Enrol ment Guide Community Consolidated School District #59 PPO/HSA/HMO July 1, 2015

Transcription

1 Enrollment Guide Community Consolidated School District #59 PPO/HSA/HMO July 1, 2015

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3 The Choice for Nearly 1 in 3 Americans Nearly one in every three Americans has a Blue Cross and Blue Shield product. Experience Preventive care is essential to maintaining a healthier life, and no one understands this better than Blue Cross and Blue Shield of Illinois (BCBSIL). For more than 75 years, BCBSIL has provided quality health care benefits and services to its members and communities. BCBSIL provides members with programs and support to create customized wellness action plans, make smarter health care choices and help manage their health care. Your Journey to Wellness Wellness is defined as the state of being healthy in body and mind, especially as the result of deliberate effort. The choices you make each day can affect your health now and in the future. Deciding on the best approach for a healthier lifestyle can be challenging, but it may be easier than you think. BCBSIL offers access to convenient online tools and resources to help you plan and manage your health care. BCBSIL health care plans include flexible options with the right combination of benefits, choice of providers and access to a wide variety of educational resources. Whether you are trying to improve your health or reach the next level of wellness, BCBSIL is here to help. Take time to explore what Blue Cross and Blue Shield of Illinois has to offer. The coverage options, tools and resources can help you on your journey to wellness. In This Guide The following pages include a description of the medical plan and other features and services available to you. In some cases, your employer may be offering you more than one medical plan to choose from. Think carefully about how you and your family will use these benefits. Before you make a decision, consider the services that are covered, provider network, potential out-of-pocket costs and other options. Blue Cross and Blue Shield of Illinois is a leader in health care benefits. If you have questions, your employer can provide additional information or direct you to other resources for assistance

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5 Community Consolidated School District #59: PPO Plan Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? For In-Network $300 Individual/$600 Family For Out-of-Network $300 Individual/$600 Family Doesn't apply to certain preventative care. No. Yes. For In-Network $1,500 Individual/$3,000 Family For Out-of-Network $3,750 Individual/$7,500 Family Prescription drugs have a separate out-of-pocket maximum limit. See Prescription Drug coverage section. Prescription copay, premiums, balanced-billed charges, and healthcare this plan doesn t cover. You must pay all the costs up to the deductible, amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? Yes. Visit or call for a list of In- Network providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. No. You can see a specialist you choose without permission from this plan. Yes. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 1 of 8

6 Community Consolidated School District #59: PPO Plan Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need You Use an In-Network You Use an Out-of-Network Primary care visit to treat an injury or illness 10% coinsurance 30% coinsurance ---none--- Limitations & Exceptions If you visit a health care provider s office or clinic Specialist visit 10% coinsurance 30% coinsurance ---none--- Other practitioner office visit 10% coinsurance 30% coinsurance ---none--- Preventive care/screening/immunization No Charge No Charge ---none--- If you have a test Diagnostic test (x-ray, blood work) 10% coinsurance 30% coinsurance ---none--- Imaging (CT/PET scans, MRIs) 10% coinsurance 30% coinsurance ---none--- Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

7 Community Consolidated School District #59: PPO Plan Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Services You May Need Generic drugs Formulary brand drugs Non-Formula brand drugs You Use an In-Network $10 copay / prescription for up to 34 day supply. $20 copay / prescription for up to 90 day supply. $30 copay / prescription for up to 34 day supply. $60 copay / prescription for up to 90 day supply. $45 copay / prescription for up to 34 day supply. $90 copay / prescription for up to 90 day supply. You Use an Out-of-Network $10 copay / prescription for up to 34 day supply. $30 copay / prescription for up to 34 day supply. $45 copay / prescription for up to 34 day supply. Limitations & Exceptions 34 day retail/ 90 day mail Dispensing limit may apply to certain drugs. For Out-of Network drug provider you are responsible for 25% of the eligible amount after the copay. Certain women s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. RX Out-of-Pocket Expense Limit: $2,000 Individual/ $4,000 Family Specialty drugs Covered Not Covered Coverage based on group policy. Prior authorization may be required. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 10% coinsurance 30% coinsurance ---none--- Physician/surgeon fees 10% coinsurance 30% coinsurance ---none--- If you need immediate medical attention Emergency room services $150 copay/visit $150 copay/visit Copay waived if admitted. Emergency medical transportation 20% coinsurance 20% coinsurance ---none--- Urgent care 10% coinsurance 30% coinsurance ---none--- Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

8 Community Consolidated School District #59: PPO Plan Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO Common Medical Event If you have a hospital stay Services You May Need You Use an In-Network You Use an Out-of-Network Limitations & Exceptions Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance Preauthorization is required Physician/surgeon fee 10% coinsurance 30% coinsurance ---none--- If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services 10% coinsurance 30% coinsurance ---none--- Mental/Behavioral health inpatient services 10% coinsurance 30% coinsurance Preauthorization is required Substance use disorder outpatient services 10% coinsurance 30% coinsurance ---none--- Substance use disorder inpatient services 10% coinsurance 30% coinsurance Preauthorization is required If you are pregnant If you need help recovering or have other special health needs Prenatal and postnatal care 10% coinsurance 30% coinsurance ---none--- Delivery and all inpatient services 10% coinsurance 30% coinsurance Preauthorization is required Home health care 10% coinsurance 30% coinsurance ---none--- Rehabilitation services 10% coinsurance 30% coinsurance ---none--- Habilitation services 10% coinsurance 30% coinsurance ---none--- Skilled nursing care 10% coinsurance 30% coinsurance Preauthorization is required Durable medical equipment 10% coinsurance 30% coinsurance Hospice service 10% coinsurance 30% coinsurance ---none--- Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). If your child needs dental or eye care Eye exam No Charge Not Covered Limited to 1 exam per benefit period. Glasses Covered Not Covered Dental check-up Not Covered Not Covered ---none--- Please refer to your policy or plan document for covered benefit payment levels. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

9 Community Consolidated School District #59: PPO Plan Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-Term Care Routine Foot Care (with the exception of person with diagnosis of diabetes) Weight Loss Programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric Surgery Chiropractic Care Infertility Treatment Most coverage provided outside the United States. See Non-Emergency Care When Traveling Outside the U.S. Private Duty Nursing (with the exception of inpatient private duty nursing) Routine Eye Care (Adult) Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

10 Community Consolidated School District #59: PPO Plan Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Blue Cross and Blue Shield of Illinois at or visit or contact the U.S Department of Labor's Employee Benefits Security Administration at EBSA (3272) or visit Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) or visit Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

11 Community Consolidated School District #59: PPO Plan Coverage Period: 07/01/ /30/2016 Coverage Examples Coverage for: Individual + Family Plan Type: PPO About these Coverage Examples: Having a baby (normal delivery) Managing type 2 diabetes (routine maintenance of a well-controlled condition) These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Amount owed to providers: $7,540 Plan pays $6,370 Patient pays $1,170 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $300 Copays $20 Coinsurance $700 Limits or exclusions $150 Total $1,170 Amount owed to providers: $5,400 Plan pays $4,400 Patient pays $1,000 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $300 Copays $400 Coinsurance $220 Limits or exclusions $80 Total $1,000 Note: These examples are based on individual coverage only. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

12 Community Consolidated School District #59: PPO Plan Coverage Period: 07/01/ /30/2016 Coverage Examples Coverage for: Individual + Family Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

13 Community Consolidated School District #59: BlueEdge HSA Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HSA This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? For In-Network $1,300 Individual /$2,600 Family For Out-of-Network $2,600 Individual /$5,200 Family Doesn't apply to certain preventative care. You must pay all the costs up to the deductible, amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? No. Yes. Prescription drugs are included. For In-Network $2,400 Individual /$4,800 Family For Out-of-Network $4,800 Individual /$9,600 Family Premiums, balanced-billed charges, and healthcare this plan doesn t cover. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? Yes. Visit or call for a list of In-Network providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. No. You can see a specialist you choose without permission from this plan. Yes. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 1 of 8

14 Community Consolidated School District #59: BlueEdge HSA Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HSA Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need You Use an In-Network You Use an Out-of-Network Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance ---none--- Limitations & Exceptions If you visit a health care provider s office or clinic Specialist visit 20% coinsurance 40% coinsurance ---none--- Other practitioner office visit 20% coinsurance 40% coinsurance ---none--- Preventive care/screening/immunization No Charge 40% coinsurance ---none--- If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance ---none--- Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance ---none--- Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

15 Community Consolidated School District #59: BlueEdge HSA Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HSA Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Services You May Need You Use an In-Network You Use an Out-of-Network Generic drugs 20% coinsurance 20% coinsurance Formulary brand drugs 20% coinsurance 20% coinsurance Non-Formulary brand drugs 20% coinsurance 20% coinsurance Limitations & Exceptions Up to 34 day retail /90 day mail. Dispensing limit may apply to certain drugs. Certain women s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. Specialty drugs 20% coinsurance 20% coinsurance Coverage based on group policy. Prior authorization may be required. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance ---none--- Physician/surgeon fees 20% coinsurance 40% coinsurance ---none--- If you need immediate medical attention Emergency room services 10% coinsurance 10% coinsurance ---none--- Emergency medical transportation 20% coinsurance 20% coinsurance ---none--- Urgent care 20% coinsurance 40% coinsurance ---none--- If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Preauthorization is required Physician/surgeon fee 20% coinsurance 40% coinsurance ---none--- If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services 20% coinsurance 40% coinsurance ---none--- Mental/Behavioral health inpatient services 20% coinsurance 40% coinsurance Preauthorization is required Substance use disorder outpatient services 20% coinsurance 40% coinsurance ---none--- Substance use disorder inpatient services 20% coinsurance 40% coinsurance Preauthorization is required Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

16 Community Consolidated School District #59: BlueEdge HSA Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HSA Common Medical Event If you are pregnant Services You May Need You Use an In-Network You Use an Out-of-Network Prenatal and postnatal care 20% coinsurance 40% coinsurance ---none--- Limitations & Exceptions Delivery and all inpatient services 20% coinsurance 40% coinsurance Preauthorization is required Home health care 20% coinsurance 40% coinsurance ---none--- If you need help recovering or have other special health needs Rehabilitation services 20% coinsurance 40% coinsurance ---none--- Habilitation services 20% coinsurance 40% coinsurance ---none--- Skilled nursing care 20% coinsurance 40% coinsurance Preauthorization is required Durable medical equipment 20% coinsurance 40% coinsurance Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). Hospice service 20% coinsurance 40% coinsurance ---none--- Eye exam No Charge Not Covered Limited to 1 exam per benefit period. If your child needs dental or eye care Glasses Covered Not Covered Dental check-up Not Covered Not Covered ---none--- Please refer to your policy or plan document for covered benefit payment levels. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

17 Community Consolidated School District #59: BlueEdge HSA Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HSA Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-Term Care Routine Foot Care (with the exception of person with diagnosis of diabetes) Weight Loss Programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric Surgery Chiropractic Care Infertility Treatment Most coverage provided outside the United States. See Non-Emergency Care When Traveling Outside the U.S. Private Duty Nursing (with the exception of inpatient private duty nursing) Routine Eye Care (Adult) Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

18 Community Consolidated School District #59: BlueEdge HSA Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HSA Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Blue Cross and Blue Shield of Illinois at or visit or contact the U.S Department of Labor's Employee Benefits Security Administration at EBSA (3272) or visit Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) or visit Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

19 Community Consolidated School District #59: BlueEdge HSA Coverage Period: 07/01/ /30/2016 Coverage Examples Coverage for: Individual + Family Plan Type: HSA About these Coverage Examples: Having a baby (normal delivery) Managing type 2 diabetes (routine maintenance of a well-controlled condition) These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Amount owed to providers: $7,540 Plan pays $4,990 Patient pays $2,550 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $1,300 Copays $0 Coinsurance 1,100 Limits or exclusions $150 Total $2,550 Amount owed to providers: $5,400 Plan pays $3,230 Patient pays $2,170 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $1,300 Copays $0 Coinsurance $790 Limits or exclusions $80 Total $2,170 Note: These examples are based on individual coverage only. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

20 Community Consolidated School District #59: BlueEdge HSA Coverage Period: 07/01/ /30/2016 Coverage Examples Coverage for: Individual + Family Plan Type: HSA Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

21 CCSD#59 HMO and Blue Advantage HMO: Blue Cross and Blue Shield of Illinois Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL Plan Type: HMO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? $0 See the chart starting on page 2 for your costs for services this plan covers. No. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Is there an out of pocket limit on my expenses? Yes. $1,500 Individual/$3,000 Family. Prescription Drug Out-of-Pocket: $2,000 Individual/$4,000 Family The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out of pocket limit? Prescription copays, premiums, balanced-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. Does this plan use a network of providers? Yes. Visit or call for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I 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 the plan s permission before you see the specialist. Are there services this plan doesn t cover? Yes. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. Blue Cross and Blue Shield of Illinois, a] [A] Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 1 of 8

22 CCSD#59 HMO and Blue Advantage HMO: Blue Cross and Blue Shield of Illinois Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL Plan Type: HMO Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic Services You May Need You Use a Participating You Use a Non-Participating Primary care visit to treat an injury or illness $20 copay/visit Not Covered Limitations & Exceptions Specialist visit $40 copay/visit Not Covered Referral required. Services or supplies that are not ordered by your Primary Care Physician or Women s Principal Health Care, except emergency and routine vision exams, are not covered. Other practitioner office visit $20 copay/visit Not Covered Referral required. Preventive care/screening/immunization No Charge Not Covered ---none--- If you have a test Diagnostic test (x-ray, blood work) No Charge Not Covered Referral required. Imaging (CT/PET scans, MRIs) No Charge Not Covered Referral required. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

23 CCSD#59 HMO and Blue Advantage HMO: Blue Cross and Blue Shield of Illinois Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL Plan Type: HMO Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Services You May Need Generic drugs Formulary brand drugs Non-Formulary brand drugs You Use a Participating $10 copay / prescription for up to a 34 day supply. $20 copay / prescription for up to a 90 day supply. $30 copay / prescription for up to a 34 day supply. $60 copay / prescription for up to a 90 day supply. $45 copay / prescription for up to a 34 day supply. $90 copay / prescription for up to a 90 day supply. You Use a Non-Participating Limitations & Exceptions Not Covered Dispensing limit may apply to certain drugs. Not Covered Not Covered Certain women s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. 34 day retail / 90 day mail. RX Out-of-Pocket Expense Limit: $2,000 Individual/ $4,000 Family Specialty drugs Covered Not Covered Coverage based on group policy. Prior authorization may be required. If you have outpatient surgery If you need immediate medical attention Facility fee (e.g., ambulatory surgery center) $50 copay/visit Not Covered Referral required. Physician/surgeon fees No Charge Not Covered Referral required. Emergency room services $150 copay/visit $150 copay/visit Copay waived if admitted. Emergency medical transportation No Charge No Charge Ground transportation only. Urgent care $20 copay/visit Not Covered Must be affiliated with member s chosen medical group or referral required. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

24 CCSD#59 HMO and Blue Advantage HMO: Blue Cross and Blue Shield of Illinois Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL Plan Type: HMO Common Medical Event If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need Facility fee (e.g., hospital room) You Use a Participating $250 copay/ admission You Use a Non-Participating Not Covered Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. Limitations & Exceptions Referral required. Preauthorization is required. Physician/surgeon fee No Charge Not Covered Referral required. Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services $20 copay/visit Not Covered $250 copay/ admission Not Covered Substance use disorder outpatient services $20 copay/visit Not Covered Substance use disorder inpatient services $250 copay/ admission Not Covered Prenatal and postnatal care $20 copay Not Covered Delivery and all inpatient services $250 copay/ admission Not Covered ---none--- Unlimited visits. Referral required. Unlimited days. Referral required. Preauthorization is required. Use a plan provider only. Referral required. Unlimited days. Referral required. Preauthorization is required. Home health care No Charge Not Covered Referral required. Copay applies for the 1 st prenatal visit only. Rehabilitation services $20 copay/visit Not Covered 60 treatments combined for all therapies. Habilitation services $20 copay/visit Not Covered Referral required. Skilled nursing care $250 copay/ admission Not Covered Durable medical equipment No Charge Not Covered Hospice service No Charge Not Covered Excludes custodial care. Referral required. Preauthorization is required. Referral required. Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). Inpatient copay may apply. Referral required. 4 of 8

25 CCSD#59 HMO and Blue Advantage HMO: Blue Cross and Blue Shield of Illinois Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL Plan Type: HMO Common Medical Event If your child needs dental or eye care Services You May Need You Use a Participating You Use a Non-Participating Eye exam No Charge Not Covered ---none--- Limitations & Exceptions Glasses Covered Not Covered $75 allowance every 12 months. Dental check-up Not Covered Not Covered ---none--- Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Custodial Care Services Dental Care (Adult) Hearing Aids Long-Term Care Non-Emergency Care When Traveling Outside the U.S. Private-Duty Nursing Routine Foot Care (with the exception of person with diagnosis of diabetes) Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric Surgery Chiropractic Care Infertility Treatment Most coverage provided outside the United States. See Routine Eye Care (Adult) Weight Loss Programs (except when nonmedically supervised) Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

26 CCSD#59 HMO and Blue Advantage HMO: Blue Cross and Blue Shield of Illinois Coverage Period: 07/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL Plan Type: HMO Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Blue Cross and Blue Shield of Illinois at or visit or contact the U.S Department of Labor's Employee Benefits Security Administration at EBSA (3272) or visit Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) or visit Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

27 CCSD#59 HMO and Blue Advantage HMO: Blue Cross and Blue Shield of Illinois Coverage Period: 07/01/ /30/2016 Coverage Examples Coverage for: ALL Plan Type: HMO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $7,100 Patient pays $440 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $290 Coinsurance $0 Limits or exclusions $150 Total $440 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,720 Patient pays $680 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $600 Coinsurance $0 Limits or exclusions $80 Total $680 Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

28 CCSD#59 HMO and Blue Advantage HMO: Blue Cross and Blue Shield of Illinois Coverage Period: 07/01/ /30/2016 Coverage Examples Coverage for: ALL Plan Type: HMO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

29 The PPO Plan With the PPO plan, you can choose any doctor whenever you need care. The PPO plan offers a wide range of benefits and the flexibility to choose any doctor or hospital when you need care. The plan includes an annual deductible that you must satisfy before your benefits begin. Qualified medical expenses are applied toward your deductible. PPO Network Access to the large network of contracting providers is one of the many reasons to select the PPO plan. The network includes hospitals, physicians, therapists, behavioral health professionals and alternative care practitioners. You and your covered dependents can receive care from any licensed doctor, hospital or other provider. However, when you use a contracting network provider, you will pay less out of pocket, you won t have to file any claims and you will receive the highest level of benefits. If you use a doctor outside the network, you ll still be covered, but your out-of-pocket costs may be significantly higher. To find a contracting doctor or hospital, just go to bcbsil.com and use the Finder, or call BlueCard Access at BLUE ( ) for help. Once you become a member, you can also call the toll-free customer service number on the back of your member ID card. Medical Care Your benefits may include coverage for*: physician office visits breast cancer screenings cervical cancer screenings inpatient hospital services muscle manipulation services outpatient hospital services physical, speech and occupational therapies outpatient surgery and diagnostic tests infertility treatment maternity care behavioral health and substance abuse hospital emergency medical and accident treatment *Coverage levels vary by health plan, so refer to your plan documents for details

30 The HMO Illinois Plan The HMO Illinois plan from Blue Cross and Blue Shield of Illinois provides valuable benefits, member services and flexibility, along with the security of predictable copayments so there are no financial surprises. Unlike other plans, BCBSIL s HMO does not require you to pay a deductible. When you join HMO Illinois, you choose a contracting medical group within your network and then a family practitioner, internist or pediatrician from your chosen medical group to serve as your primary care physician (PCP). Your PCP provides or coordinates your health care, helps you make informed decisions and, when necessary, makes referrals to specialists who are usually within your medical group network. Each specialist referral is authorized for a specific number of visits or timeframe (up to one year). In addition to their PCP, female members also have the option of choosing a Woman s Principal Health Care (WPHCP) to provide or coordinate their health care services. The WPHCP and PCP must be affiliated with or employed by your Participating Medical Group. Physicians in the same medical group do have a referral arrangement. You do not need a PCP referral to see your WPHCP. HMOs offer valuable benefits with the security of predictable copayments. The HMO Illinois Network HMO Illinois offers access to one of the largest contracting health care provider networks in Illinois. In fact, your regular doctor may already be part of the network. If your doctor is not in the network and you are undergoing a course of evaluation and/or medical treatment or are in the second or third trimester of pregnancy when you join the plan, you may request transition of care benefits. Benefits for transitional services may be authorized for up to 90 days. After this period, all care must be transferred to a new PCP/medical group in the HMO network. Contact Member Services for more information. HMO Illinois has been awarded a Commendable Accreditation from the National Committee for Quality Assurance (NCQA). This accreditation level is awarded to plans that demonstrate levels of service and clinical quality that meet or exceed NCQA s rigorous requirements for consumer protection and quality improvement. The NCQA results are publicly reported in five categories: If you have a question, visit bcbsil.com or call Member Services at

31 Medical Care The range of benefits includes coverage for: outpatient treatment (Note: Physicians Care Network (PCN), Inc. members mental health care is directly coordinated with the network behavioral health provider.) Our HMOs have been awarded an Excellent Accreditation from the National Committee for Quality BlueCard Urgent Care SM occupational Assurance therapy) (NCQA). This accreditation level is awarded to plans that demonstrate levels of service This program covers HMO members traveling outside of and clinical quality that meet or exceed NCQA s rigorous Illinois requirements who need for medical consumer attention protection for a condition and that is quality improvement. The NCQA results are publicly reported not an emergency. in five categories: To find a medical group and PCP in the network, go to bcbsil.com and use the Finder or refer to a printed To find a contracting provider in the area in which you are directory. You can request a directory by calling Member Services at the toll-free number on the back of your BCBSIL ID card. Each covered family member can choose a different medical group or PCP from the network. It s also easy to change your PCP or medical group for any reason. To select a different PCP within your existing medical group, just call the medical group. To change your medical group, call Member Services or use the Blue Access for Members online service at bcbsil.com. See Your Health Care Benefit Program booklet or call Member Services for more information. Preventive Care Another HMO benefit is coverage for preventive care and wellness services for children and adults, such as routine physicals, screenings, tests and immunizations, including childhood immunizations. Also, BCBSIL sends reminders to members to schedule flu shots, mammograms and Pap tests, and to have early childhood immunizations completed. Vision Care You and your covered dependents are eligible to receive an eye examination and contact lens evaluation, fitting and follow-up once every 12 months, for the cost of your PCP or wellness copayment. Your vision care benefits are available through Davis Vision SM, a leading national provider of routine vision care programs. traveling, call the BlueCard program toll-free at BLUE ( ) or search the Blue Cross and Blue Shield Association s Web site at bcbs.com. You can then call the provider directly to make an appointment. You pay the applicable copayment at the time of service and don t need to submit claim forms. If you have a question, visit bcbsil.com or call Member Services at

32 Guest Membership This program covers members who are living out of the participating service area for at least 90 consecutive days. You can become a Guest Member with full benefits through a Blue Cross and Blue Shield HMO in another state. Guest Membership is a particularly valuable benefit for covered students who are living out of state while attending school or for members on extended travel out of state. To find out if guest membership is available at your destination or to sign up with a host Blue Cross and Blue Shield HMO in another state, you must call Member Services before leaving home or before receiving any out-of-state services. If not, there will be no coverage for services received out of state. After applying, if you plan to continue with guest membership, you must renew it after a defined period of time. Out-of-Area Coverage HMO Illinois gives you access to health care benefits when traveling or temporarily living out of state. Emergency Care If you, as a prudent layperson with an average knowledge of health and medicine, need to go to the emergency room of any hospital, your care will be covered. When a medical emergency occurs, we recommend you first try to call your PCP. Someone from your medical group is available 24 hours a day, seven days a week. Your PCP or another doctor in your medical group may be able to treat you in the office. If you are unable to call your PCP, go directly to the nearest hospital emergency room and notify your PCP as soon as possible. If you are admitted, someone must contact your PCP immediately upon admission. Your emergency room copayment will be waived, but you will have to pay your inpatient hospital copayment, if applicable. Emergency care benefits are limited to the initial emergency treatment. To receive additional benefits, your PCP must provide or coordinate follow-up care. Reconstructive Surgery Federal and State of Illinois legislation require that group health plans and health insurers provide coverage for reconstructive surgery following a mastectomy. These laws state that health plans that cover mastectomies must also provide coverage in a manner determined in consultation with the attending physician and patient for reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment for physical complications for all stages of mastectomy care, including lymphedemas. HMO Illinois covers these procedures and annual mammograms when ordered by a member s primary care physician or Woman s Principal Health Care, subject to the terms of the member s applicable health care benefit coverage. Visit bcbsil.com or call Member Services for more information. Utilization Management HMO Illinois supports the belief that the best people to determine what medical care you need are you and your doctor. BCBSIL does not get involved in deciding your course of treatment. This sets it apart from most other HMOs. Your doctor is encouraged to listen to your concerns and discuss all treatment options with you to help you make informed decisions. Your network medical group may review certain referrals or procedures for appropriateness of care. Your HMO doesn t get involved unless you request an appeal from BCBSIL because you disagree with decisions made by your PCP or medical group. Substance Abuse Treatment Substance abuse treatment is provided at contracting facilities and a PCP referral is not needed. Call the number on the back of your ID card to locate a participating substance abuse provider. This document is for comparison purposes only and is a brief summary of benefits. For full benefit information, please refer to your contract or certificate (Health Care Benefit Program booklet). If you have a question, visit bcbsil.com or call Member Services at

33 BlueEdge HSA SM and BlueEdge Select HSA SM Plans Why Choose BlueEdge? BlueEdge HSA is a consumer-directed health care plan (CDHP) that helps you achieve your health and financial goals. It combines a qualified high-deductible health plan with a health savings account (HSA) where you decide to either pay for qualified medical expenses with tax-free dollars or leave the funds untouched to work as a savings vehicle. Deposits to the account can be made by you, your employer or anyone else. BlueEdge HSA ensures you have: Affordability Use health savings account funds to help meet your annual deductible, or leave them untouched to grow as savings. Tax Savings Health savings account funds that are used for qualified medical expenses are tax-exempt. Portability Your health savings account belongs to you, unused funds can rollover at the end of the year, or you can take the money with you if you change health plans or your job, or if you retire. Control You decide how, when and where your health care dollars are spent. The savvier a consumer you are, the more you extend how far your health savings account will take you. Freedom and Choice Choose any doctor whenever you need care, but choosing a network doctor means getting care at the highest level of benefits. There s more to BlueEdge: Preventive care and wellness visits Adults and children are covered at 100 percent when you use network providers*. You don t need to meet the deductible to enjoy these benefits. Online decision tools Personalize how you manage your health care and your health care spending. Log in to Blue Access for Members SM (BAM), a safe, secure website at bcbsil.com to: Manage your benefits Search for a network provider Estimate the cost of a procedure or treatment Find health and wellness information and resources Ask health care professionals for help with your concerns through 24/7 Nurseline Network Information Use Finder at bcbsil.com to see if your doctor is in the network or to search for another network provider. You may also call BlueCard Access toll-free at BLUE ( ) for provider information. Once you become a member, you can call the toll-free customer service telephone number on the back of your ID card for assistance. *Coverage levels vary by health plan, so refer to your plan documents for details

34 Health Savings Account Administration Your health savings account is administered by a separate custodian not Blue Cross and Blue Shield of Illinois. If your employer chooses BenefitWallet TM' ** as the health care account administrator and you seek care from contracting PPO providers, qualified medical expenses may be paid automatically from your HSA at our discounted PPO rate with no outof-pocket expenses or paperwork for you**. To request this direct claims payment process, you must contact BenefitWallet at their toll-free number, ***. If your employer chooses HSA Bank ' or another administrator, and you seek care from contracting PPO providers, BCBSIL will process the claim and determine your liability for the qualified medical expense, if any***. If you have a balance, the amount will be listed on your Explanation of Benefits statement and you may use the debit card, checkbook, or your own personal funds to pay any balance due to the provider***. Special Notice about HSAs Under IRS regulations, anyone enrolling in this health plan should be aware that any adult can contribute to a health savings account (HSA) if he/she: Has coverage under an HSA-qualified high deductible health plan (HDHP) Has no other first-dollar medical coverage (other types of insurance such as specific injury insurance or accident, disability, dental care, vision care, or long term care insurance are permitted) tax return There are other regulations regarding contributions and distributions. If you are enrolling in a plan that includes a health savings account, you should first seek professional tax counsel to determine if your individual situation permits use of an HSA. If you have a flexible spending account (FSA), or a health care account (HCA), check with your employer to confirm that you are eligible for an HSA. Both the FSA and HCA are considered a limited purpose account that can only be used for certain expenses. ** Xerox HR Solutions, LLC. and The Bank of New York Mellon (BNY Mellon) are affiliated companies that provide HSA administration services as BenefitWallet. Xerox is the administrator of the BenefitWallet HSA product. BNY Mellon is the custodian. ***The relationship between Blue Cross and Blue Shield of Illinois, Xerox, BNY Mellon and HSA Bank is that of independent contractors. Xerox, BNY Mellon and HSA Bank are separate companies that are solely responsible for administration of the health savings account associated with the BlueEdge HSA plan. Please note that the HSA is a separate account established by the member in accordance with an agreement with an independent third-party bank over whom Blue Cross and Blue Shield of Illinois has no relationship or contractual agreement.

35 How It Works BlueEdge HSA Example Ben and Aileen Ben and Aileen and their two children have BlueEdge Select HSA family coverage through Aileen s employer. The plan is paired with a health savings account that includes a debit card and checks from the HSA administrator*. At the beginning of the year, Ben and Aileen put $3,000 into their health savings account (the contribution cannot exceed the maximum determined annually by the IRS). Year One Aileen s health savings account annual contribution = $3,000 Aileen s annual family deductible = $3,000 Ben and Aileen had physicals and preventive care lab tests. Both children had annual physicals and routine immunizations. Ben tore a ligament in his knee that required surgery. paid with the health savings account debit card, which counts toward the deductible. with the debit card. With this, the $3,000 family deductible had been satisfied and health plan benefits began. Of the remaining $3,675, the health plan paid 80 percent ($2,940) and Ben paid his 20 percent coinsurance ($735). Aileen saw a dermatologist and had several moles removed. percent ($960), and Aileen paid her 20 percent coinsurance ($240). All of the health savings account money was spent so there was no amount to roll over to next year. Year Two Ben and Aileen decide to contribute $3,000 once again to their health savings account at the beginning of the year. Ben and Aileen had physicals and preventive care lab tests. Both children had annual physicals. Aileen saw her dermatologist for a follow-up visit. card, which also counted toward the deductible. Ben participated in a smoking cessation program. a check from the health savings account. This expense did not count toward the deductible. At the end of year two, $2,375 remains in the health savings account and this rolls over to the next year. * The provider should first submit your claim for processing so that you receive benefits at the Blue Cross and Blue Shield of Illinois negotiated rate. You may then use the debit card or checks to pay any balance due to the provider. In these examples, in-network preventive care is covered at 100%. Not all groups cover preventive care. Ask your employer for details. Funds must be available in your health savings account before you can use them to pay for medical services. Ask your employer when funds will be deposited to your account (each pay period, quarterly, annually, etc).

36 Sam has BlueEdge HSA coverage through his employer. His plan is paired with a health savings account. The HSA administrator issues Sam a debit card and checks that can be used to pay for eligible health care expenses that aren t covered by the health plan*. Year One Sam s health savings account annual contribution = $1,500 (Sam contributes $750 and his employer contributes $750. The combined contribution cannot exceed the maximum determined annually by the IRS.) Sam s annual deductible = $1,500 Sam had a physical and preventive care lab tests. He injured his back and saw a specialist in the network. health savings account debit card. This amount was also applied to the deductible. He had six physical therapy visits for his back with a physical therapist who is part of the network. $1,050. Sam paid with his debit card and the total was applied to his deductible. Sam broke his leg. his debit card, which satisfied the annual $1,500 deductible, leaving $2,865. Health plan benefits paid 80 percent ($2,292) and Sam paid his 20 percent coinsurance ($573). Sam used all the funds in her health savings account. Year Two Sam and his employer each contributed $750 to his health savings account for a total of $1,500. The annual deductible is $1,500. He had an annual physical and several preventive care lab tests. He had an eye exam and purchased a year s supply of contact lenses. debit card. Charges for the routine eye exam do not count toward the deductible. At the end of the year, Sam changed health plans. His health savings account is completely portable, so he kept the unspent funds to be used tax free for qualified medical expenses. * The provider should first submit your claim for processing so that you receive benefits at the Blue Cross and Blue Shield of Illinois negotiated rate. You may then use the debit card or checks to pay any balance due to the provider. In these examples, in-network preventive care is covered at 100%. Not all groups cover preventive care. Ask your employer for details. Funds must be available in your health savings account before you can use them to pay for medical services. Ask your employer when funds will be deposited to your account (each pay period, quarterly, annually, etc).

37 Frequently Asked Questions About BlueEdge HSA What is a health savings account? If you have a qualified high-deductible health plan (HDHP), you can establish a tax-exempt health savings account with your own funds, those from your employer or both. You can use these funds to pay for qualified medical care services. Qualified expenses also count toward your annual deductible. Balances roll over from year to year and the account is portable, which means it stays with you if you change benefit plans, jobs or if you retire. How can I decide if BlueEdge HSA is right for me? Comparing covered benefits, network providers, the cost of coverage and other out-of-pocket expenses are important when choosing a health plan. For more information on HSAs, visit the U.S. Treasury s website at treasury.gov. How is the HSA account funded? IRS rules for contributions include, but are not limited to the following: Any person (an employer, a family member or any other person) may make contributions to an HSA on behalf of an eligible individual. Is there a specific health plan design for HSAs? Yes. HSA law and IRS guidance have focused on four elements of the HDHP plan design: significant benefits at all times to those covered by the HDHP Who is eligible to open an HSA account? Only eligible individuals may open an HSA account. To qualify for an HSA, you: of the month; HDHP, including Medicare coverage; certain exceptions apply; Health reimbursement arrangements (HRAs) and health savings accounts (HSAs), including products under our BlueEdge product portfolio have tax and legal ramifications. Blue Cross and Blue Shield of Illinois does not provide legal or tax advice, and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on, for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the transaction(s) or matter(s) addressed by these materials. You may seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products.

38 Other Benefits for non-hmo plans Your health care benefit plan travels with you wherever you go across the country or around the world. Preventive Care Your coverage may include preventive care benefits for children and adults, including physical exams, diagnostic tests and immunizations. Check your group plan for the specific coverage. Emergency Care If you, as a prudent layperson (with an average knowledge of health and medicine) need to go to the emergency room of any hospital, your care will be covered subject to your plan s deductible and any applicable copayments or coinsurance. In an emergency, you should seek care from an emergency room or other similar facility. Call 911 or other community emergency resources to obtain assistance in life-threatening situations. Your group plan may require that you, a family member or friend contact BCBSIL if you are admitted to the hospital. National Coverage You have nationwide access to contracting providers in networks linked through the BlueCard program when you or your covered dependents live, work or travel anywhere in the country. The national network includes more than 85 percent of all physicians and hospitals in the country. Be sure to use a BlueCard network provider to receive the highest level of benefits. With the BlueCard program, there are two ways to locate contracting doctors and hospitals: to find provider names and locations using the Finder. Maps and driving directions are also available. your ID card

39 physical complications for all stages of mastectomy, including lymphedemas. Your coverage may also include benefits for baseline and annual mammograms. Check your group plan documents for details. Reconstructive Surgery Following Mastectomy Federal and State of Illinois legislation require group health plans and health insurers to provide coverage for reconstructive surgery following a mastectomy. Specifically, these laws state that health plans that cover mastectomies must also provide coverage in a manner determined in consultation with the attending physician and patient for reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of Illinois Dependent Eligibility Mandate Under new, Federal law, your dependents are eligible for health and/or dental coverage up to the dependent limiting age and may not be denied coverage due to marital, student or employment status before age 26. Check with your employer for additional details regarding eligibility requirements. In addition, eligible military personnel may not be denied coverage before age 30 under Illinois law. If you elect BlueChoice Select coverage, your dependents must live within the defined service area. This Illinois law applies to all individual plans and insured group medical and/or dental plans, as well as self-insured municipalities, counties and schools. The law does not apply to self-funded national account groups or local non-municipal self-funded groups. If you have questions about this law, contact your benefits administrator. International Coverage When you travel outside the United States and need medical assistance services, call BLUE ( ) or call collect to for information. Blue Cross and Blue Shield has contracts with doctors and hospitals in more than 200 countries. An assistance coordinator, in conjunction with a medical professional, can arrange your doctor s appointment or hospitalization, if necessary. s that participate in the BlueCard Worldwide program, in most cases, will not require you to pay up front for inpatient care. You are responsible for the out-of-pocket expenses such as a deductible, copayment, coinsurance and non-covered services. The doctor or hospital should submit your claim. You also have coverage at non-contracting hospitals, but you will have to pay the doctor or hospital for care at the time of service, then submit an international claim form with original bills. Call the toll-free customer service number on your ID card for the address to send the claim. You can get a claim form from your employer, customer service or online at