Summary of Benefits and : W hat this Plan Covers & What it Costs C overage f: G old 25 C opayments a re fixed dollar amounts (f example, $15) you pay

Transcription

1 Summary of Benefits and : W hat this Plan Covers & What it Costs C overage f: G old 25 T his is only a summary. If you want me detail about your coverage and costs, you can get complete terms in policy plan document at w ww. h ealthydollarsin by calling. I mptant Questions A nswers W hy this Matters: What is overall d eductible? A re re or d eductibles f specific s ervices? Is re an o ut o f p ocket limit on my e xpenses? What is not included in o ut o f pocket l imit? Is re an overall a nnual limit on what t he plan pays? Does this plan use a n etwk of providers? Do I need a referral to see a s pecialist? Are re services this p lan doesn't cover? $ 1, 3 p erson / $ 2, 6 2- Person F a mily D oesn t apply to preventive c are This plan has no o ut o f p ocket limit. Yes. $ 1, 2 p erson / $ 2, 4 2-P erson Fa mily must pay all costs up to d eductible a mount befe this p lan begins to pay f c overed services you use. Check your policy o r plan document to see when d eductible starts over (usually, but not always, January 1st). See chart starting on page 2 f how much you pay f covered services after you meet dedu ctible. don't have to meet d eductibles f specific services, but see chart starting on page 2 f or costs f services this plan covers. There's no limit on how much you could pay during a coverage period f your share of c ost of covered services. Not applicable because re's no o ut o f p ocket limit. T his plan will pay f covered services only up to this limit during each coverage period, even if your own need is greater. 're responsible f all expenses above this limit. The chart starting on page 2 describes s pecific coverage limits, such as limits on number of o ffice visits. This plan treats p roviders t he same in determining payment f same services. No. don't need a referral to s ee a specialist. Y es. can see s pecialist y ou choose without permission from this plan. Some of services this plan doesn't cover are listed on page 4. See your policy plan document f additional infmation about e xcluded services. This plan provides reimbursements only. This Plan wks in codination with a high deductible health plan which allows you to participate in a Health Savings Account. The Plan will not pay r eimburse any medical expense incurred befe minimum annual deductible is met u nder high deductible health plan. I f you aren't clear about any of underlined terms used in this fm, see Glossary. can view Glossary at w ww.dol.gov/ebsa/healthrefm 1 o f 8

2 Summary of Benefits and : W hat this Plan Covers & What it Costs C overage f: G old 25 C opayments a re fixed dollar amounts (f example, $15) you pay f covered health care, usually when you receive service. C oinsurance i s your s hare of costs of a covered service, calculated as a percent of a llowed amount f service. F example, if t he p lan s a llowed amount f an overnight hospital stay is $1,, your coi nsurance p ayment of 2% would be $2. T his may change if you haven t met your d eductible. The amount plan pays f covered services is based on a llowed amount. If an out-of-n etwk p rovider charges me than allowed amount, you may have to pay difference. F example, if an out-of- netwk hospital charges $1,5 f an overnight stay and a llowed amount is $1,, you may have to pay $5 difference. (This is called b alance billing. ) r cost sharing does not depend on wher a p rovider is in a n etwk. C ommon M edical Event S ervices May Need Y our Cost Limitations E xceptions & If you visit a health care p rovider's o ffice clinic I f you have a test P rimary S pecialist O r P reventive care visit to treat an injury illness visit practitioner office visit care/screening/immunization Diagnostic test (x- r ay, blood wk) I maging (CT/PET scans, MRIs) any any I f you aren't clear about any of underlined terms used in this fm, see Glossary. can view Glossary at w ww.dol.gov/ebsa/healthrefm 2 o f 8

3 Summary of Benefits and : W hat this Plan Covers & What it Costs C overage f: G old 25 C ommon M edical Event S ervices May Need Y our Cost Limitations E xceptions & If you need drugs to treat y our illness condition If you have outpatient s urgery If you need immediate m edical attention I f you have a hospital stay P rescription drugs O ver F acility counter drugs fee (e.g., ambulaty surgery center) P hysician/surgeon fees E mergency E mergency U rgent care room services medical transptation F aci lity fee (e.g., hospital room) P hysician/surgeon fee amount available in your account only if you have a p rescription I f you aren't clear about any of underlined terms used in this fm, see Glossary. can view Glossary at w ww.dol.gov/ebsa/healthrefm 3 o f 8

4 Summary of Benefits and : W hat this Plan Covers & What it Costs C overage f: G old 25 C ommon M edical Event S ervices May Need Y our Cost Limitations E xceptions & If you have mental health, behavial health, s ubstance abuse needs I f you are p regnant If you n eed help recovering o r h ave or special health needs If your child needs dental e ye care M ental/behavial M ental/behavial S ubstance S ubstance P renatal D elivery H ome health outpatient services health inpatient services use disder outpatient services use disder inpatient services and postnatal care and all inpatient services health care R ehabilitation and S killed nursing D urable E ye exam G lasses Habilitation services care and/ hospice service medical equipment Reimbursement up to account balance if child is covered by VT Vitality G old HDHP Reimbursement up to account balance if child is covered by VT Vitality G old HDHP I f you aren't clear about any of underlined terms used in this fm, see Glossary. can view Glossary at w ww.dol.gov/ebsa/healthrefm 4 o f 8

5 Summary of Benefits and : W hat this Plan Covers & What it Costs C overage f: G old 25 C ommon M edical Event S ervices May Need Y our Cost Limitations E xceptions & Dental check-u p Reimbursement up to account balance if child is covered by VT Vitality G old HDHP E xcluded Services & Or Covered Services: P lease Note: T his plan provides reimbursements only. This Plan wks in codination with a high deductible health plan which allows you to participate in a Health Savings Account. As a result, Plan will not pay reimburse any medical e xpense incurred befe minimum annual deductible is met under high deductible health plan ($1,3 f a single p erson and $2,6 f family coverage in 217). S ervices r Plan Does NOT Cover ( This isn t a complete list. Check your policy plan document f or e xcluded services. ) A cupuncture B ariatric surgery C osmetic surgery D ental care (Adult) Long-t erm care Non-e mergency care when traveling o utside U.S. R outine eye care (Adult) Private- d uty nursing W eight loss programs O r Covered Services (This isn t a complete list. Check your policy plan document f or covered services and your costs f se s ervices.) M edical Deductible Expenses N ote: Review services not covered above and P rescription Deductible Expenses d elete (and add into this box) as applicable. The S BC is required to list services above in a lphabetical der and with bullet points. I f you aren't clear about any of underlined terms used in this fm, see Glossary. can view Glossary at w ww.dol.gov/ebsa/healthrefm 5 o f 8

6 Summary of Benefits and : W hat this Plan Covers & What it Costs C overage f: G old 25 Y our Rights to Continue : I f you lose coverage under plan, n, depending upon 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 premium you p ay while covered under plan. Or limitations on your rights to continue coverage may also apply. F me infmation on your rights to continue coverage, contact plan at. may also contact your state insurance department, U.S. Department of Lab, Employee Benefits Security Administration at w ww.dol.gov/ebsa, U.S. Department of Health and Human Services at x Y our Grievance and Appeals Rights: I f you have a complaint are dissatisfied with a denial of coverage f claims under your plan, you may be able to a ppeal o r file a g rievance. F q uestions about your rights, this notice, assistance, you can contact Department of Lab's Employee Benefits Security Administration at EBSA (3272) can also contact plan at. T o see examples o f how this plan might cover costs f a sample medical situation, see t he next p age. I f you aren't clear about any of underlined terms used in this fm, see Glossary. can view Glossary at w ww.dol.gov/ebsa/healthrefm 6 o f 8

7 Light Technologies, Inc Restated - RA H C overage Examples f: T hose covered by VT Vitality Gold HDHP About se E xamples: These examples s how how this p lan might cover m edical care in given situations. Use se examples t o see, in general, how much financial p rotection a sample patient m ight get if y are c overed under different p lans. T his is n ot a cost e stimat. Don t use se examples to estimate your actual costs under this p lan. The actual care you r eceive will be different from se examples, and cost of t hat care will a lso be different. S ee next page f imptant infmation about t hese examples. H aving a baby ( nmal delivery) A mount owed to providers: $7,54 P lan pays S ee "Note" below P atient pays $ 7,54 S ample care costs: H ospital charges (mor) $2, 7 R outine obstetric care $2, 1 H ospital charges (baby) $9 A nessia $9 L abaty tests $5 Pr escriptions $2 R adiology $ 2 V accines, or preventive $ 4 T otal $ 7, 54 P atient pays: T otal $ 7,54 M anaging type 2 diabetes ( r outine maintenance of a well-c ontrolled condition) A mount owed to providers: $5,4 P lan pays S ee "Note" below P atient pays $ 5,4 S ample care costs: P rescriptions $2,9 M edical Equipment a nd Supplies $ 1,3 Office V isits a nd P rocedures $ 7 E ducation $ 3 L abaty tests $ 1 V accines, or preventive $ 1 T otal $5,4 P atient pays: T otal $ 5,4 N ote: This plan does not provide insurance. This plan may be available to reimburse some all of remaining costs subject to types of services this plan covers (see page 5) and your account balance after any applicable i nsurance has paid. I f you aren't clear about any of underlined terms used in this fm, see Glossary. can view Glossary at w ww.dol.gov/ebsa/healthrefm 7 o f 8

8 Light Technologies, Inc Restated - RA H C overage Examples f: T hose covered by VT Vitality Gold HDHP Q uestions and a nswers a bout What are some of assumptions behind Examples? Costs don t include p remiums. Sample care costs are based on national a verages supplied b y U.S. Department of Health and Human Services, and aren t specific to a particular geographic area health p lan. T he patient s condition was not an e xcluded o r p reexisting condition. All services and treatments started and e nded in same c overage p eriod. There are no or medical expenses f any member covered under this p lan. Out-of- pocket expenses are based only o n treating condition in exampl e. T he patient received all care from in- netwk p roviders. If patient had received care from out-of- netwk p roviders, costs would have been higher. t he C overage Examples: W hat does a Example s how? F each treatment situation, Example helps you see how d eductibles, cop ayments, and coi nsurance c an add up. It also helps you see what expenses might be left u p to you t o pay because service t reatment isn t covered payment is limited. Does C overage E xample p redict my own care needs? I f you aren't clear about any of underlined terms used in this fm, see Glossary. can view Glossary at w ww.dol.gov/ebsa/healthrefm Treatments shown are just e xamples. The care you would r eceive f thi s condition could be different based on your d oct s advice, your age, h ow serious your c ondition i s, and many or facts. Does Example predict my f uture expenses? Examples are n ot cost estimats. c an t use examples to e stimate costs f an actual condition. They a re f comparative purposes only. r own costs will be different depending on care you r eceive, prices your p roviders charge, and reimbursement your health p lan a llows. Can I use Examples t o compare plans? Y es. When you look at Summary of B enefits and C overage f or plans, you ll find same C overage Examples. When you compare p lans, check P atient Pays box i n each e xample. The smaller that number, me coverage p lan p rovides. Are re or costs I should consider when comparing plans? V-3. Y es. An imptant cost is p remium you pay. Generally, lower your premium, me you ll pay in out-of- pocket costs, such as cop ayments, d eductibles, and coi nsurance. s hould a lso consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) health reimbursement accounts ( HRAs) that help you pay out-of- pocket e xpenses. 8 o f 8