Putnam County Schools : Plan 4

Transcription

1 Summary of Beefits ad Coverage: What This Pla Covers & What it Costs This is oly a summary. If you wat more detail about your coverage ad costs, you ca get the complete terms i the policy or pla documet at MedMutual.com/SBC or by callig Importat Questios Aswers Why This Matters: What is the overall deductible? Are there other deductibles for specific services? Is there a out-of-pocket limit o my expeses? What is ot icluded i the out-of-pocket limit? Is there a overall aual limit o what the isurer pays? Does this pla use a etwork of providers? $1,000/sigle,$2,000/family Network $2,000/sigle,$4,000/family No-Network Does't apply to coisurace, copays ad etwork prevetive care No Yes, Coisurace Limit: $2,000/sigle,$4,000/family Network $4,000/sigle,$8,000/family No-Network Out-of-pocket Limit: $7,150/sigle,$14,300/family Network $6,000/sigle,$12,000/family No-Network Premiums, balace-billed charges ad health care this pla does't cover. No Yes, See MedMutual.com/SBC or call for list of participatig providers. You must pay all the costs up to the deductible amout before this pla begis to pay for covered services you use. Check your policy or pla documet to see whe the deductible starts over (usually, but ot always, Jauary 1st). See the chart startig o page 2 for how much you pay for covered services after you meet the deductible. You do t have to meet deductibles for specific services, but see the chart startig o page 2 for other costs for services this pla covers. The out-of-pocket limit is the most you could pay durig a coverage period (usually oe year) for your share of the cost of covered services. This limit helps you pla for health care expeses. The coisurace limit is icluded i the out-of-pocket limit. Eve though you pay these expeses, they do t cout toward the out of pocket limit. The chart startig o page 2 describes ay limits o what the pla will pay for specific covered services, such as office visits. If you use a i-etwork doctor or other health care provider, this pla will pay some or all of the costs of covered services. Be aware, your i-etwork doctor or hospital may use a out-of-etwork provider for some services. Plas use the term i-etwork, preferred, or participatig for providers i their etwork. See the chart startig o page 2 for how this pla pays differet kids of providers. Page 1 of 8

2 Summary of Beefits ad Coverage: What This Pla Covers & What it Costs Do I eed a referral to see a specialist? Are there services this pla does't cover? No Yes You ca see the specialist you choose without permissio from this pla. Some of the services this pla does t cover are listed o page 5. See your policy or pla documet for additioal iformatio about excluded services. Copaymets are fixed dollar amouts (for example, $15) you pay for covered health care, usually whe you receive the service. Coisurace is your share of the costs of a covered service, calculated as a percet of the allowed amout for the service. For example, if the pla's allowed amout for a overight hospital stay is $1,000, your coisurace paymet of 20% would be $200. This may chage if you have't met your deductible. The amout the pla pays for covered services is based o the allowed amout. If a out-of-etwork provider charges more tha the allowed amout, you may have to pay the differece. For example, if a out-of-etwork hospital charges $1,500 for a overight stay ad the allowed amout is $1,000, you may have to pay the $500 differece. (This is called balace billig.) This pla may ecourage you to use Network providers by chargig you lower deductibles, copaymets ad coisurace amouts. Commo Medical Evet Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use a No-Network Provider Limitatios ad Exceptios Primary care visit to treat a ijury or $25 copay/visit 40% coisurace oe If you visit a health care illess provider's office or cliic Specialist visit $25 copay/visit 40% coisurace oe Other practitioer office visit $25 copay/visit 40% coisurace (12 visits per beefit period) (Chiropractic) Other practitioer office visit Not Covered Excluded Service (Acupucture) Prevetive care/ screeig/ immuizatio No charge 50% coisurace does ot apply to out-of-pocket limit oe If you have a test Diagostic test (x-ray) 20% coisurace 40% coisurace oe Diagostic test (blood work) 20% coisurace 40% coisurace oe Imagig (CT/PET scas, MRIs) 20% coisurace 40% coisurace oe Page 2 of 8

3 Summary of Beefits ad Coverage: What This Pla Covers & What it Costs Commo Medical Evet Services You May Need Your Cost If You Use a Network Provider If you eed drugs to treat your illess or coditio More iformatio about prescriptio drug coverage is available at MedMutual.com/SBC Your Cost If You Use a Limitatios ad Exceptios No-Network Provider Geeric copay - retail Tier 1 $15 Does Not Apply Covers up to a 30-day supply. Geeric copay - home delivery Tier 1 $30 Does Not Apply Covers up to a 90-day supply. Preferred brad copay - retail Tier 2 $40 Does Not Apply Covers up to a 30-day supply. Preferred brad copay - home delivery Tier 2 No-preferred brad copay - retail Tier 3 No-preferred brad copay - home delivery Tier 3 Specialty drugs $80 Does Not Apply Covers up to a 90-day supply. $60 Does Not Apply Covers up to a 30-day supply. $120 Does Not Apply Covers up to a 90-day supply. Applicable drug tier copay applies Does Not Apply Covers up to a 30-day supply. If you have outpatiet Facility fee (e.g., ambulatory surgery 20% coisurace 40% coisurace oe surgery ceter) Physicia/surgeo fees (Outpatiet) 20% coisurace 40% coisurace oe Emergecy room services $100 copay/visit oe If you eed immediate Emergecy medical trasportatio 20% coisurace 40% coisurace oe medical attetio Urget care $25 copay/visit 40% coisurace oe If you have a hospital stay Facility fee (e.g., hospital room) 20% coisurace 40% coisurace oe Physicia/ surgeo fee (ipatiet) 20% coisurace 40% coisurace oe Page 3 of 8

4 Summary of Beefits ad Coverage: What This Pla Covers & What it Costs Commo Medical Evet Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use a No-Network Provider Limitatios ad Exceptios Metal/Behavioral health outpatiet Beefits paid based o correspodig medical beefits oe services Metal/Behavioral health ipatiet Beefits paid based o correspodig medical beefits oe services Substace use disorder outpatiet services (alcoholism) Beefits paid based o correspodig medical beefits oe Substace use disorder outpatiet Beefits paid based o correspodig medical beefits oe If you have metal health, services (drug use) behavioral health, or substace abuse eeds Substace use disorder ipatiet Beefits paid based o correspodig medical beefits oe services (alcoholism) Substace use disorder ipatiet services (drug use) Beefits paid based o correspodig medical beefits oe If you are pregat Preatal ad postatal care 20% coisurace 40% coisurace (Preatal Visits are covered at o charge with i-etwork providers) Delivery ad all ipatiet services 20% coisurace 40% coisurace oe Home health care 20% coisurace 40% coisurace (No-Network limited to 30 visits per If you eed help recoverig beefit period) or have other special health Rehabilitatio services (Physical $25 copay/visit 40% coisurace (40 visits per beefit period) eeds Therapy) Habilitatio services (Occupatioal $25 copay/visit 40% coisurace (40 visits per beefit period) Therapy) Habilitatio services (Speech $25 copay/visit 40% coisurace (20 visits per beefit period) Therapy) Skilled ursig care 20% coisurace 40% coisurace oe Durable medical equipmet 20% coisurace oe Hospice service 20% coisurace oe Eye exam (Child) No charge 50% coisurace does ot oe If your child eeds detal or apply to out-of-pocket limit eye care Glasses Not Covered Excluded Service Detal check-up (Child) Not Covered Excluded Service Page 4 of 8

5 Summary of Beefits ad Coverage: What This Pla Covers & What it Costs Excluded Services & Other Covered Services: Services Your Pla Does NOT Cover (This is't a complete list. Check your policy or pla documet for other excluded services.) Acupucture Cosmetic Surgery Detal check-up (Child) Detal Care (Adult) Glasses Hearig Aids Ifertility Treatmet Log-Term Care No-emergecy care whe travelig outside the U.S. Routie Eye Care (Adult) Routie Foot Care Weight Loss Programs Other Covered Services (This is't a complete list. Check your policy or pla documet for other covered services ad your costs for these services.) Bariatric Surgery Chiropractic Care Private-Duty Nursig Your Rights to Cotiue Coverage: If you lose coverage uder the pla, the, depedig upo the circumstaces, Federal ad State laws may provide protectios that allow you to keep health coverage. Ay such rights may be limited i duratio ad will require you to pay a premium, which may be sigificatly higher tha the premium you pay while covered uder the pla. Other limitatios o your rights to cotiue coverage may also apply. For more iformatio o your rights to cotiue coverage, cotact the pla at You may also cotact your state isurace departmet, the U.S. Departmet of Labor, Employee Beefits Security Admiistratio at or or the U.S. Departmet of Health ad Huma Services at X61565 or Page 5 of 8

6 Summary of Beefits ad Coverage: What This Pla Covers & What it Costs Your Grievace ad Appeals Rights: If you have a complait or are dissatisfied with a deial of coverage for claims uder your pla, you may be able to appeal or file a grievace. For questios about your rights, this otice, or assistace, you ca cotact: the pla at Does this Coverage Provide Miimum Essetial Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as miimum essetial coverage. This pla or policy does provide miimum essetial coverage. Does this Coverage Meet the Miimum Value Stadard? The Affordable Care Act establishes a miimum value stadard of beefits of a health pla. The miimum value stadard is 60% (actuarial value). This health coverage does meet the miimum value stadard for the beefits it provides To see examples of how this pla might cover costs for sample medical situatios, see the ext page Page 6 of 8

7 Coverage Examples About these Coverage Examples: These examples show how this pla might cover medical care i give situatios. Use these examples to see, i geeral, how much fiacial protectio a sample patiet might get if they are covered uder differet plas. This is ot a cost estimator. Do t use these examples to estimate your actual costs uder this pla. The actual care you receive will be differet from these examples, ad the cost of that care will also be differet. See the ext page for importat iformatio about these examples. Havig a baby (ormal delivery) Amout owed to providers: $7,540 Pla Pays $5,020 Patiet Pays $2,520 Sample care costs: Hospital charges (mother) $2,700 Routie obstetric care $2,100 Hospital charges (baby) $900 Aesthesia $900 Laboratory tests $500 Prescriptios $200 Radiology $200 Vaccies, other prevetive $40 Total $7,540 Patiet Pays: Deductibles $1,000 Copays $20 Coisurace $1,300 Limits or exclusios $200 Total $2,520 These umbers assume that the patiet does ot use a HRA or FSA. If you participate i a HRA or FSA ad use it to pay for out-of-pocket expeses, the your costs may be lower. For more iformatio about your HRA or FSA, please cotact your employer group. Maagig Type 2 diabetes (routie maiteace of a well-cotrolled coditio) Amout owed to providers: $5,400 Pla Pays $4,460 Patiet Pays $940 Sample care cost: Prescriptios $2,900 Medical Equipmet ad Supplies $1,300 Office Visits ad Procedure $700 Educatio $300 Laboratory tests $100 Vaccies, other prevetive $100 Total $5,400 Patiet Pays: Deductibles $100 Copays $800 Coisurace $0 Limits or exclusios $40 Total $940 Note: These umbers assume the patiet is participatig i our diabetes welless program. If you have diabetes ad do ot participate i the welless program, your costs may be higher. For more iformatio about the diabetes welless program, please cotact: Page 7 of 8

8 Coverage Examples Questios ad aswers about Coverage Examples: What are some of the assumptios behid the Coverage Examples? Costs do t iclude premiums. Sample care costs are based o atioal averages supplied by the U.S. Departmet of Health ad Huma Services, ad are t specific to a particular geographic area or health pla. Patiet s coditio was ot a excluded or preexistig coditio. All services ad treatmets started ad eded i the same coverage period. There are o other medical expeses for ay member covered uder this pla. Out-of-pocket expeses are based oly o treatig the coditio i the example. The patiet received all care from i-etwork providers. If the patiet had received care from out-of-etwork providers, costs would have bee higher. What does a Coverage Example show? For each treatmet situatio, the Coverage Example helps you see how deductibles, copaymets,ad coisurace ca add up. It also helps you see what expeses might be left up to you to pay because the service or treatmet is t covered or paymet is limited. Does the Coverage Example predict my ow care eeds? û No. Treatmets show are just examples. The care you would receive for this coditio could be differet, based o your doctor s advice, your age, how serious your coditio is, ad may other factors. Does the Coverage Example predict my future expeses? û No. Coverage Examples are ot cost estimators. You ca t use the examples to estimate costs for a actual coditio. They are for comparative purposes oly. Your ow costs will be differet depedig o the care you receive, the prices your providers charge, ad the reimbursemet your health pla allows. Ca I use Coverage Examples to compare plas? ü Yes. Whe you look at the Summaries of Beefits ad Coverage for other plas, you ll fid the same Coverage Examples. Whe you compare plas, check the Patiet Pays box o each example. The smaller that umber, the more coverage the pla provides. Are there other costs I should cosider whe comparig plas? üyes. A importat cost is the premium you pay. Geerally, the lower your premium, the more you ll pay i out-of-pocket costs, such as copaymets, deductibles, ad coisurace. You should also cosider cotributios to accouts such as health savigs accouts (HSAs), flexible spedig arragemets (FSAs) or health reimbursemet accouts (HRAs) that help you pay out-of-pocket expeses. Page 8 of 8

9 Multi-Laguage Iterpreter Services & Nodiscrimiatio Notice ATTENTION: If you speak <isert laguage>, laguage assistace services, free of charge, are available to you. Call (TTY: 711). Spaish ATENCIÓN: Si habla español, tiee a su disposició servicios gratuitos de asistecia ligüística. Llame al (TTY: 711). Chiese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Germa ACHTUNG: We Sie Deutsch spreche, stehe Ihe kostelos sprachliche Hilfsdiestleistuge zur Verfügug. Rufummer: (TTY: 711). Arabic ملحوظة:إذاكنتتتحدثاذكراللغة فإنخدماتالمساعدةاللغویةتتوافرلك (بالمجان.اتصلبرقم رقمھاتفالصموالبكم: 117 ). Pesylvaia Dutch Wa du Deitsch schwetzscht, kascht du mitaus Koschte ebber gricke, ass dihr helft mit die eglisch Schprooch. Ruf selli Nummer uff: Call (TTY: 711). Russia ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Frech ATTENTION: Si vous parlez fraçais, des services d aide liguistique vous sot proposés gratuitemet. Appelez le (ATS: 711). Vietamese CHÚ Ý: Nếu bạ ói Tiếg Việt, có các dịch vụ hỗ trợ gô gữ miễ phí dàh cho bạ. Gọi số (TTY: 711). Oromo XIYYEEFFANNAA: Afaa dubbattu Oroomiffa, tajaajila gargaarsa afaaii, kafaltiidhaa ala, i argama. Bilbilaa (TTY: 711). Korea 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Italia ATTENZIONE: I caso la ligua parlata sia l italiao, soo dispoibili servizi di assisteza liguistica gratuiti. Chiamare il umero (TTY: 711). Japaese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください Dutch AANDACHT: Als u ederlads spreekt, kut u gratis gebruikmake va de taalkudige dieste. Bel (TTY: 711). Ukraia УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: 711). Romaia ATENȚIE: Dacă vorbiți limba româă, vă stau la dispoziție servicii de asisteță ligvistică, gratuit. Suați la (TTY: 711). Y0121_S0121_2017_Aug16 CMS ACCEPTED Z8188-MCA 8/16

10 Nodiscrimiatio Notice Medical Mutual of Ohio complies with applicable federal civil rights laws ad does ot discrimiate o the basis of race, color, atioal origi, age, disability or sex i its operatio of health programs ad activities. Medical Mutual does ot exclude people or treat them differetly because of race, color, atioal origi, age, disability or sex i its operatio of health programs ad activities. Medical Mutual provides free aids ad services to people with disabilities to commuicate effectively with us, such as qualified sig laguage iterpreters, ad writte iformatio i other formats (large prit, audio, accessible electroic formats, etc.). Medical Mutual provides free laguage services to people whose primary laguage is ot Eglish, such as qualified iterpreters ad iformatio writte i other laguages. If you eed these services or if you believe Medical Mutual failed to provide these services or discrimiated i aother way o the basis of race, color, atioal origi, age, disability or sex, you ca cotact: Paul Macio, Vice Presidet, Assistat Geeral Cousel & Deputy Compliace Officer Medical Mutual of Ohio 2060 East Nith Street Clevelad, OH Phoe: (216) Fax: (216) Paul.Macio@MedMutual.com You ca file a grievace i perso or by mail, fax or . You ca also file a civil rights complait with the U.S. Departmet of Health ad Huma Services, Office for Civil Rights: Electroically through the Office for Civil Rights Complait Portal available at: ocrportal.hhs.gov/ocr/portal/lobby.jsf By mail at: U.S. Departmet of Health ad Huma Services 200 Idepedece Aveue, SW Room 509F HHH Buildig Washigto, DC By phoe at: (800) (TDD: (800) ) Complait forms are available at: hhs.gov/ocr/office/file/idex.html