COMMUNITY CARE PLAN-BCG

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1 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you, and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call (866) For general definitions of common terms, such as allowed amount, balance billing, coinsurance, ment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call (866) to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-ofpocket limit for this plan? What is not included in the out-of-pocket limit? Network: $1,300 Individual / $2,600 Family per calendar year. Copays and services listed below as No Charge do not apply to the deductible. Yes. No. Network: $2,800 individual $5,600 family Premium, balance billing and health care services this plan doesn t cover You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. For example, this plan covers certain preventive services without cost sharing before services meet your deductible. See a list of covered preventive services at You don t have to meet a deductible for specific 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-ofpocket limit. [* For more information about limitations and exceptions, please contact Broward County Government at for the plan 1 or of 10

2 Will you pay less if you use a network provider? Do you need a referral to see a specialist? Yes. For a list of network providers, see Member.Services@ccpcare s.org or call (866) No. 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, that 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. You can see the specialist you choose without permission from this plan. [* For more information about limitations and exceptions, please contact Broward County Government at for the plan 2 or of 10

3 All ment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Network Provider least) What You Will Pay Out-of-Network Provider most) $25 per visit Specialist visit $50 per visit Other practitioner office visit (e.g. chiropractor) Preventive care/screening/ immunization Diagnostic test (x-ray, ultrasound, lab work) No Charge Office or Independent Lab: No Charge Outpatient Facility: 20% co-insurance; up to $100; then covered at 100%; deductible does not apply Limitations, Exceptions, & Other Important Information Virtual visits (Telehealth) - $40 per visit by a designated virtual network provider. If you receive services in addition to office visit, additional s, deductibles, or co-ins may apply. If you receive services in addition to office visit, additional s, deductibles, or co-ins may apply. Cost share applies for only manipulative (chiropractic) services and is limited to 24 visits per calendar year. Includes preventative health services specified in the health care reform law. No coverage non-network. Excludes OB-related ultrasounds [* For more information about limitations and exceptions, please contact Broward County Government at for the plan 3 or of 10

4 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at m. Mail Order through EnvisionRx: s.com If you have outpatient surgery Services You May Need Advanced Imaging (CT/PET/SPECT/MRI) Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Network Provider least) Office: No Charge Outpatient Facility: 20% co-insurance; up to $100; then covered at 100%; deductible does not apply 30 Day Retail: $7 90 Day Retail and Mail Order: $14 30 Day Retail: $30 90 Day Retail and Mail Order: $60 30 Day Retail: $45 90 Day Retail and Mail Order: $90 30 Day Supply: $75 What You Will Pay Out-of-Network Provider most) Not Applicable Limitations, Exceptions, & Other Important Information PET/SPECT scans require prior authorization Coverage for prescription drugs with EnvisionRx. Not integrated with overall medical deductible. Coverage for prescription drugs with EnvisionRx. Not integrated with overall medical deductible. Coverage for prescription drugs with EnvisionRx. Not integrated with overall medical deductible. Coverage for prescription drugs with EnvisionRx Specialty. Not integrated with overall medical deductible. Some services require prior authorization [* For more information about limitations and exceptions, please contact Broward County Government at for the plan 4 or of 10

5 Common Medical Event Services You May Need Physician/surgeon fees Network Provider least) What You Will Pay Out-of-Network Provider most) None Limitations, Exceptions, & Other Important Information If you need immediate medical attention Emergency room care Emergency medical transportation Urgent Care CVS Minute Clinic or MDNow Clinic $250 per visit $50 per visit CCP Network only $25 per visit $250 per visit Non-emergency use is not covered * Non-emergency transportation requires prior authorization Facility fee (e.g., hospital If you have a room) Requires prior authorization hospital stay Physician/surgeon fees First 20 visits per Partial hospitalization/intensive If you need mental year: No Charge outpatient treatment: $25 per health, behavioral Outpatient services After 20 visits: $25 visit. health, or per visit Requires prior authorization. substance abuse services Inpatient services Requires prior authorization. If you are Office visits No charge None [* For more information about limitations and exceptions, please contact Broward County Government at for the plan 5 or of 10

6 Common Medical Event pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Childbirth/delivery professional services Network Provider least) What You Will Pay Out-of-Network Provider most) Limitations, Exceptions, & Other Important Information Requires prior authorization for global OB; Maternity care may include tests and services described elsewhere in the SBC. Labor Checks None Childbirth/delivery facility services Requires prior authorization Home health care Limited to 60 visits per calendar year. Requires prior authorization. Limits per calendar year: 60 combined Rehabilitation services visits for physical, speech, occupational therapies; cardiac unlimited visits; pulmonary unlimited visits. Habilitation services Limits are combined with Rehabilitation Services limits listed above. Limited to 60 days per calendar year. Skilled nursing care (combined with inpatient rehabilitation) Requires prior authorization. Durable medical equipment Some services require prior authorization Hospice services Some services require prior authorization Children s eye exam No Charge Limited to 1 exam every year Children s glasses Covered See Vision service and Discount Benefits Children s dental checkup See Dental service and Discount Covered Benefits [* For more information about limitations and exceptions, please contact Broward County Government at for the plan 6 or of 10

7 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Bariatric Surgery Cosmetic Surgery Infertility Treatment (Rx only) Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care Weight loss programs Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Glasses (Adult/Child) Hearing Aids limited to two ears per year Annual Dental Evaluation Annual Vision Evaluation (annual maximum of $1500 per covered (Adult/Child) (Adult/Child) member) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. For information regarding those agencies contact: Government Employee Benefit Services at Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Community Care Plan, Member Services at Does this plan provide Minimum Essential Coverage? YES If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? YES If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: [* For more information about limitations and exceptions, please contact Broward County Government at for the plan 7 or of 10

8 [Spanish (Español): Para obtener asistencia en Español, llame al (866) [Creole: Pou asistans nan kreyòl, rele (866) [* For more information about limitations and exceptions, please contact Broward County Government at for the plan 8 or of 10

9 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, ments and coinsurance) and excluded services under the plan. The total Use this Peg information would pay to is compare $3,587 the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan s overall deductible $1300 Specialist [cost sharing] $50 Hospital (facility) [cost sharing] 20% Other [cost sharing] 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,84 0 In this example, Peg would pay: Cost Sharing Deductibles $1,300 Copayments $50 Coinsurance $2,237 What isn t covered Limits or exclusions $0 Managing Joe s type 2 Diabetes (a year of routine in-network care of a well-controlled condition) The plan s overall deductible $1300 Specialist [cost sharing] $50 Hospital (facility) [cost sharing] 20% Other [cost sharing] 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,460 In this example, Joe would pay: Cost Sharing Deductibles $1,300 Copayments $400 Coinsurance $800 What isn t covered Limits or exclusions $0 The total Joe would pay is $2,500 The plan would be responsible for the other costs of these EXAMPLE covered services. 9 of 10

10 Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $1300 Specialist [cost sharing] $50 Hospital (facility) [cost sharing] 20% Other [cost sharing] 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,010 In this example, Mia would pay: Cost Sharing Deductibles $1,300 Copayments $0 Coinsurance $390 What isn t covered Limits or exclusions $0 The total Mia would pay is $1,690 The plan would be responsible for the other costs of these EXAMPLE covered services. 10 of 10

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