Coverage Period: 1/1/2017 – 12/31/2017 Insurance Company 1: Plan Option 1 Coverage for: Family



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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 1/1/2017 – 12/31/2017

Istraight arrow connector 1nsurance Company 1: Plan Option 1 Coverage for: Family | Plan Type: PPO

The 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, [insert contact information]. 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 www.[insert].com or call 1-800-[insert] to request a copy.



Important Questions

Answers

Why This Matters:

What is the overall deductible?

$500/Individual or $1,000/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 policy, they have to meet their own individual deductible until the overall family deductible amount has been met.

Are there services covered before you meet your deductible?

Yes. Preventive care and primary care services are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the annual 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?

Yes. $300 for prescription drug coverage and $300 for occupational therapy services.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

What is the out-of-pocket limit for this plan?

For network providers $2,500 individual / $5,000 family; for out-of-network providers $4,000 individual / $8,000 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?

Copayments for certain services, premiums, balance-billed charges, 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. See www.[insert].com or call 1-800-[insert] for a list of network 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 (a balance bill). 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 you need a referral to see a specialist?

Yes.

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



All copayment and coinsurance costs shown in this chart are after your overall deductible has been met, if a deductible applies.




Common
Medical Event


Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information

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

$35 copay/office visit and 20% coinsurance for other outpatient services; deductible does not apply

40% coinsurance

----------None----------

Specialist visit

$50 copay/visit

40% coinsurance

Preauthorization is required. Failure to obtain preauthorization may result in a reduction in benefits by 50% of the total cost of the service.

Preventive care/screening/immunization

No charge for covered services

40% coinsurance

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

If you have a test

Diagnostic test (x-ray, blood work)

$10 copay/test

40% coinsurance

----------None----------

Imaging (CT/PET scans, MRIs)

$50 copay/test

40% coinsurance

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.[insert].com



Generic drugs (Tier 1)

$10 copay/prescription (retail & mail order)

40% coinsurance

Covers up to a 30-day supply (retail subscription); 31-90 day supply (mail order prescription).


Preferred brand drugs (Tier 2)

$30 copay/prescription (retail & mail order)

40% coinsurance

Non-preferred brand drugs (Tier 3)

40% coinsurance

60% coinsurance

Specialty drugs (Tier 4)

50% coinsurance

70% coinsurance

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

$100/day copay

40%coinsurance

Preauthorization is required. Failure to obtain preauthorization may result in a reduction in benefits by 50% of the total cost of the service.

Physician/surgeon fees

20% coinsurance

40% coinsurance

50% coinsurance for anesthesia.

If you need immediate medical attention

Emergency room care

20% coinsurance

20% coinsurance

----------None----------

Emergency medical transportation

20% coinsurance

20% coinsurance

Urgent care

$30 copay

40% coinsurance

If you have a hospital stay

Facility fee (e.g., hospital room)

20% coinsurance

40% coinsurance

Preauthorization is required. Failure to obtain preauthorization may result in a reduction in benefits by 50% of the total cost of the service.

Physician/surgeon fees

20% coinsurance

40% coinsurance

50% coinsurance for anesthesia.

If you need mental health, behavioral health, or substance abuse services

Outpatient services

$35 copay/office visit and 20% coinsurance for other outpatient services

40% coinsurance

----------None----------

Inpatient services

20% coinsurance

40% coinsurance

If you are pregnant

Office visits

20% coinsurance

40% coinsurance

Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery professional services

20% coinsurance

40% coinsurance

Childbirth/delivery facility services

20% coinsurance

40% coinsurance

If you need help recovering or have other special health needs

Home health care

20% coinsurance

40% coinsurance

60 visits/calendar year

Rehabilitation services

20% coinsurance

40% coinsurance

60 visits/calendar year. Includes physical therapy, speech therapy, and occupational therapy.

Habilitation services

20% coinsurance

40% coinsurance

Skilled nursing care

20% coinsurance

40% coinsurance

60 visits/calendar year

Durable medical equipment

20% coinsurance

40% coinsurance

Excludes vehicle modifications, home modifications, exercise, and bathroom equipment.

Hospice services

20% coinsurance

40% coinsurance

Preauthorization is required. Failure to obtain preauthorization may result in a reduction in benefits by 50% of the total cost of the service.

If your child needs dental or eye care

Children’s eye exam

$35 copay/visit

Not covered

Coverage limited to one exam/year.

Children’s glasses

20% coinsurance

Not covered

Coverage limited to one pair of glasses/year.

Children’s dental check-up

No charge

Not covered

----------None----------


Excluded Services & Other Covered Services:

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

  • Dental Care

  • Non-emergency care outside the U.S.

  • Infertility Treatment

  • Long Term Care

  • Routine eye care (Adult)




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

  • Acupuncture (if prescribed for rehabilitation purposes)

  • Bariatric Surgery

  • Chiropractic Care

  • Hearing Aids

  • 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: [insert State, HHS, DOL, and/or other applicable agency contact information]. Other options to continue coverage are 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: [insert applicable contact information from instructions].
Does this plan provide Minimum Essential Coverage? Yes.

If you don’t have Minimum Essential Coverage for a month under this plan or under other coverage, 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 [insert telephone number].]

[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [insert telephone number].]

[Chinese (中文): 如果需要中文的帮助,请拨打这个号码 [insert telephone number].]

[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [insert telephone number].]

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




About these Coverage Examples:


This 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 the 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-network pre-natal care and a hospital delivery)


The plan’s overall deductible $500

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

$500

Copayments

$300

Coinsurance

$2,300

What isn’t covered

Limits or exclusions

$60

The total Peg would pay is

$3,160



Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: [insert].



Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a well-controlled condition)

The plan’s overall deductible $500

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

$800

Copayments

$1,200

Coinsurance

$300

What isn’t covered

Limits or exclusions

$60

The total Joe would pay is

$2,360


Mia’s Simple Fracture


(in-network emergency room visit and follow up care)

The plan’s overall deductible $500

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

$2,500



In this example, Mia would pay:

Cost Sharing

Deductibles

$700

Copayments

$200

Coinsurance

$400

What isn’t covered

Limits or exclusions

$0

The total Mia would pay is

$1,300





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