Schedule of Benefits

Transcription

1 Schedule of Benefits 3

2 Schedule of Benefits Patient Protection and Affordable Care Act ( PPACA ) Compliance: The Plan will at all times be in compliance with PPACA rules and regulations. Notes regarding the Plan This Plan provides coverage for preventive services. Claims will be processed based upon the billing practices of your healthcare provider. Services that are not Preventive Services as defined by the Patient Protection and Affordable Care Act ( PPACA ) will not be covered by the Plan. Network provider service payments will be based on the applicable network access agreement and non-network provider services will be paid based on the reasonable and customary amount. Effective Date of Coverage The date following the Employer's eligibility waiting period. Child Maximum Age To age 26. Preferred Provider Network Benefits at a network provider will be paid at 100%, while benefits at a non-network provider will be paid at 40%, resulting in a 60% penalty. Benefits are paid subject to the coinsurance maximums as indicated below in the schedule of benefits. If a participant or covered dependent receives ancillary and physician services, (i.e., anesthesiologists, radiologists, pathologists, etc.,) at a participating provider, the services provided by the non-participating provider will be paid at the participating provider benefit level. Payments for covered services will be made directly to the participating provider and will not be assignable to any other person. Covered services provided by a non-participating provider will be subject to penalty and paid at a lower percentage unless one of the following are applicable: a. If a participating provider within a 50-mile radius of the employer is unable to provide the necessary care to the covered person, the penalty will not apply. b. If the covered person resides outside of a 50-mile radius of a participating provider, the penalty will not apply. 4

3 Schedule of Benefits Deductibles Network Non-Network Individual None None Family None None Individual Coinsurance Network Non-Network Plan pays 100% Plan pays 40% The plan pays the above percentages of eligible charges, unless otherwise stated. Out-of-pocket Maximums Network Non-Network Individual Maximum None Unlimited Family Maximum None Unlimited Preventive/Wellness Lifetime Maximum None Annual Maximum None Network Non-Network Limitations 100% not subject to 40% This benefit is limited to the following list of the deductible services. Non-network services will be payable at the network benefit level if the service is not available at a network provider The following are considered Preventive Services and are covered by the Plan and payable at 100% when services are rendered at an in-network provider. However, non-network charges are subject to usual and customary fee limitations. 5

4 Schedule of Benefits If a listed service does not specify the frequency, method, treatment or setting for the provision of the service, the Plan will use reasonable medical management techniques to determine any coverage limitations. Office exams billed with the below services or with a covered preventive diagnosis is covered under the Plan. 15 Covered Preventive Services for Adults (ages 18 and older) 1. Abdominal Aortic Aneurysm one time screening for age Alcohol Misuse screening and counseling 3. Aspirin use for men ages and for women ages to prevent Cardiovascular Disease when prescribed by a physician 4. Blood Pressure screening for all adults 5. Cholesterol screening for adults 6. Colorectal Cancer screening for adults starting at age 50 limited to one every 5 years 7. Depression screening for adults 8. Type 2 Diabetes screening for adults 9. Diet counseling for adults 10. HIV screening for all adults 11. Immunization vaccines for adults: o Hepatitis A o Hepatitis B o Herpes Zoster o Human Papillomavirus o Influenza (Flu Shot) o Measles, Mumps, Rubella o Meningococcal o Pneumococcal o Tetanus, Diphtheria, Pertussis o Varicella 12. Obesity screening and counseling for all adults 13. Sexually Transmitted Infection (STI) prevention counseling and screening for adults 14. Tobacco Use screening for all adults and cessation interventions 15. Syphilis screening for all adults 6

5 Schedule of Benefits 23 Covered Preventive Services for Women, Including Pregnant Women 1. Anemia screening on a routine basis for pregnant women 2. Bacteriuria urinary tract or other infection screening for pregnant women 3. BRCA counseling and genetic testing for women at higher risk 4. Breast Cancer Mammography screenings every year for women age 40 and over 5. Breast Cancer Chemoprevention counseling for women 6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women. Non-network services will be payable as network services. 7. Cervical Cancer screening 8. Chlamydia Infection screening 9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs 10. Domestic and interpersonal violence screening and counseling for all women 11. Folic Acid supplements for women who may become pregnant when prescribed by a physician 12. Gestational diabetes screening 13. Gonorrhea screening for all women 14. Hepatitis B screening for pregnant women 15. Human Immunodeficiency Virus (HIV) screening and counseling 16. Human Papillomavirus (HPV) DNA Test: HPV DNA testing every three years for women with normal cytology results who are 30 or older 17. Osteoporosis screening over age Routine prenatal visits for pregnant women 19. Rh Incompatibility screening for all pregnant women and follow-up testing 20. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users 21. Sexually Transmitted Infections (STI) counseling 22. Syphilis screening 23. Well-woman visits to obtain recommended preventive services 7

6 Schedule of Benefits 26 Covered Preventive Services for Children 1. Alcohol and Drug Use assessments 2. Autism screening for children limited to two screenings up to 24 months 3. Behavioral assessments for children limited to 5 assessments up to age Blood Pressure screening 5. Cervical Dysplasia screening 6. Congenital Hypothyroidism screening for newborns 7. Depression screening for adolescents age 12 and older 8. Developmental screening for children under age 3, and surveillance throughout childhood 9. Dyslipidemia screening for children. 10. Fluoride Chemoprevention supplements for children without fluoride in their water source when prescribed by a physician 11. Gonorrhea preventive medication for the eyes of all newborns 12. Hearing screening for all newborns 13. Height, Weight and Body Mass Index measurements for children. 14. Hematocrit or Hemoglobin screening for children 15. Hemoglobinopathies or sickle cell screening for newborns 16. HIV screening for adolescents 17. Immunization vaccines for children from birth to age 18 doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis Haemophilus influenzae type b Hepatitis A Hepatitis B Human Papillomavirus Inactivated Poliovirus Influenza (Flu Shot) Measles, Mumps, Rubella Meningococcal Pneumococcal Rotavirus Varicella 18. Iron supplements for children up to 12 months when prescribed by a physician 19. Lead screening for children 8

7 Schedule of Benefits 20. Medical History for all children throughout development Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 21. Obesity screening and counseling 22. Oral Health risk assessment for young children up to age Phenylketonuria (PKU) screening in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents 25. Tuberculin testing for children 26. Vision screening for all children under the age of 5 For more information regarding preventive care recommendations and immunizations, visit the websites for the Centers for Disease Control and Preventions or the United States Department of Human Services: For Adults: Preventive Services for Adults: Immunization Schedule: For Women s Health For Men s Health For Children Well child check-ups: Immunization schedule: 9

8 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee, Family Plan Type: MEC 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? $ 0 See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? Is there an overall annual limit on what the plan 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? No. No. No. No. No. You don t need a referral to see a specialist. Yes. 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. There s no limit on how much you could pay during a coverage period for your share of the cost of covered services. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. This plan treats providers the same in determining payment for the same services. 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 4. 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. Co-insurance 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 co-insurance payment of 100% 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.) Your cost sharing does not depend on whether a provider is in a network. 1 of 8

9 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee, Family Plan Type: MEC 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 or by calling If you have outpatient surgery If you need immediate medical Your cost if you use an Services You May Need In-network Provider Out-of-network Provider Limitations & Exceptions Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/screening/immunization 0% co-insurance 0% co-insurance Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) as may be defined as covered under No Prescription Drug Coverage except Generic drugs PPACA Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services No Prescription Drug Coverage except as may be defined as covered under PPACA No Prescription Drug Coverage except as may be defined as covered under PPACA No Prescription Drug Coverage except as may be defined as covered under PPACA 2 of 8

10 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee, Family Plan Type: MEC Common Medical Event 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 Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services Your cost if you use an In-network Out-of-network Provider Provider Limitations & Exceptions 3 of 8

11 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee, Family Plan Type: MEC Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service Eye exam Glasses Dental check-up Your cost if you use an In-network Provider Out-of-network Provider Limitations & Exceptions 0% co-insurance 0% co-insurance Screening for visual acuity in children up to age 5. No coverage for glasses. under Medical No coverage for dental check-up Plan. 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 Bariatric surgery Chiropractic Care Cosmetic services and surgery Dental care (Adult) Detoxification Hearing aids Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine eye care (Adult) Routine foot care Weight loss programs 4 of 8 Mem

12 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee, Family Plan Type: MEC 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.) 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: Your health plan at , or the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or 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? In order for certain types of health coverage (for example, individually purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed charges for covered services. This is called the minimum value standard. This health coverage does meet the minimum value standard for the benefits it provides. 5 of 8

13 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee, Family Plan Type: MEC 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. 6 of 8

14 Coverage Examples Coverage for: Employee, Family Plan Type: MEC 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 $40 Patient pays $7,500 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 $0 Co-insurance $0 Limits or exclusions $7500 Total $7500 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $100 Patient pays $5,300 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 $0 Co-insurance $0 Limits or exclusions $5300 Total $ of 8

15 Coverage Examples Coverage for: Employee, Family Plan Type: MEC 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 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-ofpocket costs, such as copayments, deductibles, 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. 8 of 8