Open Choice Consumer Driven Health Plan Coverage Period: 01/01/ /31/2017

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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 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? Answers For each Calendar Year In-network: Individual $3,400 / Family $3,400 Out-of-network: Individual $3,400 / Family $3,400 Does not apply to preventive care in-network No. Yes, In-network: Individual $6,850 / Family $8,000; Out-of-network: Individual $6,850 / Family $8,000 Premiums, balance-billed charges, penalties for failure to obtain preauthorization for services and health care this plan doesn t cover. No. Yes. For a list of in-network providers, see or call No. Yes. Why this Matters: 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-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 6. See your policy or plan document for additional information about excluded services. Page 1 of 10

2 Common Medical Event 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 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. Services You May Need Primary care visit to treat an injury or illness Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions If you visit a health care provider s office or clinic If you have a test Specialist visit Other practitioner office visit Preventive care /screening /immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) No charge, deductible waived. No charge, deductible waived. Coverage is limited to 30 visits per calendar year for chiropractic care Age and frequency schedules may apply. Page 2 of 10

3 Your Cost If You Use an Common Medical Services You May Your Cost If You Use an Out-Of-Network Event Need In-Network Provider Provider Limitations & Exceptions Generic drugs After deductible: $10 copay Same as in-network plus any Retail limited to 3 prescriptions; then mail order is (retail), $25 copay (mail additional charges over the innetwork required unless CVS pharmacy is used; covers up order) retail price. to a 30-day supply (retail) and up to a 90-day supply (mail order or CVS pharmacy). Deductible does not apply to certain preventive drugs. If you need drugs to treat your illness or condition Preferred brand drugs Non-preferred brand drugs After deductible: $25 copay (retail), $60 copay (mail order) After deductible: $45 copay (retail), $100 copay (mail order) Same as in-network plus Retail limited to 3 prescriptions; then mail order is additional charges over the innetwork retail price. to a 30-day supply (retail) and up to a 90-day required unless CVS pharmacy is used; covers up supply (mail order or CVS pharmacy). Deductible does not apply to certain preventive drugs. Same as in-network plus any Retail limited to 3 prescriptions; then mail order is additional charges over the innetwork retail price. to a 30-day supply (retail) and up to a 90-day required unless CVS pharmacy is used; covers up supply (mail order or CVS pharmacy). Deductible does not apply to certain preventive drugs. Specialty drugs After deductible: $45 copay (retail), $100 copay (mail order). Specialty drugs are covered the same as any other drug but are subject to certain restrictions based on the particular drug. All specialty medications must be ordered through an approved specialty pharmacy. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Page 3 of 10

4 If you need immediate medical attention If you have a hospital stay Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Non-emergency use covered at 50%. Pre-authorization required for out-of-network care. Failure to pre-authorize will result in 40% coinsurance Page 4 of 10

5 Your Cost If You Use an Common Medical Services You May Your Cost If You Use an Out-Of-Network Event Need In-Network Provider Provider Limitations & Exceptions Mental/Behavioral health outpatient services. If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health inpatient services Substance use disorder outpatient services. Pre-authorization required for out-of-network care. Failure to pre-authorize will result in 40% coinsurance If you are pregnant Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services Pre-authorization required for out-of-network care. Failure to pre-authorize will result in 40% coinsurance No charge for preventive prenatal care Page 5 of 10

6 Your Cost If You Use an Common Medical Services You May Your Cost If You Use an Out-Of-Network Event Need In-Network Provider Provider Limitations & Exceptions Home health care Coverage is limited to 120 visits. Pre-authorization required for out-of-network care. Failure to preauthorize will result in 40% coinsurance Rehabilitation services Coverage is limited to 60 visits for Speech, Physical and Occupational Therapy combined. If you need help recovering or have other special health needs Habilitation services Skilled nursing care Coverage is limited to 120 visits. Pre-authorization required for out-of-network care. Failure to preauthorize will result in 40% coinsurance Durable medical equipment If your child needs dental or eye care Hospice service Eye exam Glasses Dental check-up Pre-authorization required for out-of-network care. Failure to pre-authorize will result in 40% coinsurance Page 6 of 10

7 Excluded Services & Other Covered Services: Coverage for: Individual+ Family Plan Type: PPO Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture Glasses Routine eye care (Adult & Child) Cosmetic surgery Weight loss programs Routine foot care Dental care (Adult & Child) Long-term care 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.) Infertility treatment (Diagnosis and treatment of Hearing aids (Limited to $900 per ear every 3 Private-duty nursing (Limited to 70 shifts per calendar underlying cause) calendar years) year) Chiropractic care (Limited to 30 visits per Bariatric surgery Non-emergency care when traveling outside the U.S. calendar year) 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 or the U.S. Department of Health and Human Services at x61565 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 does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum. 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: Aetna at ; for prescription drug coverage contact: CVS Caremark at , or the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Additionally, a consumer assistance program can help you file an appeal. Contact information is at Page 7 of 10

8 Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 如果需要中文的帮助, 请拨打这个号码 Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page. Page 8 of 10

9 Coverage Examples Open Choice Consumer Driven Health Plan 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. Having a baby (normal delivery) Coverage Period: 01/01/ /31/2017 Amount owed to providers: $7,540 Amount owed to providers: Plan pays: $3,390 Plan pays: $1,640 Patient pays: $4,150 Patient pays: $3,760 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Total $2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540 Patient pays: Deductibles $3,400 Copays $20 Coinsurance $580 Limits or exclusions $150 Total $4,150 Note: You receive an annual contribution of up to $2,400 to a health savings account (HSA) or Health Reimbursement Account (HRA) that can be used to help pay your costs. Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total Managing type 2 diabetes (routine maintenance of a well-controlled condition) $5,400 $2,900 $1,300 $700 $300 $100 $100 $5,400 Patient pays: Deductibles $3,400 Copays $180 Coinsurance $100 Limits or exclusions $80 Total $3,760 Note: Your plan may have both copays and coinsurance for covered services; if so, these examples use copays only. Your costs may be higher. Page 9 of 10

10 Coverage Examples Open Choice Consumer Driven Health Plan Coverage Period: 01/01/ /31/2017 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 services and treatments started and ended in the same coverage 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 for 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. Page 10 of 10