Application Checklist. Client Name: Rep Name: 1. Identification a. Driver's License and Birth Certificate or b. Passport

Transcription

1 Strategic Transitions Inc. 13 North 6th St. New Bedford, MA Office Fax Application Checklist Client Name: Rep Name: 1. Identification a. Driver's License and Birth Certificate or b. Passport 2. Proof of Income a. Paystub from all jobs b. If self employed, incorporated, rental, etc.: Both pages of Federal 1040 Both pages of any Schedule C, E, Etc. 3. Dr's. Name and Locations

2 Application for Health Care Coverage Primary Applicant - We need one adult in the family to be the contact for the application 1. First Name Middle Name Last Name Suffix (e.g. Jr., I, II etc.) 2. Gender M F 3. Date of Birth Month: Day: Year: 4. Are you applying for Medical coverage? Yes No 5. Are you applying for Dental coverage? Yes No 6. Do you have a Social Security number? Yes No If you have an SSN, enter it here. 6a. Social Security number (SSN): 7. My Name is different on my Social Security card: Yes No 7a. If YES, Name on Card: Family Member 2 You can skip questions if this person is not applying for health coverage 8. First Name Middle Name Last Name Suffix (e.g. Jr., I, II etc.) 9. Gender M F 10. Date of Birth Month: Day: Year: 11. Is this person applying for Medical coverage? Yes No 12. Is this person applying for Dental coverage? Yes No 13. Does this person have a Social Security number? Yes No 14. Is this person s name is different on my Social Security card: If this person has an SSN, enter it here. Yes No 13a. Social Security number (SSN): 14a. If YES, Name on Card: Family Member 3 You can skip questions if this person is not applying for health coverage 15. First Name Middle Name Last Name Suffix (e.g. Jr., I, II etc.) 16. Gender M F 17. Date of Birth Month: Day: Year: 18. Is this person applying for Medical coverage? Yes No 19. Is this person applying for Dental coverage? Yes No 20. Does this person have a Social Security number? Yes No If this person has an SSN, enter it here. 20a. Social Security number (SSN): 21. Is this person s name is different on his or her Social Security card: Yes No 21a. If YES, Name on Card: Family Member 4 You can skip questions if this person is not applying for health coverage 22. First Name Middle Name Last Name Suffix (e.g. Jr., I, II etc.) 23. Gender M F 24. Date of Birth Month: Day: Year: 25. Is this person applying for Medical coverage? Yes No 26. Is this person applying for Dental coverage? Yes No 27. Does this person have a Social Security number? Yes No If this person has an SSN, enter it here. 27a. Social Security number (SSN): 28. Is this person s name different on his or her Social Security card: Yes No 28a. If YES, Name on Card:

3 Tell Us About Yourself Primary Applicant 1. First Name Middle Name Last Name Suffix (e.g. Jr., I, II etc.) 1a. Primary Phone Number Cell Home Work ( ) 1b. Secondary Phone Number Cell Home Work ( ) 1c. Address 5. Home Address Apt/Unit # City State Zip Code 6. Mailing Address (if different) Apt/Unit # City State Zip Code 10. Are you pregnant? Yes No 10a. If YES: Pregnancy Due Date: Month: Day: Year: 10b. Number of babies expected: Your Current Job and Income Are you currently self-employed? Yes No type of work: Gross monthly Self-Employment Income: Are you currently employed (other than self-employed)? Yes No Employer 1 Name:. Employer Address City State Zip Code Wages/Tips before Taxes: Wages/Tips Frequency: Hourly Daily Weekly Every 2 Weeks Monthly Yearly Average Number of hours you work each week Will you file a federal income tax return next year? Yes No Will you file jointly with a spouse? Yes No If yes, name of spouse: Will you claim any dependents on your income tax return? Yes No If yes, list name(s) of dependents: Will someone else claim you as a dependent on his or her tax return? Yes No If yes, name of tax filer: How are you related to the tax filer?

4 Spouses Job and Income Is this person currently self-employed? Yes No type of work: Gross monthly Self-Employment Income: Is this person currently employed (other than self-employed)? Yes No If this person is currently employed, please complete the following information on your employer and income. Employer 1 Name: Employer Address City State Zip Code Wages/Tips before Taxes: Your Other Income Do you have other sources of Income? If YES, check all that apply. If NO, go to question 25. NOTE: Do not include child support, non-pension veteran s payments, or Supplemental Security Income (SSI) Sources How much ($) How often Social Security Benefits Unemployment Retirement Alimony Received Dividend Payments Companies report this income to you on an IRS 1099-DIV form each year. Capital Gains These are profits from the sales of investments, such as stocks. Pensions Farming/Fishing Income Rental or Royalty Income This is monthly income from renting a property that wasn t included in self-employment. Interest Investment Other income Type: Your Deductions Wages/Tips Frequency: Hourly Daily Weekly Every 2 Weeks Monthly Yearly Alimony paid Health savings account contributions Self-employment deductions Interest on student loans Pre-tax retirement account contributions Self-employment retirement plan (excluding Roth IRA contributions) Tuition and school fees Moving costs related to a job change Self-employment health insurance premium Deductions How much ($) How often Type: Type: Average Number of hours Is this person works each week

5 Applicants References (Individual) AGENT NAME/PRODUCER CODE: Strategic Transitions Inc 13 North Sixth St. Suite 300 New Bedford, MA Office Fax REFERANCES Provide three (3) references that have known the proposed insured for at least one year. Name: Address: City: State: Zip: Occupation: Employer: Family Relation Y / N Years Known? Cell: ( ) How Known? Bus: ( ) Hm:( ) Name: Address: City: State: Zip: Occupation: Employer: Family Relation Y / N Years Known? Cell: ( ) How Known? Bus: ( ) Hm:( ) Name: Address: City: State: Zip: Occupation: Employer: Family Relation Y / N Years Known? Cell: ( ) How Known? Bus: ( ) Hm:( )

6 Strategic Transitions Inc 13 North Sixth St. Suite 300 New Bedford, MA Office Fax CONTACT PERSON EMPLOYER STREET ADDRESS EFFECTIVE DATE ADDRESS CELL PHONE NUMBER CONTACT NUMBER 1. One Time Enrollment Fee: $ 2. Monthly Administration & Consulting Fee (This fee is collected after approval): $ 3. Supplemental Benefit Deduction $ via check/cash/money order. TODAYS TOTAL: NEXT MONTHS TOTAL: PAYMENT OPTIONS: $ $ Elecronic Funds Transfer Consulting Fee Option (Fill out EFT Authorization Form below) Initial Payment: I am paying my one time enrollment fee with check, cash, money order, or Auto Draft. There is a $10 insufficient funds fee Monthly Payment: Please EFT my bank account for the monthly consulting fee I stand a draft on my account will occur between the 15th & 20th of the month prior to the next months coverage. There is a $10 insufficient funds fee Invoicing Consulting Fee'Option Initial Payment: I am paying my first 3 month s consulting fee and one time enrollment fee via check/cash/money order. I am sending my check, cash, or money order with my completed Enrollment Form. There is a $10 insufficient funds fee Invoiced Payment: I would like to receive a invoice to pay my consulting fee I stand an additional billing fee of $10 will apply. ACCOUNT HOLDER SIGNATURE (REQUIRED if paying via EFT) X PRINT NAME DATE EFT AUTHORIZATION FORM BANK NAME BANK ROUTING NUMBER BANK ACCOUNT NUMBER Voided check is required and must be legible. No monthly charge for EFT. PLEASE ATTACH A CHECK MARKED VOID TO ENSURE ACCURACY I stand this authority is to remain in full force and effect until the company has received written notification from me of its termination in such time and such manner as to afford the company and depositor a reasonable opportunity to act on it. I have the right to stop payment of a debit entry (deduction) by notification to Strategic 3 business days or more before this payment is scheduled to be made. Please be aware that your bank statement will reflect the debit as ( Strategic ) Rep Name Date Phone

7 Strategic Transitions Inc. 13 North 6th St. New Bedford, MA Office Fax I agree to use Strategic Transitions Inc. (ST) as my designated representative to the state. I fully stand that these resources are available to me from the state and it is something I can do independently. I stand that I am paying ST for a service. Initial You might be eligible for an Federal Premium Tax Credit if your household income is up to 400% of the Federal Poverty Level (FPL). The Department of Health and Human Services sets the FPL. If you are eligible for a tax credit, then the United States government will pay part premiums directly to the carrier you choose. You might also be eligible for a lower cost CommonCare plan if your household income is up to 300% of the FPL. If you are eligible, the state of Massachusetts will pay part of your premiums directly to the carrier. This would be in addition to any tax credits you might qualify for, further decreasing your cost sharing. Changes in Circumstances can Affect your Premium Tax Credit IRS Health Care Tax Tip , March 25, 2014 If you receive advance payment of the premium tax credit in 2014 it is important that you report changes in circumstances, such as changes in your income or family size, to your Health Insurance Marketplace. Most people already have insurance and they won t have to do anything new. If you are looking for health insurance, you may be able to get it through the Health Insurance Marketplace and you may qualify for the premium tax credit. You can get it now as an advance payment or you can get it later when you file your tax return. Advance payments of the premium tax credit provide financial assistance to help you pay for the insurance you buy through the Health Insurance Marketplace. Having at least some of your credit paid in advance directly to your insurance company will reduce the out-of-pocket cost of the health insurance premiums you ll pay each month. If you decide to get the credit in advance, it s important to report any changes in your income or family size to the Marketplace throughout the year. Reporting these changes, will help you get the proper type and amount of financial assistance so you can avoid getting too much or too little in advance. The government makes advance payments of the credit based on an estimate of the credit that you will claim on your tax return when you file in If you report changes in your income or family size to the Marketplace when they happen in 2014, the advance payments will more closely match the credit amount on your 2014 federal tax return. This will help you avoid getting a smaller refund than you expected or even owing money that you did not expect to owe. Initial ST will take my application and process it. There is a one-time fee for the submittal of this application. This is a non-refundable application fee. This covers ST following my application through the system from initial application to approval. If for some reason my application is not approved due to an income miscalculation on ST part a full refund of the application fee will be given. Once I am approved ST will charge me a monthly service charge for as long as I use their services. This monthly service fee includes: 1. Allows calls into our call center to answer any questions you may have. 2. We will provide assistance with handling any related correspondence received from the state. 3. We will conduct a yearly review and any requested renewal paperwork will be submitted to the state. 4. We will handle all necessary dealings with the state on your behalf. 5. We will give temporary cards with your selected physician for use until the actual health plan cards arrive. If I no longer require ST services, I will give 30 day written notice in advance of my termination via , mail, or fax. If termination occurs within the first 90 days a early termination fee applies. Applicant: Signature:

8 Strategic Transitions Inc. 13 North 6th St. New Bedford, MA Office Fax I agree to use Strategic Transitions Inc. (ST) as my designated representative to the state. I fully stand that these resources are available to me from the state and it is something I can do independently. I stand that I am paying ST for a service. Initial You might be eligible for an Federal Premium Tax Credit if your household income is up to 400% of the Federal Poverty Level (FPL). The Department of Health and Human Services sets the FPL. If you are eligible for a tax credit, then the United States government will pay part premiums directly to the carrier you choose. You might also be eligible for a lower cost CommonCare plan if your household income is up to 300% of the FPL. If you are eligible, the state of Massachusetts will pay part of your premiums directly to the carrier. This would be in addition to any tax credits you might qualify for, further decreasing your cost sharing. Changes in Circumstances can Affect your Premium Tax Credit IRS Health Care Tax Tip , March 25, 2014 If you receive advance payment of the premium tax credit in 2014 it is important that you report changes in circumstances, such as changes in your income or family size, to your Health Insurance Marketplace. Most people already have insurance and they won t have to do anything new. If you are looking for health insurance, you may be able to get it through the Health Insurance Marketplace and you may qualify for the premium tax credit. You can get it now as an advance payment or you can get it later when you file your tax return. Advance payments of the premium tax credit provide financial assistance to help you pay for the insurance you buy through the Health Insurance Marketplace. Having at least some of your credit paid in advance directly to your insurance company will reduce the out-of-pocket cost of the health insurance premiums you ll pay each month. If you decide to get the credit in advance, it s important to report any changes in your income or family size to the Marketplace throughout the year. Reporting these changes, will help you get the proper type and amount of financial assistance so you can avoid getting too much or too little in advance. The government makes advance payments of the credit based on an estimate of the credit that you will claim on your tax return when you file in If you report changes in your income or family size to the Marketplace when they happen in 2014, the advance payments will more closely match the credit amount on your 2014 federal tax return. This will help you avoid getting a smaller refund than you expected or even owing money that you did not expect to owe. Initial ST will take my application and process it. There is a one-time fee for the submittal of this application. This is a non-refundable application fee. This covers ST following my application through the system from initial application to approval. If for some reason my application is not approved due to an income miscalculation on ST part a full refund of the application fee will be given. Once I am approved ST will charge me a monthly service charge for as long as I use their services. This monthly service fee includes: 1. Allows calls into our call center to answer any questions you may have. 2. We will provide assistance with handling any related correspondence received from the state. 3. We will conduct a yearly review and any requested renewal paperwork will be submitted to the state. 4. We will handle all necessary dealings with the state on your behalf. 5. We will give temporary cards with your selected physician for use until the actual health plan cards arrive. If I no longer require ST services, I will give 30 day written notice in advance of my termination via , mail, or fax. If termination occurs within the first 90 days a early termination fee applies. Applicant: Signature:

9 2014 Income Standards and Federal Poverty Guidelines Family Size 150% Federal Poverty Level 200% Federal Poverty Level 250% Federal Poverty Level 300% Federal Poverty Level 400% Federal Poverty Level Monthly Yearly Monthly Yearly Monthly Yearly Monthly Yearly Monthly Yearly 1 $1,459 $17,508 $1,945 $23,340 $2,432 $29,184 $2,918 $35,016 $3,890 $46,680 2 $1,967 $23,604 $2,622 $31,464 $3,278 $39,336 $3,933 $47,196 $5,244 $62,928 3 $2,474 $29,688 $3,299 $39,588 $4,123 $49,476 $4,948 $59,376 $6,597 $79,164 4 $2,982 $35,784 $3,975 $47,700 $4,969 $59,628 $5,963 $71,556 $7,950 $95,400 5 $3,489 $41,868 $4,652 $55,824 $5,815 $69,780 $6,978 $83,736 $9,304 $111,648 6 $3,997 $47,964 $5,329 $63,948 $6,661 $79,932 $7,993 $95,916 $10,657 $127,884 7 $4,504 $54,048 $6,005 $72,060 $7,507 $90,084 $9,008 $108,096 $12,010 $144,120 8 $5,012 $60,144 $6,682 $80,184 $8,353 $100,236 $10,023 $120,276 $13,364 $160,368 For each additional person add $508 $6,096 $677 $8,124 $846 $10,152 $1,015 $12,180 $1,354 $16,248 DG-FPL (Rev. 03/14) Institutional Income Standard $72.80

10 Connecticut HUSKY Health Program Annual Income Guidelines effective March 1, 2014 Family of 2 Family of 3 Family of 4 Family of 5 Family of 6 Overview $31,617 $39,777 $47,938 $56,099 $64,259 HUSKY A: Medicaid health care coverage for children 19 th birthday; and for parents or a relative caregiver with dependent child 19 in household. No cost. Note: Parent/relative caregiver will lose HUSKY eligibility when youngest child turns 18 if the child is not going to graduate high school by 19 th birthday (federal rule). $41,369 $52,047 $62,725 $73,403 $84,081 HUSKY A: Medicaid health care coverage for pregnant women. No cost. Note: for eligibility of pregnant women, unborn child is also counted as a family member. $21,707 (single-person household $16,104) $27,310 $32,913 $38,515 $44,118 HUSKY D: Medicaid health care coverage for Connecticut residents from age 19 to 65 th birthday. No cost. For those who do not qualify for HUSKY A; who do not receive federal Supplemental Security Income or Medicare; and who are not pregnant; and who do not have dependent child(ren) 19 in household. from $31,617 to $39,953 from $39,777 to $50,265 from $47,938 to $60,578 from $56,099 to $70,890 from $64,259 to $81,202 HUSKY B: Children s Health Insurance Program coverage for children 19 th birthday. No monthly premiums; some co-payments. Eligible for HUSKY Plus Physical from $39,954 to $50,807 from $50,266 to $63,921 from $60,579 to $77,035 from $70,891 to $90,149 from $81,203 to $103,263 HUSKY B: Children s Health Insurance Program coverage for children 19 th birthday. Monthly premium of $30 for first child; maximum monthly premium of $50, regardless of number of children; some co-payments. Eligible for HUSKY Plus Physical over $50,807 over $63,921 over $77,035 over $90,149 over $103,263 HUSKY B: Health care coverage for children 19 th birthday. Unsubsidized group premium rate of $314 monthly per child; some copayments.

11 Individual Blue Cross PPO: Individual Husky 150% 200% 250% Yearly $16,000 $17,235 $22,980 $29,175 AGES COI COI SUB Net Cost COI SUB Net Cost COI SUB Net Cost % 400% $34,470 $45,960 AGES COI SUB Net Cost COI SUB Net Cost

12 Individual Blue CroDual/Single with 1 Child Husky 150% 200% 250% Husky S/C Yearly $21,000 $23,600 $31,400 $39,300 AGES COI COI SUB NET COI SUB NET COI SUB NET % 400% $47,100 $62,000 AGES COI SUB NET COI SUB NET

13 Individual Blue Cross PPO#1..12 Year Old Child Yearly 200% 250% 300% 400% $39,500 $59,000 (Child Husky & Below $49,000 77K) $78,000 AGES COI SUB NET COI SUB NET COI SUB NET 25 Husky Husky Husky Husky Husky Husky Husky Husky Husky Individual Blue Cross PPO#2..12 Year Old Child Yearly 200% 250% 300% 400% $47,900 & Below $59,500 $71,500 $95,000 AGES COI SUB NET COI SUB NET COI SUB NET 25 Husky Husky Husky Husky Husky Husky Husky Husky

14 Anthem Blue Cross and Blue Shield Anthem Gold Direct Access - cddm Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/ /31/2014 Coverage for: Individual + Family 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 (855) 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? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? $1,500 person / $3,000 family for In-Network. Does not apply to Preventive Care, Primary Care visit and Specialist visit. Yes; $50 person / $0 family for In-Network Pediatric Dental. There are no other specific deductibles. Yes; $3,000 person / $6,000 family for In-Network. Premiums, Balance-Billed charges, and Health Care This Plan Doesn't Cover. No; This policy has no overall annual limit on the amount it will pay each year. Yes; See or call (855) for a list of participating providers. You must pay all 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 3 for how much you pay for covered services after you meet the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. 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 The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. 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

15 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 provider by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at om/pharmacyinforma tion/ Services You May Need Your Cost if You Use an In- Network Your Cost if You Use a Non-Network Primary care visit to treat an injury or illness $20 copay none Specialist visit $35 copay none Other practitioner office visit Chiropractor 0% coinsurance Acupuncturist Chiropractor Acupuncturist Preventive care/screening/immunization No charge none Diagnostic test (x-ray, blood work) Lab - Office 0% coinsurance X-Ray Office 0% coinsurance Lab - Office X-Ray Office Imaging (CT/PET scans, MRIs) 0% coinsurance Tier 1 - Typically Generic Tier 2 - Typically Preferred/Formulary Brand $15 copay per prescription (retail only) and $30 copay per prescription (home delivery only) $40 copay per prescription (retail only) and $100 copay per prescription (home Limitations & Exceptions Chiropractor Coverage for In-Network is limited to 20 visits per benefit period. Acupuncturist none Lab - Office none X-Ray Office none Failure to obtain preauthorization may result in non-coverage or reduced coverage. Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). No coverage for non-formulary drugs. Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). No coverage for non-formulary drugs.

16 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs Services You May Need Tier 3 Typically Non-preferred/Nonformulary and Specialty Drugs Tier 4 -Typically Specialty Drugs Your Cost if You Use an In- Network delivery only) 0% coinsurance (retail and home delivery) 0% coinsurance (retail and home delivery) Your Cost if You Use a Non-Network Limitations & Exceptions Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). No coverage for non-formulary drugs. Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). No coverage for non-formulary drugs. Facility fee (e.g., ambulatory surgery center) 0% coinsurance none Physician/surgeon fees 0% coinsurance none $150 copay and $150 copay and Emergency room services then 0% then 0% coinsurance coinsurance Copay waived if admitted. Emergency medical transportation 0% coinsurance 0% coinsurance none Urgent care $50 copay and then $50 copay and then 0% coinsurance 0% coinsurance none $500 copay and Facility fee (e.g., hospital room) then 0% coinsurance Physician/surgeon fee 0% coinsurance none Mental/Behavioral Mental/Behavioral Health Office Visit Health Office Visit 0% coinsurance Mental/Behavioral health outpatient Mental/Behavioral Mental/Behavioral services Health Facility Health Facility Visit-Facility Visit-Facility Charges Charges 0% coinsurance coverage. Mental/Behavioral health inpatient services Substance use disorder outpatient services 0% coinsurance Substance Abuse Office Visit 0% coinsurance Substance Abuse Substance Abuse Office Visit Substance Abuse Failure to obtain preauthorization may result in non-coverage or reduced coverage. Mental/Behavioral Health Office Visit none Mental/Behavioral Health Facility Visit-Facility Charges Failure to obtain preauthorization may result in non-coverage or reduced Failure to obtain preauthorization may result in non-coverage or reduced coverage. Substance Abuse Office Visit none Substance Abuse

17 Common Medical Event Services You May Need Your Cost if You Use an In- Network Facility Visit - Facility Charges 0% coinsurance Your Cost if You Use a Non-Network Facility Visit - Facility Charges Substance use disorder inpatient services 0% coinsurance If you are pregnant Prenatal and postnatal care 0% coinsurance none If you need help recovering or have other special health needs If your child needs dental or eye care Delivery and all inpatient services $500 copay and then 0% coinsurance Home health care No charge Rehabilitation services 0% coinsurance Habilitation services 0% coinsurance Skilled nursing care 0% coinsurance Limitations & Exceptions Facility Visit -Facility Charges Failure to obtain preauthorization may result in non-coverage or reduced coverage. Failure to obtain preauthorization may result in non-coverage or reduced coverage. Applies to inpatient facility. Other cost shares may apply depending on services provided. Failure to obtain preauthorization may result in noncoverage or reduced coverage. Coverage is limited to 100 visits per benefit period. Apply to In-Network s. Coverage for physical therapy, occupational therapy and speech therapy combined In-Network is limited to 40 visits per benefit period. Habilitation and Rehabilitation visits count towards your Rehabilitation limit. Coverage for In-Network is limited to 90 days per benefit period. Failure to obtain preauthorization may result in noncoverage or reduced coverage. Durable medical equipment 0% coinsurance none Hospice service 0% coinsurance none Eye exam none Glasses No charge Coverage for In-Network is limited to 1 unit per benefit period. Dental check-up No charge none

18 Standard Gold Point-of-Service (POS) : POS HD 1000 Gold Coverage Period: 2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: POS 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 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? Is there an overall annual limit on what the insurer pays? 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? Answers In-Network: $0; Out-of-Network: $3,000 member / $6,000 family Yes. $150 member/$300 family for drug coverage. $1,000 member/ $2,000 family Inpatient/Outpatient Facility. Yes. For participating providers $3,000 member / $6,000 family. For non-participating providers $6,000 member / $12,000 family Premiums, balance-billed charges, and health care this plan doesn't cover. No. Yes. See or call for a list of participating providers and hospitals. No. You don't need a referral to see a specialist. Yes. Why this Matters: See the chart starting on page 2 for your other costs for services this plan covers. You must pay all the costs for these services up to the specific deductible amount before this plan begins to pay for these services. 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. The chart starting on page 2 describes any limits on what the insurer will pay for specific covered services, such as office visits. 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 providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. See your policy or plan document for additional information about excluded services.

19 : POS HD 1000 Gold Coverage Period: 2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: POS 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) The plan may encourage you to use In-network providers by charging you lower deductibles, copayments, and coinsurance amounts. Common Medical Services You May Need Your cost if you use an Limitations & Exceptions Event In-network Out-of-network If you visit a health Primary care visit to treat an $20 Copayment per visit 30% after Plan Deductible -----none----- care provider's office injury or illness or clinic Specialist visit $45 Copayment per visit 30% after Plan Deductible -----none----- Other practitioner office visit $45 Copayment per visit for 30% after Plan Deductible for chiropractor chiropractor Preventive care / screening / No Member cost 30% immunization up to 20 visits per year Frequency limits apply If you have a test Diagnostic test (x-ray, blood Xray: $45 Copayment per 30% after Plan Deductible work) visit, Lab: $20 Copayment -----none----- per visit Imaging (CT / PET scans, MRIs) $75 Copayment per service 30% after Plan Deductible up to a combined calendar year maximum of $375 for MRI and CT scans; $400 for PET scans

20 : POS HD 1000 Gold Coverage Period: 2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: POS Common Medical Services You May Need Your cost if you use an Limitations & Exceptions Event In-network Out-of-network If you need drugs to Generic drugs $10 Copayment (retail); $20 30% after Plan Deductible Covers up to a 30 day supply treat your illness or Copayment (mail order) (retail); 100% (mail order) (retail prescription); 90 day condition supply (mail order prescription) More information Preferred brand drugs $25 Copayment after Benefit 30% after Plan Deductible about prescription Covers up to a 30 day supply Deductible (retail); $50 (retail); 100% (mail order) drug coverage is (retail prescription); 90 day Copayment after Benefit available at supply (mail order prescription) Deductible (mail order) Non-preferred brand drugs $40 Copayment after Benefit 30% after Plan Deductible Covers up to a 30 day supply Deductible (retail); $80 (retail); 100% (mail order) (retail prescription); 90 day Copayment after Benefit supply (mail order prescription) Deductible (mail order) Specialty drugs 30% after Benefit Deductible 30% after Plan Deductible Covers up to a 30 day supply (retail); 100% (mail order) (retail); 100% (mail order) (retail prescription); 90 day supply (mail order prescription); If you have outpatient Facility fee (e.g., ambulatory $500 Copayment after Plan 30% after Plan Deductible surgery surgery center) Deductible -----none----- Physician/surgeon fees No Member cost 30% after Plan Deductible -----none----- If you need immediate Emergency room services $150 Copayment per visit Same as In-Network -----none----- medical attention Emergency medical transportation No Member cost Same as In-Network -----none----- Urgent care $75 Copayment per visit 30% after Plan Deductible -----none----- If you have a hospital Facility fee (e.g., hospital room) $500 Copayment per day up 30% after Plan Deductible stay to $1,000 per admission after -----none----- Plan Deductible Physician/surgeon fee No Member cost 30% after Plan Deductible -----none-----

21 : POS HD 1000 Gold Coverage Period: 2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: POS Common Medical Services You May Need Your cost if you use an Limitations & Exceptions Event In-network Out-of-network If you have mental Mental/Behavioral health $20 Copayment per visit 30% after Plan Deductible -----none----- health, behavioral outpatient services health, or substance Mental/Behavioral health $500 Copayment per day up 30% after Plan Deductible abuse needs inpatient services to $1,000 per admission after -----none----- Plan Deductible Substance use disorder outpatient $20 Copayment per visit services 30% after Plan Deductible -----none----- Substance use disorder inpatient $500 Copayment per day up 30% after Plan Deductible services to $1,000 per admission after -----none----- Plan Deductible If you become Prenatal and postnatal care No Member cost 30% -----none----- pregnant Delivery and all inpatient $500 Copayment per day up 30% after Plan Deductible services to $1,000 per admission after -----none----- Plan Deductible If you need help Home health care No Member cost 25% after $50 deductible up to 100 visits per year recovering or have Rehabilitation services $20 Copayment per visit 30% after Plan Deductible up to 40 visits per year other special health needs Habilitation services $20 Copayment per visit 30% after Plan Deductible up to 40 visits combined with Rehabilitative Therapy Skilled nursing care $500 Copayment per day up 30% after Plan Deductible to $1,000 per admission after Plan Deductible up to 90 days per year Durable medical equipment 30% 30% after Plan Deductible -----none----- Hospice service No Member cost 30% after Plan Deductible Pre-authorization is required

22 HealthyCT: Healthy Partner Preferred Coverage Period: 01/01/ /31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual 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? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? $1,000 person / $2,000 family for in-network providers; $3,000 person / $6,000 family for out-of-network providers. Does not apply to preventive care; office visits; ER services; diagnostic services; and certain other services. Yes. $150 person / $300 family for in-network prescription drug coverage. Yes. $3,000 person / $6,000 family for participating providers. $6,000 person / $12,000 family for out-ofnetwork providers. Premiums, balance-billed charges, and health care this plan doesn t cover. No. Yes. See or call for a list of participating providers. For services subject to the deductible (e.g., hospitalization, outpatient surgery), 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. For Tier 2 (preferred brand name drugs), Tier 3 (non-preferred brand name drugs) and Tier 4 (specialty drugs), you must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. 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. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. 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.

23 HealthyCT: Healthy Partner Preferred Coverage Period: 01/01/ /31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Plan Type: PPO Do I need a referral to see a specialist? Are there services this plan doesn t cover? No. You don t need a referral to see a specialist. Yes. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 6. See your policy or plan document for additional information about excluded services. 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 If you have a test Services You May Need Your Cost If You Use an In-network Primary care visit to treat an injury or illness $20 copay Specialist visit Chiropractic care $45 copay $45 copay Your Cost If You Use an Out-of-network Limitations & Exceptions Maximum of 20 visits per year Preventive care/screening/immunization No charge Diagnostic test (x-ray, blood work) $45 copay CT scans, MRI, MRA, CAT scans, and nuclear cardiac imaging maximum Imaging (CT/PET scans, MRIs) $75 copay annual cost-share amount may not exceed $375 per person; PET scans maximum annual cost-share amount may not exceed $400 per person

24 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Your Cost If You Use an In-network $10 copay $25 copay after prescription drug deductible $40 copay after prescription drug deductible after prescription drug deductible Facility fee (e.g., ambulatory surgery center) $500 copay after Physician/surgeon fees deductible Your Cost If You Use an Out-of-network Emergency room services $150 copay $150 copay Emergency medical transportation No charge No charge Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee $75 copay $500 copay/day up to $1,000/admit Mental/Behavioral health outpatient services $20 copay Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services $500 copay/day up to $1,000/admit $20 copay $500 copay/day up to $1,000/admit No charge $500 copay/day up to $1,000/admit Limitations & Exceptions Cost-share applicable to well visits

25 HealthyCT: Healthy Partner Preferred Coverage Period: 01/01/ /31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Plan Type: PPO Common Medical Event Services You May Need Home health care Rehabilitation services Your Cost If You Use an In-network No charge $20 copay Your Cost If You Use an Out-of-network 25% coinsurance after $50 deductible Limitations & Exceptions Maximum of 100 visits per calendar year Maximum of 40 visits per calendar year for all rehabilitative and habilitative services combined If you need help recovering or have other special health needs If your child needs dental or eye care Habilitation services Skilled nursing care Durable medical equipment Hospice service $20 copay $500 copay/day up to $1,000/admit before deductible No charge Eye exam $20 copay Glasses No charge for collection frames 100% coinsurance Dental check-up No charge Maximum of 40 visits per calendar year for all rehabilitative and habilitative services combined Maximum of 90 days per calendar year One exam per year One pair per year One check-up every six months

26 Anthem Blue Cross and Blue Shield Anthem Gold DirectAccess Standard - cddk Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/ /31/2014 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 (855) 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? Is there an overall $1,000 person / $2,000 family for In-Network. Does not apply to Prescription Drugs, Preventive Care, Primary Care visit and Specialist visit. $3,000 person / $6,000 family for Outof-Network. Does not apply to Prescription Drugs and Preventive Care. Yes; $150 person / $300 family for In-Network $3,000 person / $6,000 family for Non-Network Tier 2, Tier 3 and Tier 4 Prescription Drugs. There are no other specific deductibles. Yes; $3,000 person / $6,000 family for In-Network. $6,000 person / $12,000 family for Out-of-Network. Premiums, Balance-Billed charges, and Health Care This Plan Doesn't Cover. No; This policy has no overall You must pay all 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 3 for how much you pay for covered services after you meet the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. 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 The chart starting on page 3 describes any limits on what the plan will pay for specific

27 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 provider by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at om/pharmacyinforma Services You May Need Your Cost if You Use an In- Network Your Cost if You Use a Non-Network Primary care visit to treat an injury or illness $20 copay none Specialist visit $45 copay none Other practitioner office visit Chiropractor $45 copay Acupuncturist Chiropractor Acupuncturist Preventive care/screening/immunization No charge none Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Tier 1 - Typically Generic Tier 2 - Typically Preferred/Formulary Brand Lab - Office $20 copay X-Ray Office $45 copay $75 copay per visit up to $375 per calendar year. $10 copay per prescription (retail only) and $20 copay per prescription (home delivery only) $25 copay per prescription and then 0% coinsurance (retail Lab - Office X-Ray Office (retail only) (retail only) Limitations & Exceptions Chiropractor Coverage for In-Network and Non-Network combined is limited to 20 visits per benefit period. Acupuncturist none Lab - Office none X-Ray Office none Failure to obtain preauthorization may result in non-coverage or reduced coverage. Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). In Network Deductible does not apply. No coverage for non-formulary drugs. Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). No coverage for non-formulary drugs.