for coverage.
Who can I add to my health plan?
- Spouse
- Registered domestic partner (see Declaration of Domestic Partnership form)
- Dependent children (up to age 26; see IRS guidelines)
- Other legal dependents (see IRS guidelines)
What is the difference between “in network” and “out of network” providers/doctors?
“In network” coverage typically provides the full benefit allowed under the plan.
“Out of network” coverage allows you to see any provider/doctor of your choosing, however at a lower benefit level (higher cost to you).
Which networks and formularies do the HDHP and PPO use?
The HDHP and PPO have the same network and formularies. The group medical network is HealthPartners Open Access Network and the prescription formulary is the PreferredRx Formulary.
What is a PPO Plan?
A Preferred Provider Organization (PPO) is a health insurance plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. The PPO plan has lower deductibles than the HDHP and participants will pay co-pays for most services. Participants in the PPO Plan may elect to participate in a health care flexible spending account (FSA) to set aside funds on a pre-tax basis for qualified expenses.
What is a High Deductible Health Plan (HDHP)?
A high deductible health plan (HDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. High deductible health plans are a form of catastrophic coverage, intended to cover for catastrophic illnesses. Participation in a qualifying HDHP is a requirement for health savings accounts (HSA) and other tax-advantaged programs.
2020 Health Plan Employee Premiums
| Plan | >.75 FTE and above | >.50-.74 FTE | ||
|---|---|---|---|---|
| PPO | HDHP | PPO | HDHP | |
| Employee | $145.14 | $96.50 | $285.29 | $188.00 |
| Employee + 1 | $440.01 | $289.31 | $728.69 | $477.51 |
| Employee + 2 or more | $642.30 | $420.82 | $1,065.84 | $696.71 |
Note: Rates shown are per month
2020 Health Plan Coverage Summary
| Plan Service/Feature | PPO In‐network services |
HDHP with HSA In‐network services |
|---|---|---|
| Annual Deductible | $500/person; $1,000/family |
$3,200/person; $6,400/family |
| Preventive Care Services Routine Health Exams, Cancer Screening, Eye and Hearing Exams, Immunizations, Prenatal & Postnatal Services, Well Child Care |
100 % of charges incurred | 100% of charges incurred |
| E-Visits Virtuwell |
The first 3 visits free, then $10 co-pay per visit thereafter |
Deductible, then 100% |
| Convenience Clinics MinuteClinic |
$10 co-pay, then 100% | Deductible, then 100% |
| Allergy Injections | No out of pocket cost | Deductible, then 100% |
| Primary Care Office Visits MD Visits (includes ancillary services received in provider’s office and palliative care) |
$30 co-pay, then 100% | Deductible, then 100% |
| Behavioral Health/ Substance Abuse Outpatient |
$30 co-pay, then 100% | Deductible, then 100% |
| Specialty Office Visits Chiropractic, Physical Therapy, Speech Therapy, Occupational Therapy, Acupuncture, etc. |
$50 co-pay, then 100% | Deductible, then 100% |
| Urgent Care Visits | $50 co-pay, then 100% | Deductible, then 100% |
| Emergency Room Visits Coverage for emergency conditions only |
$100 co-pay, then 100% | Deductible, then 100% |
| Ambulance Services | 80% of charges incurred | Deductible, then 100% |
| Inpatient Hospitalization | 80% of charges incurred | Deductible, then 100% |
| Annual Out-of-Pocket Maximums | ||
| Single (Medical/Prescriptions) | $3,200/person | $3,200/person |
| Family (Medical/Prescriptions) | $6,400/family | $6,400/family |
| Prescription Drugs | ||
| Generic Formulary Drugs 31 day supply |
$15 co-pay, then 100% | Deductible, then 100% |
| Brand Formulary Drugs 31 day supply |
$40 co-pay, then 100% | Deductible, then 100% |
| Specialty Drugs, Brand Non-Formulary 31 day supply |
20% co-pay up to $300 per script, then 100% | Deductible, then 100% |
| Mail Order, Generic Formulary Drugs 90 day supply |
$30 co-pay, then 100% | Deductible, then 100% |
| Mail Order, Brand Formulary Drugs 90 day supply |
$80 co-pay, then 100% | Deductible, then 100% |
| Other Covered Services | 80% of charges incurred | Deductible, then 100% |
| Lifetime Maximum | Unlimited | Unlimited |
| Out-of-Network Services | $2,000/person, $4,000/family calendar year deductible, services are covered at 60% of charges incurred after deductible is met and until out-of-pocket maximum is reached. |
$12,800/person, $25,600/family calendar year deductible, services are covered at 100% of charges incurred after deductible is met and until out-of-pocket maximum is reached. |
Note: The above table is a summary only. The certificate of coverage will be used in case of error and for all claims processing.
Resources
- Visit www.healthpartners.com (Registering as a HealthPartners member gives the best results)
- Call 952-883-5000 or 800-883-2177 (Toll Free)
- virtuwell.com: How it Works (PDF)
- virtuwell: Overview
- How to use virtuwell video
- HealthPartners Informational Brochure (PDF)
- Prescription Cost Management Tool (PDF)
- Prescription Savings Tool (PDF)
Plan Documents
- 2020 Summary of Benefits and Coverage: HDHP (PDF)
- 2020 Summary of Benefits and Coverage: PPO (PDF)
- 2020 Creditable Coverage Notice (PDF)
Related Benefit Forms