NOTICE OF RENEWAL AND 2018 PREMIUM RATES
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1 165 Court Street Rochester, NY A nonprofit independent licensee of the Blue Cross Blue Shield Association MAIL DATE ###SP### ATTN: GROUP ADMINISTRATOR <<GROUP NAME>> <<GROUP ADDRESS>> <<GROUP CITY, STATE ZIP CODE>> NOTICE OF RENEWAL AND 2018 PREMIUM RATES Dear Valued Customer: Your group health insurance coverage is coming up for renewal. Your group policy will be automatically renewed on Renewal Date as long as your group continues to be eligible. Your group s members will be automatically re-enrolled unless you choose another policy. Included are changes we ll be making to your policy, the new premium for this policy, and some information about options if you wish to change policies. Premium rate changes: The premium rates for your health insurance policy are changing. The new rates below will take effect on Renewal Date and have been approved by the New York State Department of Financial Services (DFS). To determine the approximate total new premium for your group just multiply your current enrollment by the new premium. This will provide an estimate based on the current enrollment of your group. This amount may change depending on the individuals who actually enroll in the policy Product Rate 2018 Product Rate Single Rate AMT YR1 Rate AMT YR2 Subscriber with Spouse Rate AMT YR1 Rate AMT YR2 Subscriber with Child Rate AMT YR1 Rate AMT YR2 Family Rate AMT YR1 Rate AMT YR2 If you have any questions about your total premium rate, please contact your independent broker or account consultant. You may visit the DFS website at for more information regarding this rate change. You may also contact us by calling general rate information line at or contact your account consultant or benefits administrator or visit ExcellusBCBS.com for further information about this rate change. PA-OFF-GRP
2 Other changes to your current health insurance policy: 2017 Plan Benefits - Out of Pocket 2018 Plan Benefits - Out of Pocket Product Name <<Marketing Plan Name YR1>> <<Marketing Plan Name YR2>> Single Deductible In-Network* <<Sngl Ded IN YR1>> <<Sngl Ded IN YR2>> Single Deductible Out of Network* <<Sngl Ded OON YR1>> <<Sngl Ded OON YR2>> Single Out of Pocket Max. In-Network* <<Sngl OOP Max IN YR1>> $<<Sngl OOP Max IN YR2>> Single Out of Pocket Max. Out of Network* <<Sngl OOP Max OON YR1>> <<Sngl OOP Max OON YR2>> Ë5h6!!""%!Ì *The Family deductibles and out of pocket maximums are two times the corresponding Single amounts. If you have an HSA (Health Savings Account) qualified HDHP (High Deductible Health Plan), your group s members must reach their deductible before the amount in Drug (Rx) will apply. Change in metal level: Plans are separated into four categories known as metal levels (Bronze, Silver, Gold or Platinum). The metal level is based on a plan s actuarial value. Actuarial value is the average percentage of the cost of all essential health benefits the plan pays. The metal level of the plan you choose affects the total amount you will likely spend for on out-of-pocket costs for your benefits during the year (not including premiums). For instance, if you choose a Bronze plan, you will likely pay more out-of-pocket for deductibles, co-pays and other cost sharing than if you choose a Platinum plan. Please note that actuarial value is an estimate of your expenses for the whole year, unlike coinsurance, in which you pay a specific percentage of the cost of a particular service. The actuarial values for each metal level are: Bronze 60% Silver 70% Gold 80% Platinum 90% In order to maintain the required actuarial value for your plan s existing metal level in 2018, we are required to make changes to the cost-sharing provisions of the plan. The new cost-sharing is described above. You also have the option to choose another plan with lower cost-sharing. See Coverage options below. Coverage options: If you do not want your group s current policy to automatically renew, you have the option of choosing a different policy either from us or from another insurer. You can make a plan change by contacting your dedicated account manager, who would be happy to assist you. You may purchase a new policy from us or another insurer directly, or with the help of a broker or agent. You may also purchase a policy (or policies) through the NY State of Health Small Business Marketplace (the Marketplace ). The Marketplace allows you to offer your employees a choice of insurance policies with a variety of cost sharing options from different insurance companies including Excellus BlueCross BlueShield. If you purchase coverage through the Marketplace, you may be eligible for a small business health care tax credit for qualified employers that can cover as much as 50% of your contribution toward employee premium costs. If you are eligible for a small business health care tax credit, you can get that credit only if you buy a policy through the Marketplace. You generally can buy coverage for a group at any time throughout the year, but to avoid gaps in coverage, you should enroll at least 15 days before your renewal date of Renewal Date. To avoid gaps in coverage when purchasing a new Marketplace policy, enrollment must be completed by the end of the month, one month prior to the policy end date (for example, November 30 th for policies effective January 1, December 31 st for policies effective February 1). Fifteen day extensions are available. Please visit or call the Small Business Marketplace customer service at for details. PA-OFF-GRP
3 Before you decide: Call the insurer or visit the insurer s website to check which doctors, other healthcare providers and prescription medications are covered by the new policy. This is an important step in selecting a policy that best meets the needs of your group. If you are considering a new policy from us, contact your account consultant or benefit administrator, or visit our website at ExcellusBCBS.com. If you have questions: Please call your account consultant or benefits administrator Monday through Friday 9 a.m. to 5 p.m. with any questions you may have or visit our website at ExcellusBCBS.com. Visit to learn more about the New York State of Health Small Business Marketplace, or call Marketplace customer service at Getting help in other languages: Para obtener asistencia en Español, llame al atención al Cliente llamando al número que aparece en el reverso de su tarjeta de identificación. Sincerely, James R. Reed Senior Vice President, Marketing and Sales Please communicate this information to the individual subscribers who receive coverage through this group policy. If you wish to have us notify your subscribers directly, please notify us within three (3) days of receipt of this notice. The member notification is enclosed with this mailing including a nondiscrimination notice. We recommend that you provide any additional information with this notice, such as expected changes in employee contribution levels, that may help your employees better understand their health coverage costs.
4 Ë5h6!!"#%!Ì
5 165 Court Street Rochester, NY A nonprofit independent licensee of the Blue Cross Blue Shield Association MAIL DATE NOTICE OF RENEWAL AND 2018 PREMIUM RATES Dear Valued Member: Your group s health insurance coverage is coming up for renewal. Your group policy will be automatically renewed on Renewal Date as long as your group continues to be eligible, and you will be automatically reenrolled unless your group chooses another policy. Included are changes we ll be making to your policy, the new premium for this policy, and some information about options if you wish to change policies. Premium rate changes: The new rates below have been approved by the New York State Department of Financial Services (DFS) and will take effect on Renewal Date Product Rate 2018 Product Rate Single Rate AMT YR1 Rate AMT YR2 Subscriber with Spouse Rate AMT YR1 Rate AMT YR2 Subscriber with Child Rate AMT YR1 Rate AMT YR2 Family Rate AMT YR1 Rate AMT YR2 To obtain your total annual premium rate, please contact your employer group s benefit administrator, or call the phone number listed on your identification card. You may visit the DFS website at for more information regarding this rate change. You may also contact us by calling general rate information line at or contact your employer group s benefit administrator, or calling the phone number listed on your identification card. PA-OFF-GRP
6 Other changes to your current health insurance policy: 2017 Plan Benefits - Out of Pocket 2018 Plan Benefits - Out of Pocket Product Name <<Marketing Plan Name YR1>> <<Marketing Plan Name YR2>> Single Deductible In-Network* <<Sngl Ded IN YR1>> <<Sngl Ded IN YR2>> Single Deductible Out of Network* <<Sngl Ded OON YR1>> <<Sngl Ded OON YR2>> Single Out of Pocket Max. In-Network* <<Sngl OOP Max IN YR1>> <<Sngl OOP Max IN YR2>> Single Out of Pocket Max. Out of Network* <<Sngl OOP Max OON YR1>> <<Sngl OOP Max OON YR2>> Ë5h6!!"$%!Ì *The Family deductibles and out of pocket maximums are two times the corresponding Single amounts. If you have an HSA (Health Savings Account) qualified HDHP (High Deductible Health Plan), you must reach your deductible before the amount in Drug (Rx) will apply. Availability of summary health information: Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format to help you compare across options. Excellus BlueCross BlueShield makes your SBC available on the benefit summary screen when you log into the member portal at ExcellusBCBS.com. A paper copy is also available, free of charge, from your employer or by calling the telephone number listed on your identification card. For all questions regarding claims and benefits, you can call Customer Service at the telephone number listed on your identification card. We appreciate the opportunity to serve you and look forward to serving you well into the future. Getting help in other languages: Para obtener asistencia en Español, llame al atención al Cliente llamando al número que aparece en el reverso de su tarjeta de identificación. Sincerely, James R. Reed Senior Vice President, Marketing and Sales PA-OFF-GRP
7 Notice of Nondiscrimination Our Health Plan complies with federal civil rights laws. We do not discriminate on the basis of race, color, national origin, age, disability, or sex. The Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, please refer to the enclosed document for ways to reach us. If you believe that the Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Advocacy Department Attn: Civil Rights Coordinator PO Box 4717 Syracuse, NY Telephone number: TTY number: Fax: You can file a grievance in person or by mail or fax. If you need help filing a grievance, the Health Plan s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at B-5495
8 Attention: If you speak English free language help is available to you. Please refer to the enclosed document for ways to reach us. Atención: Si habla español, contamos con ayuda gratuita de idiomas disponible para usted. Consulte el documento adjunto para ver las formas en que puede comunicarse con nosotros. Ë5h6!!"%%!Ì Atansyon: Si ou pale Kreyòl Ayisyen gen èd gratis nan lang ki disponib pou ou. Tanpri gade dokiman ki nan anvlòp la pou jwenn fason pou kontakte nou. Attenzione: Se la vostra lingua parlata è l italiano, potete usufruire di assistenza linguistica gratuita. Per sapere come ottenerla, consultate il documento allegato. Uwaga: je li mówisz po polsku, mo esz skorzysta z bezp atnej pomocy j zykowej. Patrz za czony dokument w celu uzyskania informacji na temat sposobów kontaktu z nami. Remarque : si vous parlez français, une assistance linguistique gratuite vous est proposée. Consultez le document ci-joint pour savoir comment nous joindre. Paunawa: Kung nagsasalita ka ng Tagalog, may maaari kang kuning libreng tulong sa wika. Mangyaring sumangguni sa nakalakip na dokumento para sa mga paraan ng pakikipag-ugnayan sa amin. Kujdes: Nëse flisni shqip, ju ofrohet ndihmë gjuhësore falas. Drejtojuni dokumentit bashkëlidhur për mënyra se si të na kontaktoni. B-5495
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