Health Insurance Administrator for the
Montgomery County Chamber of Commerce
Bouchey & Clarke Benefits, Inc.
The Chamber offers dental plans through The Guardian.  The Guardian requires a percentage of eligible
employees to apply for dental coverage.
The enrollment period is the 1st of the month following 30 days of Chamber membership/hire.  The annual
Open Enrollment period is during the month of November for an effective date of January 1. 
The Guardian has an additional open enrollment period in May for July 1st coverage.
The Guardian
In-Network Out-of-Network
Monthly Rates  (Rates include a $2 Administrative fee)            
Individual   37.52 37.52    
Family   110.47 110.47    
Deductible              
Individual   $50 Per year $50 Per year    
Family     $150 Per year   $150 Per year    
Choice of Dentist:   Participating         
      Dentists   Yes    
2 exams, Cleanings             
and Xrays   100% Reimbursed $50. Deductible per year  
               
Periodontics   60% Reimbursed 50% Reimbursed    
    6 mo waiting period 6 mo waiting period  
               
Endodontics   60% Reimbursed 50% Reimbursed    
    6 mo waiting period 6 mo waiting period  
               
Filings, Oral Surgery   100% Reimbursed 80% Reimbursed    
           
               
Orthodontics   Not Available   Not Available    
               
Prosthetics, Crowns   60% Reimbursed 50% Reimbursed    
Bridges, Dentures 6 mo waiting period 6 mo waiting period  
               
Maximum Annual           
Reimbursement $1000/Person/Yr $1000/Person/Yr    
Full-time Student To age 26 To age 26    
           
Maximum Group Size 49 or less employees 49 or less employees  
             
Group Participation                  (Employees must work a minimum of 35 hours per week)          
Requirements 1-4 100%   1-4 100% of Eligible    
(# of Employees)   5-49 75%   5-49 75% of Eligible    
For additional information, please contact Bouchey & Clarke Benefits, Inc. PO Box 1616 Troy NY 12181-1616
                                         (p) 518.272.9866  (f) 518.874.5002
Printed:  Sept. 1, 2007
  Health Insurance Rates effective January 1, 2008
 
                                                Montgomery County Chamber of Commerce           Revised: 11/27/07
Rates Pending Approval by the NYS Insurance Department
  CDPHP HDPPO CDPHP EPO 25 CDPHP HMO 25 MVP HMO 25/40 MVP HMO 20 BSNENY HMO 206
2008 MONTHLY PREMIUMS FOR EMPLOYER GROUPS OF 2+  -  Includes a $5.00 Monthly Administrative Fee
Individual  $178.06 $264.65 $320.52 $348.01 $389.50 $403.44
2-Person  $356.12 $529.30 $641.04 $696.03 $779.02 $827.06
Family $475.00 $705.98 $855.02 $937.25 $1,049.02 $1,101.40
2008 MONTHLY PREMIUMS FOR SOLE PROPRIETORS (Without Paid Employees)   -  Includes a $5.00 Monthly Administrative Fee
Individual  $202.99 $301.72 $365.38 $400.21 $447.93 $463.96
2-Person  $405.98 $603.44 $730.76 $800.43 $895.87 $951.12
Family $541.50 $804.87 $974.69 $1,077.84 $1,206.38 $1,266.61
 
PCP copay Ded/10% co-ins  $25  NO REFERRALS $25 $25 $20 $25 or $10 or $20
Specialist copay Ded/10% co-ins  $25 NO REFERRALS $25 $40 $20 $25 or $40 or $30
Well baby and child care No charge No charge No charge No charge No charge No charge
Annual adult physical No charge No charge No charge $25 $20 $25
Pharmacy Ded/50% generic $4 generic 50% generic $10/30/50 $10/30/50 50% generic
  or brand 50% brand or brand $100 ded per person $100 ded per person or brand
Mail order Rx Ded 50% copay (90 days) 2.5 times copay 50% copay (90 days) 2 copays (90 days) 2 copays (90 days) 2.5 times copay for
(Maintenance drugs)   90 day supply   Subject to ded Subject to ded 90 day supply
Inpatient hospital (IP) Ded then 10% co-ins  Ded then co-ins 20% $500 copay (3x agg) $500 copay (no agg) $500 copay (3x agg) $500
Inpatient surgery Ded then 10% co-ins  Ded then co-ins 20% $500 $500 copay $0 $0
Outpatient surgery Ded then 10% co-ins  Ded then co-ins 20% $75 copay $75 copay $75 $75 copay
Maternity/Physician
Ded then 10% co-ins  Ded then co-ins 20% One time $25 OV copay $25 copay $25 copay PCP copay
                 Hospital Ded then 10% co-ins  Ded then co-ins 20% $500 copay $500 copay $500 copay No charge
                 Nursery Ded then covered in full Ded then covered in full No charge  Delivery/$200 copay $0 No charge
Ambulance Ded then 10% co-ins  Ded then co-ins 20% $100 copay $100 copay No charge $100 copay
Emergency room Ded then 10% co-ins  Ded then co-ins 20% $100 copay 100 copay $50 copay $100 copay
Urgent care Ded then 10% co-ins  $35 copay $35 copay $25 copay N/A $35 copay
Chiropractic care Ded then 10% co-ins  $25 copay $25 copay $40 copay/Med nec $20 copay/med nec. $10 copay
Prosthetic/Durable Medical Ded;50%;25K max  50%/25K Lifetime max  50% co-ins N/A 50%/25K max 50% w/$1000 max
Mental Health In-patient Ded then 10% co-ins - 30 Days  20% co-ins -30 Days $500 copay - 30 days $500 copay- 30 days $500 facility- 30 days $500 IP 30 days
Mental Health Out-patient Ded then 10% co-ins - 20 Visits $25 copay - 20 Visit max $25 copay - 20 Visit Max $40 copay- 20 visit max $35 copay- 20 visit max 50%- 20 visit max
Skilled nursing facility Ded then 10% co-ins  N/A $500 copay-limit 45 days N/A N/A $500 copay
Out-of-network (OON) Yes - Selected benefits only N/A N/A N/A N/A $1K ded - 30% co-ins   
  Ded then 50% co-ins         $5K OOP $250K OON Max
Coinsurance 10% IN - 50% OON 20% ($2K/5K max) N/A N/A N/A N/A
Annual deductible $2,700/5,400 In-5K/10K OON $500 / 1,250 N/A N/A N/A N/A
Annual out-of-pocket max $4,000/8,000 IN-10K/20K OON $2500 Ind / $6250 Family N/A N/A None N/A
Student/dependent  Full-time Student to 25 Full-time Student to 25 Full-time Student to 25 Unmarried dep to  23 Unmarried dep to 23 Full-time Student to 25
Dental N/A N/A N/A $25 copay dep to 19 $25 copay dep to 19 Spec copay
        Exam/xray Exam/xray Annual exam/cleaning
Vision Exam       $40 copay $20 copay  Spec copay/annual exam
        Frames/contact lenses N/A N/A N/A Exam every 2 years Exam every 2 years Low copays
        Eye glass lenses           Covered in full
Domestic partner coverage Yes Yes Yes N/A N/A Yes
Annual max $1M IN and OON $1M Max N/A N/A N/A N/A
TERMS OF THE CONTRACT PREVAIL IN THE EVENT OF INCONSISTENCIES     Contact Bouchey & Clarke Benefits,  518.272.9866    

PO Box 836, 12 South Bridge Street, Fonda, NY 12068
1-800-743-7337 TEL (518) 853-1800 FAX (518) 853-1813

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