University of New Hampshire Student Health Plan: Self-Funded Coverage Period: 8/24/13 8/22/14

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1 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 Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific? 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 this plan doesn t cover? $0 In-Network Providers $250 per person/$1,000 per family for Out-of- Network Providers. Doesn t apply to preventive care, prescription drugs, medically necessary emergency room visits, and emergency transportation in an ambulance. No. Yes. For In-Network Providers: $3,500 per person; For Out-of-Network Providers: $7,000 per person. Premiums, balance-billed charges (unless balanced billing is prohibited, health care this plan doesn t cover and prescription drug copays. No. Yes. For a list of In-Network Providers, see or call No. Yes You must pay all of the costs up to the deductible amount before this plan begins to pay for covered you use Check your policy or plan document for when the deductible starts over, usually but not always, the plan s effective date. See the chart starting on page 2 for how much you pay for covered after you meet this deductible. You don t have to meet deductibles for specific, but see the chart staring on page 2 for other costs for 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. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket expenses. The chart staring on page 2 describes any limits on what the plan will pay for specific covered 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 cost of covered. Be aware, your in-network doctor or hospital may use an out-of-network provider for some. Plans use the term in-network, preferred, or participating for providers in their network. See the chart staring 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 this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded. 1 of 8

2 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 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. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need In-network Provider Out-of-network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $30 copay None Specialist visit $30 copay None $30 copay per visit then Chiropractic Care and Physical Therapy: Other practitioner office visit 15% for Chiropractor, limited to a combined plan year maximum of Physical Therapy and 20 visits; Acupuncture: limited to $1,000 per Acupuncture Treatment plan year. Preventive care/screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) No charge at UNH Health Services Not covered Preventive care is covered in compliance with the Affordable Care Act for any covered not available at UNH Health Services or for provided when SHBP covered person is away from the Durham campus. 15% None $100 copay then 15% None 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: html. If you have outpatient surgery Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees In-network Provider $15 copay ($0 copay for generic contraceptives) $25 copay $40 copay Out-of-network Provider Limitations & Exceptions Covers up to a 30 day supply The UNH Health Services Pharmacy is the only provider for in-network prescription drug benefits, except as specifically provided for Preventive Care Benefits. Out-of-network prescription drug coverage is available only if: the member is not eligible to use the UNH Health Services Pharmacy; or an urgent or emergency situation is present; or the medication is not available through the UNH Health Services Pharmacy; or the member incurs treatment for a new medical condition and needs a new prescription while outside of the Durham area. Note: Up to a 90-da y supply is only available for winter and summer breaks. In these circumstance, the UNH Health Services copayments are charged for each 30 day supply of a medication. $100 copay then 15% None % None of 8

4 Common Medical Event If you need immediate medical attention 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 Emergency room Emergency medical transportation In-network Provider Out-of-network Provider Limitations & Exceptions $75 copay then 15% $75 copay then 15% Copay waived if admitted. $100 copay then 15% $100 copayment then 15% None Urgent care $35 copay then 15% Facility fee (e.g., hospital room) Non-Surgery: $250 copay then 15% Surgery: $100 copay, 15% Not covered if benefits are provided by the UNH Health fee at Wentworth Douglass Hospital or Walk In Urgent Care at Lee None Physician/surgeon fee 15% None Mental/Behavioral health outpatient Mental/Behavioral health inpatient Substance use disorder outpatient Substance use disorder inpatient Prenatal and postnatal care Delivery and all inpatient $15 copay $250 copay then 15% $15 copay per visit $250 copay then 15% Office visit: $30 copay Related lab/x-ray: 15% 30 visit maximum per plan year for treatment of non-biologically based conditions combined with substance abuse 30 day maximum per plan year for treatment of non-biologically based conditions combined with substance abuse 30 visit maximum per plan year combined with non-biologically based mental/behavioral health conditions 30 day maximum per plan year combined with non-biologically based mental/behavioral health conditions None $250 copay then 15% None 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 In-network Provider Out-of-network Provider Limitations & Exceptions Home health care 15% Maximum 1 visit per day, 120 visits per lifetime Rehabilitation 15% None Habilitation 15% None Skilled nursing care 15% Requires admission into facility within 14 days of hospital admission. Durable medical equipment 15% None Hospice service 15% None Eye exam No Charge 100% Limited to preventive child vision screening. Glasses Not Covered 100% Not a covered expense. Limited to preventive child oral health Dental check-up No charge 100% risk assessment. 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.) Bariatric surgery Infertility treatment Private duty nursing Cosmetic surgery Long-term care Routine eye care Dental care Non-emergency care when traveling outside the Routine foot care Hearing aids U.S. Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered and your costs for these.) Acupuncture Chiropractic Care 5 of 8

6 Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering in the State You move outside the coverage area For more information on your rights to continue coverage, contact Consolidated Health Plans at You may also contact your state insurance department at 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: or consumer@ins.nh.gov. 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) Amount owed to providers: $7,540 Plan pays $6,280 Patient pays $1,260 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 Copays $20 Coinsurance $1,090 Limits or exclusions $150 Total $1,260 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,210 Patient pays $1,190 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 Copays $900 Coinsurance $210 Limits or exclusions $80 Total $1,190 7 of 8

8 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. 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 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. 8 of 8

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