Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2019

Transcription

1 Summary of Beefits ad Coverage: What this Pla Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2019 Putam Couty Schools : Pla 4 Coverage for: Sigle or Family Pla Type: PPO The Summary of Beefits ad Coverage (SBC) documet will help you choose a health pla. The SBC shows you how you ad the pla would share the cost for covered health care services. NOTE: Iformatio about the cost of this pla (called the premium) will be provided separately. This is oly a summary. For more iformatio about your coverage, or to get a copy of the complete terms of coverage, call For geeral defiitios of commo terms, such as allowed amout, balace billig, coisurace, copaymet, deductible, provider, or other uderlied terms see the Glossary. You ca view the Glossary at MedMutual.com/SBC or call to request a copy. Importat Questios Aswers Why This Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this pla? What is ot icluded i the out-of-pocket limit? Will you pay less if you use a etwork provider? $1,500/sigle,$3,000/family Network $3,000/sigle,$6,000/family No-Network Yes. Certai prevetive care ad all services with copaymets are covered ad paid by the pla before you meet your deductible. No Coisurace Limit: $3,000/sigle,$6,000/family Network $6,000/sigle,$12,000/family No-Network Out-of-pocket Limit: $7,900/sigle,$15,800/family Network $15,800/sigle,$31,600/family No-Network Premiums, balace-billed charges ad health care this pla does't cover. Yes, See MedMutual.com/SBC or call for a list of participatig providers. Geerally, you must pay all of the costs from providers up to the deductible amout before this pla begis to pay. If you have other family members o the pla, each family member must meet their ow idividual deductible util the total amout of deductible expeses paid by all family members meets the overall family deductible. This pla covers some items ad services eve if you have t yet met the deductible amout. But a copaymet or coisurace may apply. For example, this pla covers certai prevetive services without cost-sharig ad before you meet your deductible. See a list of covered prevetive services at You do t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay i a year for covered services. If you have other family members i this pla, they have to meet their ow out-of-pocket limits util the overall family out-of-pocket limit has bee met. Eve though you pay these expeses, they do't cout toward the out-of-pocket limit. This pla uses a provider etwork. You will pay less if you use a provider i the pla's etwork. You will pay the most if you use a out-of-etwork provider, ad you might receive a bill from a provider for the differece betwee the provider's charge ad what your pla pays (balace billig). Be aware your etwork provider might use a out-of-etwork provider for some services (such as lab work). Check with your provider before you get services. Page 1 of 6

2 Do you eed a referral to see a specialist? No You ca see the specialist you choose without a referral. All coisurace costs show i this chart are after your deductible has bee met, if a deductible applies. Services with copaymets are covered before you meet your deductible, uless otherwise specified. Commo Medical Evet Services You May Need What You Will Pay Limitatios, Exceptios, & Other Importat Iformatio Network Provider (You will pay the least) No-Network Provider (You will pay the most) If you visit a health care Primary care visit to treat a ijury or $25 copay/visit 40% coisurace Noe provider's office or cliic illess Specialist visit $25 copay/visit 40% coisurace Noe Prevetive care/ screeig/ immuizatio No charge 50% coisurace does ot apply to out-of-pocket limit If you have a test Diagostic test (x-ray) 20% coisurace 40% coisurace Noe If you eed drugs to treat your illess or coditio More iformatio about prescriptio drug coverage is available at MedMutual.com/SBC Diagostic test (blood work) 20% coisurace 40% coisurace Noe Imagig (CT/PET scas, MRIs) 20% coisurace 40% coisurace Noe You may have to pay for services that are't prevetive. Ask your provider if the services you eed are prevetive. The check what your pla will pay for. 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. Page 2 of 6

3 Commo Medical Evet Services You May Need What You Will Pay Limitatios, Exceptios, & Other Importat Iformatio Network Provider (You will pay the least) No-Network Provider (You will pay the most) If you have outpatiet surgery Facility fee (e.g., ambulatory surgery 20% coisurace 40% coisurace Noe ceter) Physicia/surgeo fees (Outpatiet) 20% coisurace 40% coisurace Noe If you eed immediate medical attetio Emergecy room care $100 copay/visit Noe Emergecy medical trasportatio 20% coisurace 40% coisurace Noe Urget care $25 copay/visit 40% coisurace Noe If you have a hospital stay Facility fee (e.g., hospital room) 20% coisurace 40% coisurace Noe If you eed metal health, behavioral health, or substace abuse services Physicia/ surgeo fee (ipatiet) 20% coisurace 40% coisurace Noe Outpatiet services Beefits paid based o correspodig medical beefits Noe Ipatiet services Beefits paid based o correspodig medical beefits Noe If you are pregat Office visits No charge 40% coisurace Depedig o the type of services, copay, coisurace or deductible may apply. Materity care may iclude tests ad services described elsewhere i the SBC (i.e. ultrasoud). Childbirth/delivery professioal 20% coisurace 40% coisurace Noe services Childbirth/delivery facility services 20% coisurace 40% coisurace Noe If you eed help recoverig or have other special health eeds Home health care 20% coisurace 40% coisurace (No-Network limited to 30 visits per beefit period) Rehabilitatio services (Physical $25 copay/visit 40% coisurace (40 visits per beefit period) 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 Noe Durable medical equipmet 20% coisurace Noe Hospice services 20% coisurace Noe Page 3 of 6

4 Commo Medical Evet Services You May Need What You Will Pay Limitatios, Exceptios, & Other Importat Iformatio Network Provider (You will pay the least) No-Network Provider (You will pay the most) If your child eeds detal or eye care Childre's eye exam No charge 50% coisurace does ot apply to out-of-pocket limit Noe Childre's glasses Not Covered Excluded Service Childre's detal check-up Not Covered Excluded Service Page 4 of 6

5 Excluded Services & Other Covered Services: Services Your Pla Geerally Does NOT Cover (Check your policy or pla documet for more iformatio ad a list of ay other excluded services.) Acupucture Childre's detal check-up Childre's glasses Cosmetic Surgery Detal Care (Adult) 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 (Limitatios may apply to these services. This is't a complete list. Please see your pla documet.) Bariatric Surgery Chiropractic Care Private-Duty Nursig Your Rights to Cotiue Coverage: There are agecies that ca help if you wat to cotiue your coverage after it eds.the cotact iformatio for those agecies is: the Departmet of Health ad Huma Services, Ceter for Cosumer Iformatio ad Isurace Oversight, at x61565 or cciio.cms.gov. Other coverage optios may be available to you, icludig buyig idividual isurace coverage through the Health Isurace Marketplace. For more iformatio about the Marketplace, visit HealthCare.gov or call Your Grievace ad Appeals Rights: There are agecies that ca help if you have a complait agaist your pla for a deial of a claim. This complait is called a grievace or appeal. For more iformatio about your rights, look at the explaatio of beefits you will receive for that medical claim. Your pla documets also provide complete iformatio to submit a claim, appeal, or a grievace for ay reaso to your pla. For more iformatio about your rights, this otice, or assistace, cotact your pla at Does this pla provide Miimum Essetial Coverage? Yes. If you do't have Miimum Essetial Coverage for a moth, you'll have to make a paymet whe you file your tax retur uless you qualify for a exemptio from the requiremet that you have health coverage for that moth. Does this pla meet Miimum Value Stadards? Yes. If your pla does't meet the Miimum Value Stadards, you may be eligible for a premium tax credit to help you pay for a pla through the Marketplace To see examples of how this pla might cover costs for sample medical situatios, see the ext sectio The coverage example 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. Page 5 of 6

6 About these Coverage Examples: This is ot a cost estimator. Treatmets show are just examples of how this pla might cover medical care. Your actual costs will be differet depedig o the actual care you receive, the prices your providers charge, ad may other factors. Focus o the cost sharig amouts (deductibles, copaymets ad coisurace) ad excluded services uder the pla. Use this iformatio to compare the portio of costs you might pay uder differet health plas. Please ote these coverage examples are based o self-oly coverage. Peg is havig a baby (9 moths of i-etwork pre-atal care ad a hospital delivery) Maagig Joe s type 2 Diabetes (a year of routie i-etwork care of a well-cotrolled coditio) Mia s Simple Fracture (i-etwork emergecy room visit ad follow up care) The pla's overall deductible $1,500 The pla's overall deductible $1,500 The pla's overall deductible $1,500 Specialist copay $25 Specialist copay $25 Specialist copay $25 Hospital (facility) coisurace 20% Hospital (facility) coisurace 20% Hospital (facility) coisurace 20% Other coisurace 20% Other coisurace 20% Other coisurace 20% This EXAMPLE evet icludes services like: Specialist office visits (preatal care) Childbirth/Delivery Professioal Services Childbirth/Delivery Facility Services Diagostic tests (ultrasouds ad blood work) Specialist visit (aesthesia) This EXAMPLE evet icludes services like: Primary care physicia office visits (icludig disease educatio) Diagostic tests (blood work) Prescriptio drugs Durable medical equipmet (glucose meter) This EXAMPLE evet icludes services like: Emergecy room care (icludig medical supplies) Diagostic test (x-ray) Durable medical equipmet (crutches) Rehabilitatio services (physical therapy) Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900 I this example, Peg would pay: I this example, Joe would pay: I this example, Mia would pay: Cost Sharig Cost Sharig Cost Sharig Deductibles $1,500 Deductibles $1,500 Deductibles $900 Copaymets $40 Copaymets $1,000 Copaymets $200 Coisurace $2,200 Coisurace $10 Coisurace $0 What is t covered What is t covered What is t covered Limits or exclusios $60 Limits or exclusios $60 Limits or exclusios $0 The total Peg would pay is $3,800 The total Joe would pay is $2,570 The total Mia would pay is $1,100 Note: These umbers assume the patiet does ot participate i the pla's welless program. If you participate i the pla's welless program, you may be able to reduce your costs. For more iformatio about the welless program, please cotact: The pla would be resposible for the other costs of these EXAMPLE covered services. Page 6 of 6

7 Multi-Laguage Iterpreter Services & Nodiscrimiatio Notice This documet otifies idividuals of how to seek assistace if they speak a laguage other tha Eglish. 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 711 ). 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). Navajo Díí baa akó íízi: Díí saad bee yáíłti go Dié Bizaad, saad bee áká áída áwo dę ę, t áá jiik eh, éí á hólǫ, kojį hódíílih (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). Ukraiia 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). Tagalog PAUNAWA: Kug agsasalita ka g Tagalog, maaari kag gumamit g mga serbisyo g tulog sa wika ag walag bayad. Tumawag sa (TTY: 711). Z8188-MCA R11/16

8 QUESTIONS ABOUT YOUR BENEFITS OR OTHER INQUIRIES ABOUT YOUR HEALTH INSURANCE SHOULD BE DIRECTED TO MEDICAL MUTUAL S CUSTOMER CARE DEPARTMENT AT 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, with respect to your health care beefits or services, you ca submit a writte complait to the perso listed below. Please iclude as much detail as possible i your writte complait to allow us to effectively research ad respod. Civil Rights Coordiator Medical Mutual of Ohio 2060 East Nith Street Clevelad, OH MZ: CivilRightsCoordiator@MedMutual.com 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 Products marketed by Medical Mutual may be uderwritte by oe of its subsidiaries, such as Medical Health Isurig Corporatio of Ohio or Cosumers Life Isurace Compay.