Open Enrollment. Supplement

Transcription

1 Open Enrollment Supplement 2016

2 Contents 1. Summary of Benefits & Coverage for Notre Dame HDHP Plan 2. Summary of Benefits & Coverage for Notre Dame CHA/Select HMO Plan 3. Summary of Benefits & Coverage for Notre Dame PPO Plan 4. Summary of Benefits & Coverage for Notre Dame Indemnity Plan ** About this Supplement This Open Enrollment Supplement contains Summaries of Benefits and Coverage for the 2016 medical benefit plans offered by the University of Notre Dame. These materials are provided in accordance with the Patient Protection and Affordable Care Act (PPACA), which mandates their content and format. For more information about the PPACA, visit gov/ebsa/healthreform/. The intent of the enclosed information is for you to better understand your health coverage and determine the best options for you and your family. Included in each Summary of Benefits and Coverage are policy comparison tools known as Coverage Examples. These examples will illustrate what proportion of expenses each plan would cover for three common, yet hypothetical, benefit scenarios: having a baby, treating breast cancer and managing diabetes. These hypothetical examples and the details of each, including but not limited to the hospital/provider charges, prescription costs, deductibles, co-pays, co-insurance, and other details, have been calculated using a compliance tool provided to all insurance providers by the Department of Labor and do not reflect any specific provider or plan. The examples therefore do not necessarily reflect the specific plans administered by Meritain for Notre Dame. Your actual costs, charges, deductibles, co-pays, and coinsurance will vary according to your specific plan and circumstances. ** Note: the Notre Dame Indemnity Plan is applicable only to Notre Dame employees who are situated outside the local network areas. It cannot be selected as a employee s primary benefit plan. The inclusion of the Indemnity Plan Summary of Benefits and Coverage in this Supplement is required by law.

3 University of Notre Dame High Deductible Health Plan: HDHP Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HRA 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 or Meritain Health, Inc. at 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? Do I need a referral to see a specialist? Are there services this plan doesn t cover? Is a Health Reimbursement Arrangement (HRA) available under this plan option? For participating providers $1,500 person/$3,000 family or two covered persons. For nonparticipating providers: $3,000 person/$6,000 family or two covered persons No. Yes. For participating providers $5,000 person/$10,000 family or two covered persons. For non-participating providers $10,000 person/$20,000 family or two covered persons Premiums, balance-billed charges, charges over usual and customary and health care this plan doesn't cover. No. For the CHA network see or call / or call for a list of participating providers. For the Select network see or call / or call / or call / or call for a list of participating providers. No. Yes. Yes. $500 person/$1,000 employee plus one/ $1,000 employee plus two 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. 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. 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. 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. 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. An HRA is an account that is set up and contributed to by your employer. You may not make any contributions to the HRA. The HRA may only be used to pay a portion of your out-of-pocket expenses incurred under the plan. Questions: Call your employer at or at or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call your employer at to request a copy 1 of 8 HDHP

4 University of Notre Dame High Deductible Health Plan: HDHP Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HRA Common Medical Event If you visit a health care provider s office or clinic If you have a test 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 a non-participating, provider charges more than the allowed amount, you may have to pay the difference. For example, if a non-participating provider 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. Services You May Need Participating Provider Non-Participating Provider Limitations & Exceptions Primary care visit to treat an 15% coinsurance 35% coinsurance You pay a $15 copay for office visits injury or an illness provided at the University of Notre Dame Specialist visit 15% coinsurance 35% coinsurance Wellness Center; the deductible and coinsurance does not apply. Other practitioner office visit 15% coinsurance for 35% coinsurance for none chiropractor chiropractor Preventive care/ screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) No Charge 35% coinsurance There is no charge for preventive care or immunizations provided at the University of Notre Dame Wellness Center. Deductible does not apply for Participating Providers. 15% coinsurance 35% coinsurance If testing is performed in conjunction with the office visit, the services are covered under the office visit benefit. There is no charge and the deductible does not apply for lab services provided at the University of Notre Dame Wellness Center. 15% coinsurance 35% coinsurance Precertification required for CT scans. Failure to precertify will result in a 50% penalty. Questions: Call your employer at or at or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call your employer at to request a copy 2 of 8 HDHP

5 University of Notre Dame High Deductible Health Plan: HDHP Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HRA 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 Participating Services You May Need Provider Generic drugs $5 copay (retail) / $12 copay (mail order) Brand Formulary drugs $30 copay (retail) / $60 copay (mail order Brand Non-formulary drugs $45 copay (retail) / $90 copay (mail order) Specialty drugs $100 copay (retail) / $200 copay (mail order, when clinically appropriate) Facility fee (e.g., ambulatory surgery center) Non-Participating Provider Not Covered Not Covered Not Covered Not Covered Limitations & Exceptions Covers up to a 30-day supply (retail prescription); 90-day supply (mail order prescription). The copay applies per prescription. No charge for certain preventive drugs. The deductible does not apply. 15% coinsurance 35% coinsurance none Physician/surgeon fees 15% coinsurance 35% coinsurance none Emergency room services 15% coinsurance 15% coinsurance Non-participating providers are paid at the participating provider level of benefits. Emergency medical 15% coinsurance 15% coinsurance none transportation Urgent Care 15% coinsurance 35% coinsurance none Facility fee (e.g., hospital room) 15% coinsurance 35% coinsurance Precertification required. Failure to precertify will result in a 50% penalty. Physician/surgeon fee 15% coinsurance 35% coinsurance Questions: Call your employer at or at or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call your employer at to request a copy 3 of 8 HDHP

6 University of Notre Dame High Deductible Health Plan: HDHP Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HRA Common Medical Event If you have mental health, behavioral health, or substance abuse needs Participating Provider Non-Participating Provider Services You May Need Limitations & Exceptions Mental/Behavioral health 15% coinsurance 35% coinsurance none outpatient services Mental/Behavioral health 15% coinsurance 35% coinsurance Precertification required. Failure to inpatient services precertify will result in a 50% penalty. Substance use disorder 15% coinsurance 35% coinsurance none outpatient services Substance use disorder 15% coinsurance 35% coinsurance Precertification required. Failure to inpatient services precertify will result in a 50% penalty. If you are pregnant Prenatal and postnatal care No Charge 35% coinsurance There is no charge for preventive prenatal and postnatal care from a participating provider. For prenatal and postnatal care not considered preventive, services outside the global maternity program fee will be paid at the applicable benefit level. If you need help recovering or have other special health needs Delivery and all inpatient services 15% coinsurance 35% coinsurance Precertification required for inpatient Hospital stays in excess of 48 hrs (vaginal delivery) or 96 hrs (c-section). Failure to precertify will result in a 50% penalty. Baby counts towards the mother s expense. Home health care 15% coinsurance 35% coinsurance none Rehabilitation services 15% coinsurance 35% coinsurance Includes occupational, physical and speech therapy. You pay a $15 copay for office visits provided at the University of Notre Dame Wellness Center; the deductible and coinsurance does not apply. Habilitation services Covered the same as any other Illness, with applicable deductible or coinsurance Covered the same as any other Illness, with applicable deductible or coinsurance Services for developmental delay is limited to dependent children under age 5, when medically necessary. Precertification required. Failure to precertify will result in a 50% penalty. Questions: Call your employer at or at or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call your employer at to request a copy 4 of 8 HDHP

7 University of Notre Dame High Deductible Health Plan: HDHP Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HRA Common Medical Event If your child needs dental or eye care Participating Provider Non-Participating Provider Services You May Need Limitations & Exceptions Skilled nursing care 15% coinsurance 35% coinsurance Precertification required. Failure to precertify will result in a 50% penalty. Durable medical equipment 15% coinsurance 35% coinsurance none Hospice service 15% coinsurance 35% coinsurance Bereavement counseling is only covered if received within 6 months of death. Eye exam Not Covered Not Covered Covered under stand alone vision plan Glasses Not Covered Not Covered Covered under stand alone vision plan Dental check-up Not Covered Not Covered Covered under stand alone dental 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.) Abortion Acupuncture Contraceptives Cosmetic surgery Dental care (covered under stand alone dental plan) Glasses (covered under stand alone vision plan) Infertility treatment Long-term care Routine eye care (covered under stand alone vision plan) Routine foot care Weight loss programs 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.) Bariatric surgery (if Medically Chiropractic care Private-duty nursing Necessary) Hearing aids Questions: Call your employer at or at or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call your employer at to request a copy 5 of 8 HDHP

8 University of Notre Dame High Deductible Health Plan: HDHP Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual + Family Plan Type: HRA 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 or Meritain Health, Inc. 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 University of Notre Dame at , Meritain Health, Inc. 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? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: (Español): Para obtener asistencia en Español, llame al (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 (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. HDHP 6 of 8

9 University of Notre Dame High Deductible Health Plan: HDHP Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual + Family Plan Type: HRA 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 $5,020 Patient pays $2,520 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,340 Patient pays $2,060 Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 Hospital charges (baby) $900 Office Visits and Procedures $700 Anesthesia $900 Education $300 Laboratory tests $500 Laboratory tests $100 Prescriptions $200 Vaccines, other preventive $100 Radiology $200 Total $5,400 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $1,500 Patient pays: Copays $320 Deductibles $1,500 Coinsurance $160 Copays $10 Limits or exclusions $80 Coinsurance $860 Total $2,060 Limits or exclusions $150 Total $2,520 7 of 8 HDHP

10 University of Notre Dame High Deductible Health Plan: HDHP Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual + Family Plan Type: HRA 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. Sample care costs are based on single coverage only. 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 coinsurance 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 copayments, deductibles, and coinsurance. 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 your employer at or at or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call your employer at to request a copy. 8 of 8 HDHP

11 University of Notre Dame CHA/Select HMO Plan: HMO Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: EPO 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 or Meritain Health, Inc. at Important Questions Answers Why this Matters: What is the overall There are no overall deductibles. Not applicable because there s no overall deductibles on your expenses deductible? Are there other deductibles for specific services? Yes. $350 deductible per person / $700 deductible per family for inpatient hospital facility charges, delivery charges for maternity and outpatient surgical procedures. There are no other specific 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. 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? Do I need a referral to see a specialist? Are there services this plan doesn t cover? deductibles. Yes. $2,000 person / $4,000 family for copays, inpatient hospital facility charges, delivery charges for maternity and outpatient surgical procedures. There are no other specific out-of-pocket maximums. Premiums, balance-billed charges, charges over usual and customary and health care this plan doesn't cover. No. Yes. For the CHA HMO see or call for a list of participating providers. For the Select HMO see or call / or call / or call for a list of participating providers. No. Yes. Questions: Call your employer at or at or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call your employer at to request a copy. HMO 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. 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 5. See your policy or plan document for additional information about excluded services. 1 of 8

12 University of Notre Dame CHA/Select HMO Plan: HMO Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: EPO 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 a non-participating provider charges more than the allowed amount, you may have to pay the difference. For example, if a non-participating provider 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 only provides coverage when you use a participating provider. There is no coverage under the plan if you use a non-participating provider, unless due to a medical emergency. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Participating Provider Non-Participating Provider Limitations & Exceptions Primary care visit to treat an $30 copay/visit Not Covered Copay applies to the physician office visit injury or an illness only. Copay is waived when diagnostic or Specialist visit $35 copay/visit Not Covered ancillary services are performed in the office setting and a physician office visit is billed in addition to these services. You pay a $15 copay for office visits provided at the University of Notre Dame Wellness Center. Other practitioner office visit $30 copay/visit for Not Covered Limited to 20 visits per year. Preventive care/ screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) chiropractor No Charge Not Covered There will be no charge for preventive care or immunizations provided at the University of Notre Dame Wellness Center. No Charge Not Covered If the testing is performed in conjunction with the office visit, the services are covered under the office visit benefit. There will be no charge for laboratory services provided at the University of Notre Dame Wellness Center. No Charge Not Covered Precertification required for CT scans. Failure to precertify will result in a 50% penalty. 2 of 8 HMO

13 University of Notre Dame CHA/Select HMO Plan: HMO Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: EPO 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 Services You May Need Participating Provider Non-Participating Provider Limitations & Exceptions Generic drugs $5 copay (retail) / $12 Not Covered Covers up to a 30-day supply (retail copay (mail order) prescription); 90-day supply (mail order Brand Formulary drugs $30 copay (retail) / $60 Not Covered prescription). The copay applies per copay (mail order prescription. No charge for certain Brand Non-formulary drugs $45 copay (retail) / $90 Not Covered preventive drugs. copay (mail order) Specialty drugs $100 copay (retail) / $200 Not Covered copay (mail order, when clinically appropriate) Facility fee (e.g., ambulatory 15% coinsurance Not Covered Does not include surgery in the physician's surgery center) office. Physician/surgeon fees No Charge Not Covered none Emergency room services $200 copay/visit Not Covered (See the Plan Copay is waived if admitted to the hospital. Document for additional details) Emergency medical No Charge transportation Not Covered (See the Plan Document for additional details) There is no charge for ambulance service (from area first disabled) to nearest facility qualified to provide care, if deemed medically necessary and approved by the plan. Urgent Care $50 copay/visit Not Covered $50 copay per visit at urgent care facility at Medpoint; $25 copay at Medpoint Express; $50 copay for urgent care centers outside of the network for medical emergencies. Facility fee (e.g., hospital room) Physician/surgeon fee No Charge Not Covered 15% coinsurance Not Covered Precertification required. Failure to precertify will result in a 50% penalty. If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services No Charge Not Covered For an office visit, you pay $30 copay / visit for participating providers. Same as inpatient hospital stay Not Covered Precertification required. Failure to precertify will result in a 50% penalty. HMO 3 of 8

14 University of Notre Dame CHA/Select HMO Plan: HMO Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: EPO Common Medical Event Services You May Need Substance use disorder outpatient services Participating Provider Non-Participating Provider Limitations & Exceptions No Charge Not Covered For an office visit, you pay $30 copay / visit for participating providers. Substance use disorder Same as inpatient hospital Not Covered Precertification required. Failure to inpatient services stay precertify will result in a 50% penalty. If you are pregnant Prenatal and postnatal care No Charge Not Covered There is no charge for preventive prenatal and postnatal care. For prenatal and postnatal care not considered preventive, services outside the global maternity program fee will be paid at the applicable benefit level. If you need help recovering or have other special health needs Delivery and all inpatient services 15% coinsurance Not Covered Precertification required for inpatient Hospital stays in excess of 48 hrs (vaginal delivery) or 96 hrs (c-section). Failure to precertify will result in a 50% penalty. Baby counts towards the mother s expense. Home health care $30 copay/visit Not Covered Limited to 60 visits per year. Rehabilitation services $30 copay/visit Not Covered Occupational, physical and speech therapy are each limited to 50 visits per year. For occupational therapy, inpatient short-term rehabilitation is limited to 60 consecutive days per year. You pay a $15 copay for physical therapy visits provided at the University of Notre Dame Wellness Center. Habilitation services Covered the same as any other illness, with applicable copay, deductible or coinsurance Not Covered Services for developmental delay is limited to dependent children under age 5, when medically necessary. Limited to 50 visits per year. Precertification required. Failure to precertify will result in a 50% penalty. Skilled nursing care No Charge Not Covered Limited to 60 days per year. Precertification required. Failure to precertify will result in a 50% penalty. Durable medical equipment No Charge Not Covered none HMO 4 of 8

15 University of Notre Dame CHA/Select HMO Plan: HMO Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: EPO Common Medical Event If your child needs dental or eye care Services You May Need Participating Provider Non-Participating Provider Limitations & Exceptions Hospice service No Charge Not Covered Bereavement counseling is only covered if received within 6 months of death. Eye exam Not Covered Not Covered Covered under stand alone vision plan Glasses Not Covered Not Covered Covered under stand alone vision plan Dental check-up Not Covered Not Covered Covered under stand alone dental 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.) Abortion Acupuncture Contraceptives Cosmetic surgery Dental care (covered under stand alone dental plan) Glasses (covered under stand alone vision plan) Infertility treatment Long-term care Routine eye care (covered under stand alone vision plan) Routine foot care Weight loss programs 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.) Bariatric surgery (if Medically Necessary) Chiropractic care Hearing aids Private-duty nursing HMO 5 of 8

16 University of Notre Dame CHA/Select HMO Plan: HMO Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: EPO 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 or Meritain Health, Inc. 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 University of Notre Dame at , Meritain Health, Inc. 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? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: (Español): Para obtener asistencia en Español, llame al (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 (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 HMO

17 University of Notre Dame CHA/Select HMO Plan: HMO Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual + Family Plan Type: EPO 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 $6,100 Patient pays $1,440 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,820 Patient pays $580 Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 Hospital charges (baby) $900 Office Visits and Procedures $700 Anesthesia $900 Education $300 Laboratory tests $500 Laboratory tests $100 Prescriptions $200 Vaccines, other preventive $100 Radiology $200 Total $5,400 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Patient pays: Copays $500 Deductibles $350 Coinsurance $0 Copays $10 Limits or exclusions $80 Coinsurance $930 Total $580 Limits or exclusions $150 Total $1,440 7 of 8 HMO

18 University of Notre Dame CHA/Select HMO Plan: HMO Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual + Family Plan Type: EPO 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. Sample care costs are based on single coverage only. 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 coinsurance 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 copayments, deductibles, and coinsurance. 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 your employer at or at or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call your employer at to request a copy. 8 of 8 HMO

19 University of Notre Dame PPO Plan: PPO Plan Coverage Period: 01/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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 or Meritain Health, Inc. at Important Questions Answers Why this Matters: What is the overall For participating providers: You must pay all the costs up to the deductible amount before this plan deductible? $400 person / $800 family or two covered begins to pay for covered services you use. Check your policy or plan persons For non-participating providers: document to see when the deductible starts over (usually, but not always, $800 person / $1,600 family or two covered January 1st). See the chart starting on page 2 for how much you pay for persons covered services after you meet the 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? Do I need a referral to see a specialist? Are there services this plan doesn t cover? No. Yes. For participating providers $1,950 person / $4,600 family or two covered persons For non-participating providers $3,900 person / $7,800 family or two covered persons Premiums, balance-billed charges, charges over usual and customary and health care this plan doesn't cover. No. For the CHA PPO see or call / or call for a list of participating providers. For the Select PPO see or call / or call / or call / or call for a list of participating providers. No. 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. 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. 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. 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. Questions: Call your employer at or at or visit us at 1 of 8 If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call your employer at to request a copy. PPO

20 University of Notre Dame PPO Plan: PPO Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO 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 a non-participating, provider charges more than the allowed amount, you may have to pay the difference. For example, if a non-participating provider 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 Participating Provider Non-Participating Provider Limitations & Exceptions Primary care visit to treat an $30 copay/visit 35% coinsurance Deductible does not apply for Participating injury or an illness Providers. Copay applies to the physician Specialist visit $35 copay/ visit 35% coinsurance office visit only. Copay is waived when diagnostic or ancillary services are performed in the office setting and a physician office visit is billed in addition to these services. You pay a $15 copay for office visits provided at the University of Notre Dame Wellness Center; the deductible and coinsurance does not apply. Other practitioner office visit $30 copay / visit for 35% coinsurance for Deductible does not apply for Participating Preventive care/ screening/immunization Diagnostic test (x-ray, blood work) chiropractor chiropractor Providers. No Charge 35% coinsurance There will be no charge for preventive care or immunizations provided at the University of Notre Dame Wellness Center. Deductible does not apply for Participating Providers. 15% coinsurance 35% coinsurance If the testing is performed in conjunction with the office visit, the services are covered under the office visit benefit. There will be no charge and the deductible does not apply for laboratory services provided at the University of Notre Dame Wellness Center. 2 of 8 PPO

21 University of Notre Dame PPO Plan: PPO Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO 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 Services You May Need Participating Provider Non-Participating Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) 15% coinsurance 35% coinsurance Precertification required for CT scans. Failure to precertify will result in a 50% penalty. Generic drugs $5 copay (retail) / $12 Not Covered Covers up to a 30-day supply (retail copay (mail order) prescription); 90-day supply (mail order Brand Formulary drugs $30 copay (retail) / $60 Not Covered prescription). The copay applies per copay (mail order prescription. No charge for certain preventive Brand Non-formulary drugs $45 copay (retail) / $90 Not Covered drugs. copay (mail order) Specialty drugs $100 copay (retail) / Not Covered $200 copay (mail order, when clinically appropriate) Facility fee (e.g., ambulatory 15% coinsurance 35% coinsurance none surgery center) Physician/surgeon fees 15% coinsurance 35% coinsurance none Emergency room services 15% coinsurance 15% coinsurance Non-participating providers are paid at the participating provider level of benefits. Emergency medical 15% coinsurance 15% coinsurance none transportation Urgent Care $50 copay/visit 35% coinsurance You pay a $25 copay for services provided at Medpoint Express (CHA Network only) Deductible does not apply for Participating Providers. Facility fee (e.g., hospital 15% coinsurance 35% coinsurance Precertification required. Failure to precertify room) will result in a 50% penalty. Physician/surgeon fee 15% coinsurance 35% coinsurance Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services 15% coinsurance 35% coinsurance For an office visit, you pay $30 copay/visit (deductible does not apply) for participating providers and 35% coinsurance for nonparticipating providers. 15% coinsurance 35% coinsurance Precertification required. Failure to precertify will result in a 50% penalty. 3 of 8 PPO