$1,900 per individual $3,800 per family. Any other deductibles for specific services?

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1 This is only a summary of your benefits. Always refer to the plan document for complete coverage and details. The plan document may be found in the Benefit Office or you may go online. IMPORTANT ANSWERS WHY IT MATTERS QUESTIONS What is the overall deductible? Any other deductibles for specific services? $1,900 per individual $3,800 per family Yes: $3,800 individual & $7,200 family for non- PPO service Yes: $250 admission deducible for use of a non- PPO hospital You must pay all costs up to the deductible amount for eligible benefits before the Plan will begin making payments. The Family deductible is a cumulative dollar amount and applies collectively to all covered family individuals. Once the family deductible is met no further deductibles are required. The deductible renews each January 1 st. All eligible expenses applied to the PPO deductible are applied to the non-ppo deductible. You must pay all of the costs up to the deductible amount for eligible benefits obtained from a non-ppo provider. This deductible does apply to the PPO deductible amount. Any other deductibles? You must pay all of the costs up to the deductible amount for eligible benefits obtained from a non-ppo provider. This deductible does not apply to the PPO and/or non-ppo deductible amount. Any office visit co-pay? No If you use a ProCare Primary Clinic and do not have a HSA- $30 or ProCare Are there out-of-pocket limits on my expenses? What is not included in the out-of-pocket limit? An overall annual limit? Yes $6,650/individual $13,300/family $6,650 Individual Imbedded in family maximum No Urgent Care Clinic - $112 for basic services. If you have an HSA, No office visit copay for any other provider. Must meet an annual deductible for all diagnostic services not associated with ProCare basic services. Once the out-of-pocket amounts are satisfied per individual or family, the plan pays 100% of eligible network charges. The out-of-pocket maximum renews each January 1 st. Non-PPO out-of-pocket dollars accumulate to the out-of-pocket maximum. Any Deductible and Co-insurance amount IS included in the out-of-pocket total. Does the Plan use a net- Yes The Plan uses the BC/BS network. work of providers? Do I need a referral to a specialist? No You have the option to choose any provider you want. Just remember there are network (PPO) and non-network (non-ppo) providers. Are there services this plan does not cover? Yes Please refer to the exclusions list in the Plan Document. Use of an out-of-network provider or out-of-network facility will result in a higher deductible, higher coinsurance, and possible usual and customary differences that you will be required to pay out of pocket. Page 1 of 6

2 Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the services. For example, if the Plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you have not 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 balanced billing. This Plan will encourage you to use the BC/BS network of providers by charging you lower deductibles, and co-insurance amounts; and, having a lower annual out-of-pocket maximum. MEDICAL EVENT SERVICES YOU MAY NEED YOUR COST USING A LIMITATIONS AND EXCEPTIONS PPO Non-PPO You must meet the $1,900 annual deductible unless otherwise stated Primary care visit to treat an injury or illness 20% 40% Specialist visit to treat an injury or illness 20% 40% Other practitioner office visit 20% 40% If you visit a health care provider s office or clinic for medical attention Preventive care exams, diagnostic screening, immunizations; annual PAP, Mammogram, and PSA test; Colorectal cancer testing 0% 100% Non-PPO Not covered No deductible requirement. Please see Plan Document for specifics on covered exams and immunizations If you have a test Diagnostic tests (x-ray, blood work, urinalysis) 20% 40% Plan pays 100% to specified providers. Diagnostic imaging (CT/PET scans, MRI) 20% 40% If you need drugs to treat your illness or condition Tier Title Retail Mail Co-pays / Minimum Payment Co-pays and/or Minimum Payment Generic drugs Must Meet Plan Deductible, then the Preferred brand drugs Plan pays 80% of the cost of the Non-preferred brand drugs prescription up to the maximum annual Specialty Rx drugs from Medical and/ or Rx out-of-pocket. Accredo Mail Order required for Maintenance Rx. Specialty Rx s may require authorization Maximum out-of-pocket for any Rx is part of the maximum annual out-of-pocket for all medical and prescription services. Page 2 of 6

3 MEDICAL EVENT SERVICES YOU MAY NEED YOUR COST USING A LIMITATIONS AND EXCEPTIONS PPO Non-PPO You must meet the $1,100 annual deductible unless otherwise stated If you have outpatient Facility fee such as ambulatory surgery center 20% 40% surgery Physician/Surgeon fee 20% 40% If you need immediate Emergency room services 20% 40% The emergency room should not be used medical attention Emergency medical transportation 20% 40% for routine medical care. Go to your Dr. Urgent care 20% 40% or an urgent care center. If you have a hospital Facility fee (room, lab. X-ray, OR, ICU, etc.) 20% 40% All inpatient hospital stays must be pre- stay If you have mental health, behavioral health, or substance abuse needs Physician/surgeon fee 20% 40% Certified. Please see Plan Document. Mental/Behavioral health outpatient services 20% 40% Limited to 45 visits per year Mental/Behavioral health inpatient services 20% 40% Limited to 30 inpatient days per year Substance abuse disorder outpatient services 20% 40% Limited to 45 visits per year Substance abuse disorder inpatient services 20% 40% Limited to 30 inpatient days per year If you are pregnant Prenatal and postnatal care 20% 40% Pregnancy must be pre-certified Delivery and all inpatient services 20% 40% Minimum stay of 48 hours for vaginal delivery and 72 hours for c-section If you need help recovering or have other special health needs If your child needs dental or eye care Home health care 20% 40% Limited to 100 visits per year Rehabilitation services 20% 40% Habilitation services 20% 40% Skilled nursing care 20% 40% Limited to 60 days per year Durable medical equipment 20% 40% Hospice services 20% 40% May be in hospice center or at home Chiropractic Services 20% 40% Limited to 24 visits per year Eye exam n/a n/a Not covered through medical plan Glasses n/a n/a Not covered through medical plan Dental check-up n/a n/a Not covered through medical plan Page 3 of 6

4 EXCLUDED SERVICES & OTHER COVERED SERVICES: Services your Plan does not cover: Cosmetic, Reconstructive or Plastic surgery Long-term care Routine adult eye care Adult dental care Non-emergency care when traveling outside US Routine foot care Private duty nursing Chelation therapy Infertility treatment including in vitro fertilization Sterilization reversal Transsexual surgery Sexual dysfunctions Occupational illness or injury Acupuncture Elective abortions TMJ services and care Experimental and Investigational services You should refer to the Plan Document for a complete list of Medical Limitations and Exclusions. Other covered services (This is not a complete list. Refer to the Plan Document for a complete list of covered services.) Bariatric surgery (under specific conditions) Wigs Chiropractic services YOUR RIGHTS TO CONTINUE COVERAGE: This is commonly referred to as COBRA. If you lose coverage under this 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. Complete instructions are in the Plan Document. You may also contact the ECISD Benefit Office; the U.S. Department of Labor; the U.S. Department of Health and Human Services; or the Texas Department of Insurance. YOUR GRIEVANCE AND APPEAL RIGHTS: If you have a complaint or are dissatisfied with a denial of coverage for claims under this Plan, you may be able to appeal the decision of the claim administrator. The appeal process is explained in detail in the Plan Document. For questions or assistance, please contact the Benefit Department of Ector County ISD. DOES THIS COVERAGE PROVIDE MINIMUM ESSENTIAL COVERAGE? This plan does provide minimum essential coverage. DOES THIS COVERAGE MEET THE MINIMUM VALUE STANDARD? This health coverage does meet the minimum value standard. LANGUAGE ACCESS SERVICES: Spanish: Para obtener asistencia en Espanol, llame al Questions: Call the ECISD Employee Benefits Department or go to the school district web site. If you are not clear about any of the bolded terms used in this form, please see the Glossary. You can view the Glossary at the district s web site, or call the ECISD Employee Benefits Department. Page 4 of 6

5 HAVING A BABY (normal delivery) MANAGING TYPE 2 DIABETES (routine maintenance of well controlled condition) AMOUNT OWED TO PROVIDERS $7,540 AMOUNT OWED TO PROVIDERS $4,100 ECISD PLAN PAYS $4,412 ECISD PLAN PAYS $1,940 PATIENT PAYS $3,028 PATIENT PAYS $2,160 SAMPLE CARE COSTS (PPO Allowable) SAMPLE CARE COSTS (PPO Allowable) Hospital Charges for Mother $2,700 Prescriptions $1,500 Routine Obstetric Care $2,100 Medical Equipment and Supplies $1,300 Hospital Charges for Baby $ 900 Doctor s Office Visits and Procedures $ 730 Anesthesia $ 900 Diabetic Education $ 290 Laboratory Tests $ 500 Laboratory Tests $ 140 Prescriptions $ 200 Vaccines, Other Preventive Services $ 140 Radiology $ 200 Vaccines, Other Preventive Services $ 40 TOTAL COSTS $7,540 TOTAL COSTS $4,100 PATIENT PAYMENTS PATIENT PAYMENTS Deductibles $1,900 Deductibles $1,900 Co-pays $ 0 Co-pays $ 0 Co-insurance $1,128 Co-insurance $ 260 Limit or exclusions $ 0 Limits or exclusions $ 0 TOTAL PATIENT PAYMENTS $3,028 TOTAL PATIENT PAYMENTS $2,160 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. Do not 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. Questions: Call the ECISD Employee Benefits Department or go to the school district web site. If you are not clear about any of the bolded terms used in this form, please see the Glossary. You can view the Glossary at the district s web site, or call the ECISD Employee Benefits Department. Page 5 of 6

6 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 pre-existing 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. I f 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 co-insurance 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-of-pocket costs, such as co-payments, deductible, and co-insurance. 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 the ECISD Benefits Department. If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary in the Plan Document, or on the ECISD website, or call the Benefits Department for a copy. Page 6 of 6