1199SEIU National Benefit Fund for Rochester Area Members Summary of Benefits and Coverage: What This Plan Covers and What It Costs

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1 1199SEIU National Benefit Fund for Rochester Area Members Summary of Benefits and Coverage: What This Plan Covers and What It Costs Coverage Period: Beginning 04/01/2014 Coverage for: Rochester Area Employers Members Plan Type: Taft-Hartley Trust Fund This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Fund s Summary Plan Description (SPD) at or by calling (585) or (877) Active Members: Wage Class I members receive all of the benefits listed below for themselves and their eligible family members. Wage Class II members receive benefits for themselves and their eligible family members except where indicated in the Limitations & Exceptions column. Wage Class III members receive medical, hospital, surgery and vision benefits for themselves only, as indicated in the Limitations & Exceptions column. Check your 1199SEIU Health Benefits ID card to confirm your Wage Class. Important Questions Answers Why This Matters What is the overall deductible? $0 See the chart starting on page 2 for your costs for this plan covers. Are there other deductibles for You don t have to meet deductibles for specific, but see the chart starting on No specific? page 2 for other costs for this plan covers. Is there an out of pocket limit There s no limit on how much you could pay during a coverage period for your share No on my expenses? of the cost of covered. What is not included in the This plan has no out-of-pocket out of pocket limit? limit. Not applicable because there s no out-of-pocket limit on your expenses. Is there an overall annual limit The chart starting on page 2 describes any limits on what the plan will pay for specific No on what the plan pays? covered, such as office visits. Yes. For a list of participating If you use a participating doctor or other healthcare provider (also called preferred providers, call (800) or in-network providers), this plan will pay all or most of the costs of covered Does this plan use a network or visit Be aware that your participating doctor or hospital may use a nonparticipating provider for some. See the chart on page 2 for how this plan of providers? For a list of participating dental providers, call (800) pays different kinds of providers. Do I need a referral to see a specialist? No You can see the participating specialist you choose without permission from this plan. Are there this plan doesn t cover? Yes Some of the this plan doesn t cover are listed on page 5. See your Summary Plan Description (SPD) for additional information about excluded. Questions: Call (585) or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary at or call (800) to request a copy. The 1199SEIU National Benefit Fund for Rochester Area Members considers itself a grandfathered health plan under the Patient Protection and Affordable Care Act. 1 of 8

2 Co-payments are fixed dollar amounts (for example, $15) you pay for covered healthcare, 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 payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered 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.) This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and amounts. Common Medical Event If you visit a healthcare provider s office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/screening/ immunization Diagnostic test (X-ray, blood work) Imaging (CT/ PET scans, MRIs, MRAs) Participating Provider Your Cost If You Use a Non-Participating Provider Limitations & Exceptions $10 co-pay/visit None $23.50 co-pay/ visit $23.50 co-pay/ visit Chiropractor: 20% $25 co-pay/ screening $10 co-pay/ preventive care office visit and immunizations $25 co-pay/x-ray $0 co-pay/blood work Physical/Occupational/Speech Therapy: up to 25 visits combined per year Chiropractic: up to 24 treatments per year Wage Class III not covered for chiropractic. None None $25 co-pay/test Prior approval required. 2 of 8

3 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 Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Participating Provider $4 co-pay $4 co-pay You will be charged a differential. $4 co-pay. You will also be charged a differential for non-preferred brand drugs. Your Cost If You Use a Non-Participating Provider provider bills above the Fund s payment. provider bills above the Fund s payment. provider bills above the Fund s preferred drug price. provider bills above the Fund s preferred drug price. Limitations & Exceptions Wage Class II and III not covered. Participating providers are pharmacies that accept Express Scripts. Prescriptions for chronic conditions must be filled through The 90-Day Rx Solution. Prior approval required for certain medications. Certain medications are subject to clinical program management. For non preferred drugs, you must also pay the difference between the preferred and non-preferred drug price. Facility fee (e.g., ambulatory surgery center) $23.50 co-pay Prior approval required for certain procedures. Physician/ Office surgery co-pay of $23.50 may apply for officebased surgeries. No charge Surgeon fees A hospital emergency room should be used only in the $50 co-pay if not Emergency case of a legitimate medical emergency, and must occur admitted to $50 co-pay if not admitted to the hospital. room within 72 hours of an injury or the onset of a sudden the hospital. and serious illness. Emergency Wage Class III not covered. Use of emergency medical 20% medical 20% transportation in non-emergency situations is not transportation covered. Urgent care $25 co-pay $25 co-pay None 3 of 8

4 Common Medical Event 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 Facility fee (e.g., hospital room) Physician/ Surgeon fees Mental/ Behavioral health outpatient Mental/ Behavioral health inpatient Substance use disorder outpatient Substance use disorder inpatient Prenatal and postnatal care Delivery and all inpatient Participating Provider Wage Class III pays 50% after 120 days per year Your Cost If You Use a Non-Participating Provider Limitations & Exceptions Wage Class III covered up to 300 days per year. Prior approval required for non-emergency admissions. Notification required within 48 hours of an emergency admission. No charge None $10 co-pay/visit Prior approval may be required for certain. Wage Class III pays 50% after 120 days per year Wage Class III covered up to 300 days per year. Prior approval required for non-emergency admissions. Notification required within 48 hours of an emergency admission. $10 co-pay/visit Prior approval may be required for certain. Wage Class III pays 50% after 120 days per year Wage Class III covered up to 300 days per year. Prior approval required for non-emergency admissions. Notification required within 48 hours of an emergency admission. $10 co-pay/visit Lactation not covered. No charge Prior approval required. 4 of 8

5 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 Habilitation Participating Provider 20% $23.50 co-pay/ outpatient visit $23.50 co-pay/ visit Your Cost If You Use a Non-Participating Provider Limitations & Exceptions Wage Class III not covered. Prior approval required. Prior approval required. Coverage for outpatient cardiac rehab limited to 36 visits per year. Coverage for outpatient Physical/Occupational/Speech Therapy limited to 25 visits combined per year. Coverage for outpatient only. Physical/Occupational/ Speech Therapy limited to 25 visits combined per year. Speech therapy for children with developmental delay is covered through age 5. Prior approval required. Services rendered in a skilled nursing facility are not covered. Skilled nursing $23.50 co-pay care Durable 20% medical Wage Class III not covered. Prior approval required. equipment Hospice service No charge Prior approval required. Eye exam $23.50 co-pay None $60 Coverage limited to one pair of Fund program Glasses $60 reimbursement reimbursement prescription glasses or contact lenses every two years. Dental check-up No charge Excluded Services and Other Covered Services: provider bills above Excellus payment. Services Your Plan Does NOT Cover (This is not a complete list. Check your SPD for other excluded.) Acupuncture Lactation Care provided in a skilled nursing facility Long-term care Cosmetic surgery Non-emergency care when traveling outside Infertility treatment the U.S. Wage Class II and III not covered. Routine foot care Weight-loss programs 5 of 8

6 Other Covered Services (This is not a complete list. Check your SPD for other covered and your costs for these.) Ambulance (Wage Class I and II only) Dental care (Adult): Wage Class I only. Home health care (Wage Class I and II only) Maximum benefit $1,000 per year for basic Bariatric surgery (prior approval required) restorative. No maximum for preventive Limited coverage when traveling outside the U.S. care and essential oral pediatric. (see Chiropractic care: Care limited to 24 treatments per year (Wage Class I and II only) Durable Medical Equipment (Wage Class I and II only. Prior approval required.) Hearing aids (Wage Class I and II only) Private-duty nursing (prior approval required) Routine eye care (Adult): one eye exam every two years; one pair of glasses or contact lenses every two years 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 (877) You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at (866) or or the U.S. Department of Health and Human Services at (877) 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 MVP Health Care, PO Box 2207, Schenectady, NY or call (800) Additionally, a consumer assistance program can help you file your appeal. Contact Community Service Society of New York, Community Health Advocates, 105 East 22nd Street, 8th floor, New York, NY 10010, call (888) directly or visit Language Access Services: Para obtener asistencia en Español, llame al (646) Does this coverage provide minimum essential coverage? The Affordable Care Act requires most people to have healthcare coverage that qualifies as minimum essential coverage. This plan 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. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

7 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) n Amount owed to providers: $7,540 n Plan pays: $7,430 n Patient pays: $110* 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 Co-pays $80 Co-insurance $0 Limits or exclusions $30 Total $110 Managing Type 2 diabetes (routine maintenance of a well-controlled condition) n Amount owed to providers: $5,400 n Plan pays: $5,070 n Patient pays: $330* 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 Co-pays $290 Co-insurance $0 Limits or exclusions $40 Total $330 *Note: These numbers assume the patient is Wage Class I. Wage Class II and III members are not covered for prescriptions. *Note: These numbers assume the patient is Wage Class I. Wage Class II and III members are not covered for prescriptions. 7 of 8

8 1199SEIU National Benefit Fund for Rochester Area Members Summary of Benefits and Coverage: What This Plan Covers and What It Costs Questions and Answers about the Coverage Examples: Coverage Period: Beginning 04/01/2014 Coverage for: Rochester Area Employers Members Plan Type: Taft-Hartley Trust Fund 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 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 in-network 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, co-payments and can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as co-payments, deductibles and. 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 (585) or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary at or call (800) to request a copy. The 1199SEIU National Benefit Fund for Rochester Area Members considers itself a grandfathered health plan under the Patient Protection and Affordable Care Act. 8 of 8