2016 SUMMARIES OF MEDICAL BENEFITS AND COVERAGE GLOSSARY OF HEALTH COVERAGE AND MEDICAL TERMS

Transcription

1 2016 SUMMARIES OF MEDICAL BENEFITS AND COVERAGE GLOSSARY OF HEALTH COVERAGE AND MEDICAL TERMS

2 University of Chicago Colleagues: The University of Chicago is required under Health Care Reform to provide a summary of benefits and coverage (or SBC ) for each medical plan offered and a list of definitions designed to make it easier for you to compare your medical options. You are receiving this booklet because you are a current employee of the University and currently participating in, or eligible to participate in, the University of Chicago s medical plans. This information is provided to help you understand and evaluate your medical choices. The following SBCs summarize important information about all your medical plan options to help you compare your choices before you enroll and understand your coverage after you enroll. They summarize the key features of the medical plans, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. The Glossary of Terms defines some of the most common medical and insurance terms. An example showing how deductibles, co-insurance, and out-of-pocket limits work together in a real life situation is also included. This is only a summary. If you want more details about your coverage and costs, you can get the complete terms in the policy or plan document by contacting each medical plan provider: Maroon Plan: bcbsil.com Maroon Savings Choice: bcbsil.com HMO Illinois: bcbsil.com Humana: humana.com UCHP: uchp.uchicago.edu If you need assistance choosing a medical plan, you may visit decisionsupportsuite.com/uchicago16. Simply answer a few questions about your benefit needs. Then in just a few minutes, The Choice is Yours will suggest the medical plan that is right for you based on your responses. Please contact a Benefit Specialist at or benefits@uchicago.edu if you have any questions about this information. Sincerely, Michael F. Knitter Interim Associate Vice President Human Resources The University of Chicago

3 The University of Chicago: Maroon Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All 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 Important Questions Answers Why this Matters: For The University of Chicago Medical Center $250 Individual/$600 Family You must pay all the costs up to the deductible amount before this plan begins to pay What is the overall For PPO and Non-PPO for covered services you use. Check your policy or plan document to see when the deductible? $400 Individual/$900 Family deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Doesn't apply to certain preventative care. Are there other deductibles for specific services? Is there an out-ofpocket limit on my expenses? What is not included in the out-of-pocket limit? 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? Yes. $200 deductible for Non-PPO hospital admission. There are no other specific deductibles For The University of Chicago Medical Center $1,500 Individual/$3,000 Family Yes. For PPO and Non-PPO $2,250 Individual/$4,500 Family Prescription copay, premiums, balanced-billed charges, and health care this plan doesn t cover. Yes. Visit or call for a list of PPO providers. No. Yes. 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. 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. 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 4. See your policy or plan document for additional information about excluded services. 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 copy. SBC IL Non-HMO LG of 9

4 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 PPO 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 Primary care visit to treat an injury or illness Your Cost If You Use an University of Chicago Medical Center Your Cost If You Use a PPO Your Cost If You Use a Non-PPO 10% coinsurance 20% coinsurance 35% coinsurance ---none--- Specialist visit 10% coinsurance 20% coinsurance 35% coinsurance ---none--- Limitations & Exceptions Other practitioner office visit 10% coinsurance 20% coinsurance 35% coinsurance Limited to 20 visits per condition; muscle manipulations subject to medical necessity review after 20 visits Preventive care/screening/immunization No Charge No Charge No Charge ---none--- Diagnostic test (x-ray, blood work) 10% coinsurance 20% coinsurance 35% coinsurance ---none--- Imaging (CT/PET scans, MRIs) 10% coinsurance 20% coinsurance 35% coinsurance ---none--- 2 of 9

5 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at or Services You May Need Generic drugs Formulary brand drugs Non-Formulary brand drugs Your Cost If You Use an University of Chicago Medical Center $8 copay/ prescription for up to a 30 day supply. $16 copay/ prescription for up to a 90 day supply. $25 copay/ prescription for up to a 30 day supply. $50 copay/ prescription for up to a 90 day supply. $45 copay/ prescription for up to a 30 day supply. $90 copay/ prescription for up to a 90 day supply. Your Cost If You Use a PPO $8 copay/ prescription for up to a 30 day supply. $16 copay/ prescription for up to a 90 day supply. $25 copay/ prescription for up to a 30 day supply. $50 copay/ prescription for up to a 90 day supply. $45 copay/ prescription for up to a 30 day supply. $90 copay/ prescription for up to a 90 day supply. Your Cost If You Use a Non-PPO $8 copay/ prescription for up to a 30 day supply. $16 copay/ prescription for up to a 90 day supply $25 copay/ prescription for up to a 30 day supply. $50 copay/ prescription for up to a 90 day supply. $45 copay/ prescription for up to a 30 day supply. $90 copay/ prescription for up to a 90 day supply. Limitations & Exceptions RX Out-of-Pocket Expense Limit: $2,000 Individual/$4,000 Family Dispensing limits may apply to certain drugs. Dispensing limits may apply to certain drugs. Dispensing limits may apply to certain drugs. Specialty drugs Covered Covered Covered Coverage based on group policy. Prior authorization may be required. 3 of 9

6 Common Medical Event 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 Facility fee (e.g., ambulatory surgery center) Your Cost If You Use an University of Chicago Medical Center Your Cost If You Use a PPO Your Cost If You Use a Non-PPO 10% coinsurance 20% coinsurance 35% coinsurance ---none--- Physician/surgeon fees 10% coinsurance 20% coinsurance 35% coinsurance ---none--- Limitations & Exceptions Emergency room services 10% coinsurance 20% coinsurance 20% coinsurance ---none--- Emergency medical Limited to local ground or air 20% coinsurance 20% coinsurance 20% coinsurance transportation transportation. Urgent care 10% coinsurance 20% coinsurance 35% coinsurance ---none--- Facility fee (e.g., hospital room) 10% coinsurance 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers. Physician/surgeon fee 10% coinsurance 20% coinsurance 35% coinsurance ---none--- Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services 10% coinsurance 20% coinsurance 35% coinsurance ---none--- 10% coinsurance 20% coinsurance 35% coinsurance 10% coinsurance 20% coinsurance 35% coinsurance ---none--- 10% coinsurance 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers. $200 deductible per admission for Non-PPO providers. 4 of 9

7 Common Medical Event If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use an University of Chicago Medical Center Your Cost If You Use a PPO Your Cost If You Use a Non-PPO Limitations & Exceptions Prenatal and postnatal care No Charge 20% coinsurance 35% coinsurance Covered at 100% after deductible at UCMC. Covered at 100% after Delivery and all inpatient deductible at UCMC. $200 No Charge 20% coinsurance 35% coinsurance services deductible per admission for Non-PPO providers. Home health care 10% coinsurance 20% coinsurance 35% coinsurance Limited to 120 visits per benefit period; precertification required. Rehabilitation services 10% coinsurance 20% coinsurance 35% coinsurance Limited to 20 visits per Habilitation services 10% coinsurance 20% coinsurance 35% coinsurance condition; subject to medical necessity review after 20 visits. Skilled nursing care 10% coinsurance 20% coinsurance 35% coinsurance Limited to 120 days per benefit period; precertification required. Benefits are limited to items used to serve a medical purpose. Durable medical equipment 10% coinsurance 20% coinsurance 35% coinsurance DME benefits are provided for both purchase and rental equipment (up to the purchase price). Hospice service 10% coinsurance 20% coinsurance 35% coinsurance ---none--- Eye exam Not Covered Not Covered Not Covered ---none--- Glasses Not Covered Not Covered Not Covered ---none--- Dental check-up Not Covered Not Covered Not Covered ---none--- 5 of 9

8 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 Cosmetic Surgery Dental Care (Adult) Hearing Aids Long Term Care Routine Eye Care (Adult) Routine Foot Care (with the exception of person with diagnosis of diabetes) 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 Chiropractic Care Infertility Treatment Most coverage provided outside the United States. See Non-Emergency Care When Traveling Outside the U.S. Private Duty Nursing (with the exception of inpatient private duty nursing) 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 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 Blue Cross and Blue Shield of Illinois at or visit or contact the U.S Department of Labor's Employee Benefits Security Administration at EBSA (3272) or visit Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) or visit 6 of 9

9 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: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (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 Navajo (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. 7 of 9

10 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 $5,610 Patient pays $1,930 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 $400 Copays $10 Coinsurance $1,370 Limits or exclusions $150 Total $1,930 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,200 Patient pays $1,200 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 $400 Copays $320 Coinsurance $400 Limits or exclusions $80 Total $1,200 Note: These examples are based on individual coverage only. 8 of 9

11 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 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-ofpocket 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 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 copy. SBC IL Non-HMO LG of 9

12 The University of Chicago: Maroon Savings Choice HSA Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All Plan Type: HSA 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 services? Is there an out-ofpocket limit on my expenses? What is not included in the out-of-pocket limit? 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? For PPO $2,000 Individual/ $4,000 Family For Non-PPO $4,000 Individual/ $8,000 Family Doesn't apply to certain preventative care. Yes. $200 deductible for Non-PPO hospital admission. There are no other specific deductibles Yes. For PPO $3,000 Individual/ $6,000 Family For Non-PPO $6,000 Individual/ $12,000 Family Premiums, balanced-billed charges, and health care this plan doesn t cover. Yes. Visit or call for a list of PPO providers. No. Yes. 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 1 st ). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. 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. 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. 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. 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 copy. SBC IL Non-HMO LG of 8

13 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 PPO 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 Your Cost If You Use an PPO Your Cost If You Use an Non-PPO Primary care visit to treat an injury or illness 20% coinsurance 35% coinsurance ---none--- Specialist visit 20% coinsurance 35% coinsurance ---none--- Limitations & Exceptions Other practitioner office visit 20% coinsurance 35% coinsurance Limited to 20 visits per condition; muscle manipulations subject to medical necessity review after 20 visits. Preventive care/screening/immunization No Charge No Charge ---none--- Diagnostic test (x-ray, blood work) 20% coinsurance 35% coinsurance ---none--- Imaging (CT/PET scans, MRIs) 20% coinsurance 35% coinsurance ---none--- 2 of 8

14 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at caremark.com Services You May Need Generic drugs Formulary brand drugs Non-Formulary brand drugs Your Cost If You Use an PPO $8 copay/ prescription for up to a 30 day supply. $16 copay/ prescription for up to a 90 day supply. $25 copay/ prescription for up to a 30 day supply. $50 copay/ prescription for up to a 90 day supply. $45 copay/ prescription for up to a 30 day supply. $90 copay/ prescription for up to a 90 day supply. Specialty drugs Covered Covered Your Cost If You Use an Non-PPO $8 copay/ prescription for up to a 30 day supply. $16 copay/ prescription for up to a 90 day supply. $25 copay/ prescription for up to a 30 day supply. $50 copay/ prescription for up to a 90 day supply. $45 copay/ prescription for up to a 30 day supply. $90 copay/ prescription for up to a 90 day supply. Limitations & Exceptions RX Out-of-Pocket Expense Limit $3,000 Individual/ $6,000 Family combined with medical. Copay for Preventative Drugs before and after Deductible is met. Copay for Non-Preventative Drurgs only after Deductible is met. Dispensing limits may apply to certain drugs. Copay for Preventative Drugs before and after Deductible is met. Copay for Non-Preventative Drurgs only after Deductible is met. Dispensing limits may apply to certain drugs. Copay for Preventative Drugs before and after Deductible is met. Copay for Non-Preventative Drurgs only after Deductible is met. Dispensing limits may apply to certain drugs. Coverage based on group policy. Prior authorization may be required. If you have outpatient surgery If you need immediate medical attention Facility fee (e.g., ambulatory surgery center) 20% coinsurance 35% coinsurance ---none--- Physician/surgeon fees 20% coinsurance 35% coinsurance ---none--- Emergency room services 20% coinsurance 20% coinsurance ---none--- Emergency medical transportation 20% coinsurance 20% coinsurance Limited to local ground or air transportation. 3 of 8

15 Common Medical Event If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use an PPO Your Cost If You Use an Non-PPO Urgent care 20% coinsurance 35% coinsurance ---none--- Limitations & Exceptions Facility fee (e.g., hospital room) 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers. Physician/surgeon fee 20% coinsurance 35% coinsurance ---none--- Mental/Behavioral health outpatient services 20% coinsurance 35% coinsurance ---none--- Mental/Behavioral health inpatient services 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers. Substance use disorder outpatient services 20% coinsurance 35% coinsurance ---none--- Substance use disorder inpatient services 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers. Prenatal and postnatal care 20% coinsurance 35% coinsurance ---none--- Delivery and all inpatient services 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers. Home health care No Charge No Charge Limited to 120 visits per benefit period; precertification required. Rehabilitation services 20% coinsurance 35% coinsurance Limited to 20 visits per condition; Habilitation services 20% coinsurance 35% coinsurance subject to medical necessity review after 20 visits. Skilled nursing care No Charge No Charge Limited to 120 days per benefit period; precertification required. Benefits are limited to items used to serve a medical purpose. DME Durable medical equipment 20% coinsurance 35% coinsurance benefits are provided for both purchase and rental equipment (up to the purchase price). Hospice service No Charge No Charge ---none--- Eye exam Not Covered Not Covered ---none--- Glasses Not Covered Not Covered ---none--- Dental check-up Not Covered Not Covered ---none--- 4 of 8

16 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 Cosmetic Surgery Dental Care (Adult) Hearing Aids Long Term Care Routine Eye Care (Adult) Routine Foot Care (with the exception of person with diagnosis of diabetes) 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 Chiropractic Care Infertility Treatment Most coverage provided outside the United States. See Non-Emergency Care When Traveling Outside the U.S. Private Duty Nursing (with the exception of inpatient private duty nursing) 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 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 Blue Cross and Blue Shield of Illinois at or visit or contact the U.S Department of Labor's Employee Benefits Security Administration at EBSA (3272) or visit Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) or visit 5 of 8

17 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: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (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 Navajo (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

18 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 $4,390 Patient pays $3,150 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 $2,000 Copays $0 Coinsurance $1,000 Limits or exclusions $150 Total $3,150 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $2,920 Patient pays $2,480 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 $2,000 Copays $320 Coinsurance $80 Limits or exclusions $80 Total $2,480 Note: These examples are based on individual coverage only. 7 of 8

19 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 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-ofpocket 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 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 copy. SBC IL Non-HMO LG of 8

20 The University of Chicago HMOI: Blue Cross and Blue Shield of Illinois Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL Plan Type: HMO 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 services? $0 See the chart starting on page 2 for your costs for services this plan covers. 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. Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? 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? Yes. $1,500 Individual/$3,000 Family. Prescription drug expense limit: $5,100 Individual/ $10,200 Family Premiums, balanced-billed charges, and health care this plan doesn t cover. Yes. Visit or call for a list of Participating providers. Yes. Yes. 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. 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. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission before you see the specialist. 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. 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 copy. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL HMO LG of 8

21 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 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 Services You May Need Your Cost If You Use a Participating Primary care visit to treat an injury or illness $20 copay/visit Your Cost If You Use a Non-Participating Not Covered Limitations & Exceptions Specialist visit $40 copay/visit Not Covered Referral required. Other practitioner office visit $20 copay/visit Not Covered Referral required. Services or supplies that are not ordered by your Primary Care Physician or Women s Principal Health Care, except emergency and routine vision exams, are not covered. Preventive care/screening/immunization No Charge Not Covered ---none--- If you have a test Diagnostic test (x-ray, blood work) No Charge Not Covered Referral required. Imaging (CT/PET scans, MRIs) No Charge Not Covered Referral required. 2 of 8

22 Common Medical Event Services You May Need Your Cost If You Use a Participating Your Cost If You Use a Non-Participating Limitations & Exceptions If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Generic drugs Formulary brand drugs Non-Formulary brand drugs $8 copay / prescription for up to a 34 day supply. $16 copay / prescription for up to a 90 day supply. $25 copay / prescription for up to a 34 day supply. $50 copay / prescription for up to a 90 day supply. $45 copay / prescription for up to a 34 day supply. $90 copay / prescription for up to a 90 day supply. Not Covered Not Covered Not Covered Dispensing limit may apply to certain drugs. Certain women s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. 34 day retail / 90 day mail. RX Out-of-Pocket Expense Limit: $5,100 Individual/ $10,200 Family If you have outpatient surgery If you need immediate medical attention Specialty drugs Covered Not Covered Facility fee (e.g., ambulatory surgery center) No Charge Not Covered Referral required. Physician/surgeon fees No Charge Not Covered Referral required. Coverage based on group policy. Prior authorization may be required. Emergency room services $100 copay/visit $100 copay/visit Copay waived if admitted. Emergency medical transportation No Charge No Charge Ground transportation only. Urgent care $20 copay/visit Not Covered Must be affiliated with member s chosen medical group or referral required. 3 of 8

23 Common Medical Event If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need Facility fee (e.g., hospital room) Your Cost If You Use a Participating $300 copay/ admission Your Cost If You Use a Non-Participating Not Covered Limitations & Exceptions Referral required. Physician/surgeon fee No Charge Not Covered Referral required. Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services $20 copay/visit Not Covered $300 copay/ admission Not Covered Substance use disorder outpatient services $20 copay/visit Not Covered Substance use disorder inpatient services $300 copay/ admission Not Covered Unlimited visits. Referral required. Unlimited days. Referral required. Use a plan provider only. Referral required. Unlimited days. Referral required. Prenatal and postnatal care $20 copay Not Covered Copay applies for the 1 st prenatal visit only. Delivery and all inpatient services $300 copay/ admission Not Covered ---none--- Home health care No Charge Not Covered Referral required. Rehabilitation services $20 copay/visit Not Covered 60 treatments combined for all therapies. Habilitation services $20 copay/visit Not Covered Skilled nursing care $300 copay/ admission Not Covered Durable medical equipment No Charge Not Covered Hospice service No Charge Not Covered Referral required. Excludes custodial care. Referral required. Referral required. Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). Inpatient copay may apply. Referral required. 4 of 8

24 Common Medical Event If your child needs dental or eye care Services You May Need Your Cost If You Use a Participating Your Cost If You Use a Non-Participating Eye exam No Charge Not Covered Glasses Covered Not Covered Dental check-up Not Covered Not Covered ---none--- Limitations & Exceptions Limited to one exam every 12 months at participating providers. $75 allowance once every 24 months at participating providers. 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.) Cosmetic Surgery Custodial Care Dental Care (Adult) Hearing Aids Long-Term Care Non-Emergency Care When Traveling Outside the U.S. Private-Duty Nursing Routine Foot Care (with the exception of person with diagnosis of diabetes) 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.) Acupuncture Bariatric Surgery Chiropractic Care Infertility Treatment Most coverage provided outside the United States. See Routine Eye Care (Adult) Weight Loss Programs (except when nonmedically supervised) 5 of 8

25 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 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 Blue Cross and Blue Shield of Illinois at or visit or contact the U.S Department of Labor's Employee Benefits Security Administration at EBSA (3272) or visit Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) or visit 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: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (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 Navajo (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

26 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 $6,780 Patient pays $760 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 $610 Coinsurance $0 Limits or exclusions $150 Total $760 Managing Type 2 Diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,800 Patient pays $600 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 $520 Coinsurance $0 Limits or exclusions $80 Total $600 7 of 8

27 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 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-ofpocket 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 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 copy. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL HMO LG of 8

28 Humana, Inc.: University of Chicago IL Platinum HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/ /31/2016 Coverage for: Individual + Family Plan Type: HMO 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 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? $0 person / $0 family No Yes, for participating providers $1,500 person / $3,000 family Premiums, balance-billed charges, Rx, vision care, and health care this plan doesn t cover. No Yes. See or call for a list of Network providers. Yes. Yes. See the chart starting on page 2 for your costs for services this plan covers. 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 medical plan 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. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission before you see the specialist. 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. 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 copy. 1 of 8

29 Humana, Inc.: University of Chicago IL Platinum HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/ /31/2016 Coverage for: Individual + Family Plan Type: HMO 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. Common Medical Event If you visit a health care 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) Your Cost If You Use an In-network Your Cost If You Use an Out-of-network Limitations & Exceptions $20 copay/visit Not covered none $40 copay/visit $40 copay/visit No charge No charge No charge Not covered Not covered Not covered Not covered Not covered Primary Care Physician s referral is required none none Primary Care Physician s referral is required. 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 copy. 2 of 8

30 Humana, Inc.: University of Chicago IL Platinum HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/ /31/2016 Coverage for: Individual + Family Plan Type: HMO 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 Generic drug Preferred brand drugs Non-preferred brand drugs Your Cost If You Use an In-network $8 copay retail $16 copay mail $25 copay retail $50 copay mail $45 copay retail $90 copay mail Your Cost If You Use an Out-of-network Drug copay plus 30% coinsurance for retail prescriptions. Mail order prescriptions not covered. Limitations & Exceptions Retail prescription covers up to a 30-day supply. Mail order prescription covers up to a 90-day supply. Specialty Drugs Included above Prior authorization required. Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee No charge No charge $100 copay/visit No charge $100 copay/visit $300 copay/admit No Charge Not covered Not covered $100 copay/ visit No charge Not covered Not Covered Not Covered Primary Care Physician s referral is required. Non-emergent emergency room visits are not covered none Primary Care Physician s referral is required. Primary Care Physician s referral is required none 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 copy. 3 of 8

31 Humana, Inc.: University of Chicago IL Platinum HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/ /31/2016 Coverage for: Individual + Family Plan Type: HMO Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services Your Cost If You Use an In-network Your Cost If You Use an Out-of-network Limitations & Exceptions $20 copay/visit Not covered none $300 copay/admit Preauthorization required. $40 copay/visit Not covered none $300 copay/admit $40 copay, first visit only $300 copay/admit Not covered Not covered Not covered Not Covered Preauthorization required. Member can self-refer to OB/GYN in the Primary Care Physician s affiliated group. Primary Care Physician notification is recommended. Home health care No charge Not covered Maximum 60 days per calendar Rehabilitation services No charge Not covered year; Primary Care Physician s Habilitation services No charge Not covered referral is required. Skilled nursing care No charge Not covered Maximum 100 days per calendar Durable medical equipment No charge Not covered year; Primary Care Physician s referral is required. Hospice service No charge Not covered Maximum 180 days per calendar year; Primary Care Physician s referral is required. Eye exam $10 copay Not covered $100 allowance plus When services are rendered by an Glasses 20% discount off Not covered EyeMed participating provider. balance over $100 Dental check-up Not covered Not covered none 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 copy. 4 of 8

32 Humana, Inc.: University of Chicago IL Platinum HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/ /31/2016 Coverage for: Individual + Family Plan Type: HMO 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 Cosmetic Surgery Dental care Hearing Aids Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine eye care (refer to coverage with EyeMed providers under vision rider) 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.) Autism Spectrum Disorder Diabetic testing and supplies Tobacco cessation Bariatric surgery Infertility Vision care with EyeMed providers Chiropractic care when medically necessary Routine foot care for diabetes Wigs for cancer patients 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 copy. 5 of 8

33 Humana, Inc.: University of Chicago IL Platinum HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/ /31/2016 Coverage for: Individual + Family Plan Type: HMO 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 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: Humana Insurance Company P.O. Box Lexington, KY 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: Spanish (Español): Para obtener asistencia en Español, llame al ASSIST To see examples of how this plan might cover costs for a sample medical situation, see the next page. 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 copy. 6 of 8

34 Humana, Inc.: University of Chicago IL Platinum HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/ /31/2016 Coverage for: Individual + Family Plan Type: HMO 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 $7,190 Patient pays $350 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 $350 Coinsurance $0 Limits or exclusions $0 Total $350 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $5,140 Patient pays $260 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 $260 Coinsurance $0 Limits or exclusions $0 Total $260 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 copy. 7 of 8