aetna Coverage Period: 07/ 01/ / 30/ 2017

Transcription

1 Board of Washington County Commissioners : Open Choi( aetna Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family I 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 ilk at or by calling Important Questions Answers Why this Matters: You must pay. T e costs up to the deductible amount e ore ' s p, egins What is the overall deductible? Are there other deductibles for specific services? Is there an In-Network: Individual$ 0/ Family$ 0. to pay for covered services you use. Check your policy or plan document to see Out of Network: Individual$ 250/ Family when the deductible starts over( usually, but not always, January 1st). See the 750. Does not apply to emergency care. chart starting on page 2 for how much you pay for covered services after you meet the deductible. No. 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. Yes. In-Network: Individual$ 2,000/ Family The out-of-pocket limit is the most you could pay during a coverage period out-of-pocket limit 6, 000. Out of Network: Individual$ 3,000/ ( usually one year) for your share of the cost of covered services. This limit on my expenses? Family$ 9,000. helps you plan for health care expenses. Premiums, balance- billed charges, penalties What is not included in for failure to obtain pre- authorization for Even though you pay these expenses, they don't count toward the out-of the out-of-pocket limit? service, and health care this plan does not pocket limit. cover. Is there an overall annual limit on what the plan pays? No The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Do I need a referral to see a specialist? Yes. See or call 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 for a list of in- network hospital may use an out-of-network provider for some services. Plans use the providers. 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. No. You can see the specialist you choose without permission from this plan. Are there services this plan doesn' t cover? Yes. Some of the services this plan doesn' t cover are listed on page 5. Sec your policy or plan document for additional information about excluded services. Questions: Call or visit us at any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 8 at or call to request a

2 aetna Board of Washington County Commissioners : Open Choice'' 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. it 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 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 in-network providers by charging you lower deductibles, copayments, and coinsurance amounts. Your Cost If Your Cost If Common You Use an You Use an Medical Event Services You May Need In-Network Provider Out of Network Limitations& Exceptions Provider Primary care visit to treat an injury or $ 25 copay/ illness Includes Internist, General Physician, Family Practitioner or Pediatrician. If you visit a health SS. ecialist visit 30 co a / none care provider' s office or clinic If you have a test Coverage is limited to 24 visitser P calendar Other practitioner office visit 25 copay/ year for Chiropractic care. Preventive care/ screening immunization No charge 30% coinsurance Age and frequency schedules may apply. Di.' ostic test( x- ra, blood work) No char_ 30% coinsurance none Imaging( CT/ PET scans, MRIs) No charge 30% coinsurance none Questions: Call or visit us at any of the underlined terms used in this form, see the Glossary. You can view the Glossary of 8 at or call to request a

3 Board of Washington County Commissioners : Open Choice. aetna ' Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family j Plan Type: PPO Your Cost If Your Cost If Common You Use an You Use an Services You May Need In-Network Provider Out of Network Limitations& Exceptions Medical Event Provider If you need drugs to Generic drugs Not covered Not covered Not covered. treat your illness or condition Prescription drug coverage is administered by ESI Preferred brand drugs Not covered Not covered Not covered. Non- preferred brand drugs Not covered Not covered Not covered. Not covered. More information about prescription drug coverage is available at Specialty drugs Not covered Not covered phar macy- insurance/ individ uals- families If you have outpatient surgery Facility fee( e. g., ambulatory surgery center) none No charge 30% coinsurance Physician/ surgeon fees No charge 30% coinsurance none If you need Emergency room services 100 copay/ visit 100 visit copay/ 50% coinsurance for non-emergency use. immediate medical Emergency medical transportation No charge No charge No coverage for non-emergency transport. attention If you have a hospital stay Urgent care 35 copay/ No coverage for non-urgent use. Facility fee( e. g., hospital room) 100 copay/ stay 30% coinsurance Pre- authorization required for Physician/ surgeon fee No charge 30% coinsurance none If you have mental health, behavioral health, or substance Mental/ Behavioral health outpatient services Mental/ Behavioral health inpatient services 30 copay/ 100 copay/ stay 30% coinsurance none Pre- authorization required for abuse needs Substance use disorder outpatient services 30 copay/ none Questions: Call or visit us at com. any of the underlined terms used in this form, see the Glossary. You can view the Glossary 3 of 8 at or call to request a

4 aetna Board of Washington County Commissioners : Open Choice Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family I Plan Type: PPO Your Cost If Your Cost If Common You Use an You Use an Medical Event Services You May Need In-Network Provider Out of Network Limitations & Exceptions Provider Substance use disorder inpatient 100 copay/ star 30% coinsurance services Pre- authorization required for If you are pregnant Prenatal and postnatal care No charge 30% coinsurance none Includes outpatient postnatal care. Delivery and all inpatient services 100 copay/ stay 30% coinsurance Pre-authorization may be required for If you need help Coverage or recovering have Coverage is limited to 40 visits per calendar Home health care No charge 30% coinsurance year. Pre- authorization required for Coverage is limited to 60 visits per calendar Rehabilitation services S25 copay/ year for Physical, Occupational& Speech Therapy combined. other special health Habilitation services 25 copay/ needs is limited to 60 visits per calendar year for Autism Physical, Occupational& Speech Therapy, combined with rehabilitation services. nursing care No charge 30% coinsurance Durable medical equipment No charge 30% coinsurance none required for P Hospice service No charge 30% coinsurance Pre- authorization required for If your child needs dental or eye care Eye exam Not covered Not covered Not covered. Glasses Not covered Not covered Not covered. Dental check- up Not covered Not covered Not covered. Questions: Call or visit us at any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a 6 6 6

5 aetna Board of Washington County Commissioners : Open Choice' - Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO 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 Glasses( Child) Prescription drugs Bariatric surgery Longterm care Routine Eye Care( Adult& Child) Cosmetic surgery Non- emergency care when outside traveling the Routine foot care Dental care ( Adult& Child) U.S. 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.) Chiropractic care- Coverage is limited to 24 visits Infertility treatment- Coverage is limited to the ' Private-duty nursing- Coverage is limited to 70-8 per calendar year. diagnosis and treatment of underlying medical hour shifts per calendar year. condition. Artificial insemination, ovulation Hearing aids- Coverage is limited to 1 pair of induction& advanced reproductive technology hearing aids per 36 months up to age 19 and 1 pair limited to$ 100,000 per lifetime, and in-vitro of hearing aids per 5 years thereafter. fertilization limited to 3 attempts per lifetime. 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 ebsa, 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 us by calling the toll free number on your Medical ID Card. If your group health plan is subject to ERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at EBSA( 3272) or ebsa/ healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact information is at individuals- families- health-insurance/ rights-resources/ complaints- grievances- appeals/ index.html Questions: Call or visit us at com. any of the underlined terms used in this form, see the Glossary. You can view the Glossary 5 of 8 at or call to request a

6 Board of Washington County Commissioners : Open Choice' aetna ' Nigh Option Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO 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 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 not meet the minimum value standard for the benefits it provides. Language Access Services: Para obtener asistencia en Espanol, llame al taram 3Zn # 1, tis gi Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holm' o see examples y.bow this plan might corer costsfor a sample medical situation, see the nextpage. Questions: Call or visit us at any of the underlined terms used in this form, see the Glossary. You can view the Glossary 6 of 8 at or call to request a

7 4 Board of Washington County Commissioners : Open Choice.' aetna. Coverage Examples Coverage for: Individual + Family! Plan Type: PPO About these Coverage Examples: Having a baby normal delivery) Managing type 2 diabetes routine maintenance of a well- controlled condition) 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. Sample care costs: Amount owed to providers: $7, 540 Amount owed to providers: $5, 400 Plan pays: $ 7, 240 Plan pays: $ 2, 200 Patient pays: $ 300 Patient pays: $3, 200 Sample care costs: Hospital charges( mother) S2,- 0O Prescriptions 2,900 This is not Routine obstetric care S2, 100 Medical Equipment and Supplies 1, 300 ki a cost Hospital charges( baby) 900 Office Visits and Procedures 700 Anesthesia 900 I ducation; 300 estimator. tests 100 Laboratory tests 500 Laboratory Don't use these examples to Prescriptions 200 Vaccines, other preventive 100 estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be Radiology 5200 Total 5, 400 Vaccines, other preventive Total Patient pays: Deductibles i $ r S40 7, 540 Patient pays: Deductibles 0 Copays _ 300 S() Coinsurance 0 different. Copays i S 1( 10 Limits or exclusions 2,900 See the next page for important information about these examples. Coinsurance Su Total 3, 200 Limits or exclusions S200 Total 300 Questions: Call or visit us at any of the underlined terms used in this form, see the Glossary. You can view the Glossary 7 of 8 at com or call to request a

8 aetna Board of Washington County Commissioners : Open Chola,* - Coverage Period: 07/ 01/ / 30/ 2017 Coverage Examples Coverage for: Individual + Family Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions What does a Coverage Can I use Coverage Examples to behind the Coverage Examples? Example show? compare plans? For each treatment situation, the Coverage Yes. When you look at the Summary of Example helps you see how deductibles, Benefits and Coverage for other plans, Costs don' t include premiums. copayments, and coinsurance can add u p. It you'll find the same Coverage Examples. Sample care costs are based on national also helps you see what expenses might be left When you compare plans, check the" Patient averages supplied by the U.S. Department up to you to pay because the service or Pays" box in each example. The smaller that of Health and Human Services, and aren't treatment isn' t covered ora P ent is limited. number, the more coverage the plan specific to a particular geographic area or health plan. The patient' s condition was not an Does the Coverage Example provides. predict my own care needs? excluded or Are there other costs I should preexisting condition. All services and treatments started and No. Treatments shown are just examples. consider when comparing plans? ended in the same coverage period. There are no other medical expenses for doctor's any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. out-of-pocket The patient received all care from The care you would receive for this condition could be different, based on your advice, your age, how serious your condition is, and many other factors. you Does the Coverage Example Yes. An important cost is the premium pay. Generally, the lower your premium, the more you'll pay in costs, such as copayments, deductibles, and coinsurance. You should in networkproviders. If thepatient had predict my future expenses? also consider contributions to accounts such received care from out-of-network providers, costs would have been higher. 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. as health savings accounts( HSAs), flexible spending arrangements( FSAs) or health reimbursement accounts( HRAs) that help you pay out-of-pocket expenses. Questions: Call 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 to request a 8 of 8