Access Health CT 2019 Alternative Standard Silver Plan Design Exhibit Individual Market. Page
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1 Access Health CT 2019 Alternative Standard Silver Plan Design Exhibit Individual Market 1
2 Ind Market Silver Coinsurance Plan, 70% AV 2019 Individual Market Silver 70% Plan Medical Deductible $3,500 (2x family) $7,400 (2x family) Rx Deductible $250 (2x family) $500 (2x family) Coinsurance 30% 40% Out-of-pocket Maximum $7,900 (2x family) $15,800 (2x family) Primary Care 30% 40% (after Specialist Care Urgent Care Emergency Room 30% (after 30% (after in-network Ambulance 30% (after 30% (after in-network Inpatient Hospital Outpatient Hospital Advanced Radiology (CT/PET Scan, MRI) Laboratory Mammography Ultrasound maximum, separate for each type Diabetic Supplies & Equipment Durable Medical Equipment Home Health Care 2019 Individual Market Silver 70% Plan Preventive 0% 50% (after Basic Pediatric Vision: Routine Eye Exam by Specialist (one exam per 30% (after 50% (after 40% (after 50% (after 50% (after 50% (after 30% (after Not Covered All Other Medical 30% 40% (after $5 * / 30% / 30% / 30% ded., $200 max per spec AVC Results 2019 AVC Results 70.11% % 2
3 Ind Market Silver Coinsurance Plan, 73% AV 2019 Individual Market Silver 73% Plan Coinsurance Medical Deductible $2,600 (2x family) $7,400 (2x family) Rx Deductible $250 (2x family) $500 (2x family) Coinsurance 30% 40% Out-of-pocket Maximum $6,300 (2x family) $15,800 (2x family) Primary Care 30% 40% (after Specialist Care Urgent Care Emergency Room 30% (after 30% (after in-network Ambulance 30% (after 30% (after in-network Inpatient Hospital Outpatient Hospital Advanced Radiology (CT/PET Scan, MRI) Laboratory Mammography Ultrasound Diabetic Supplies & Equipment Durable Medical Equipment Home Health Care 2019 Individual Market Silver 73% Plan Preventive 0% 50% (after Basic Pediatric Vision: Routine Eye Exam by Specialist (one exam per 30% (after 50% (after 40% (after 50% (after 50% (after 50% (after 30% (after Not Covered All Other Medical 30% 40% (after $5 * / 30% / 30% / 30% ded., $100 max per spec AVC Results 2019 AVC Results 73.52% 3
4 Ind Market Silver Coinsurance Plan, 87% AV 2019 Individual Market Silver 87% Plan Coinsurance Medical Deductible $500 (2x family) $7,400 (2x family) Rx Deductible $50 (2x family) $500 (2x family) Coinsurance 20% 40% Out-of-pocket Maximum $2,300 (2x family) $15,800 (2x family) Primary Care 20% 40% (after Specialist Care 20% (after 40% (after Urgent Care 20% (after 40% (after Emergency Room 20% (after 20% (after in-network Ambulance 20% (after 20% (after in-network Inpatient Hospital 20% (after 40% (after Outpatient Hospital 20% (after 40% (after Advanced Radiology (CT/PET Scan, MRI) 20% (after 40% (after 20% (after 40% (after Laboratory 20% (after 40% (after Mammography Ultrasound 20% (after 40% (after 20% (after 40% (after 20% (after 40% (after Diabetic Supplies & Equipment 20% (after 40% (after Durable Medical Equipment 20% (after 40% (after Home Health Care 2019 Individual Market Silver 87% Plan Preventive 0% 50% (after Basic Pediatric Vision: Routine Eye Exam by Specialist (one exam per 30% (after 50% (after 40% (after 50% (after 50% (after 50% (after 20% (after Not Covered 20% (after 40% (after All Other Medical 20% 40% (after $5 * / 20% / 20% / 20% ded., $60 max per spec AVC Results 2019 AVC Results 87.52% 4
5 Ind Market Silver Coinsurance Plan, 94% AV 2019 Individual Market Silver 94% Plan Coinsurance Medical Deductible $0 $7,400 (2x family) Rx Deductible $0 $500 (2x family) Coinsurance 20% 40% Out-of-pocket Maximum $750 (2x family) $15,800 (2x family) Primary Care 20% 40% (after Specialist Care 20% 40% (after Urgent Care 20% 40% (after Emergency Room 20% 20% Ambulance 20% 20% Inpatient Hospital 20% 40% (after Outpatient Hospital 20% 40% (after Advanced Radiology (CT/PET Scan, MRI) 20% 40% (after 20% 40% (after Laboratory 20% 40% (after Mammography Ultrasound 20% 40% (after 20% 40% (after 20% 40% (after Diabetic Supplies & Equipment 20% 40% (after Durable Medical Equipment 20% 40% (after Home Health Care 2019 Individual Market Silver 94% Plan Preventive 0% 50% (after Basic Pediatric Vision: Routine Eye Exam by Specialist (one exam per 30% (after 50% (after 40% (after 50% (after 50% (after 50% (after 20% Not Covered 20% 40% (after All Other Medical 20% 40% (after $5 * / 20% / 20% / 20% ($60 max per spec AVC Results 2019 AVC Results 94.76% 5
2016 Plan HSA $6,000. $6,000 individual/$12,000 family. $6,000 individual/$12,000 family
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COSE MEWA : HRA W RX
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$0 See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific
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Important Questions Answers Why this Matters:
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Important Questions Answers Why this Matters:
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Important Questions Answers Why this Matters:
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You can see the specialist you choose without permission from this plan.
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$0 See the chart starting on page 2 for your costs for services this plan covers.
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$0 See the chart starting no page 2 for your costs for services this plan covers.
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Page 1 of 8 Printed on 1/28/2015
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Enhanced. Oakland University. Important Questions Answers Why this Matters:
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 www.hap.org or by calling 1-800-422-4641. Important Questions
Important Questions Answers Why this Matters: What is the overall deductible?
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 www.pibf.org or by calling 1-918-280-4800. Important Questions
Ambetter Silver 5 + Vision + Adult Dental Summary of Benefits and Coverage: What this Plan Covers & What it Costs
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 http://ambetter.magnolia healthplan.com/ or by calling 877-687-1187,
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$0 person/$0 family See the chart starting on page 2 for your costs for services this plan covers.
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 www.gpatpa.com or by calling 972-962-3686. Important Questions
Employee Assistance Program (EAP) counseling is provided at no cost to the employee, spouse or dependents.
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 by calling 1-906-225.3145. Important Questions Answers Why this
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Tier 1: $0/$0 Tier 2: $500/$1,500 Tier 3:$1,000/$3,000 Does not apply to preventive care. What is the overall deductible?
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 by contacting benefits@northside.com or by calling 1-404-851-8393.
Important Questions Answers Why this Matters: For in-network providers: $11,000 Individual $22,000 Family of 2 or more
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Important Questions Answers Why this Matters:
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 www.bsneny.com or by calling 1-855-344-3425. Important Questions
01/01/ /31/2018 CCH
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 CCH Healthcare: American Plan Administrators/Cigna Coverage for: Individual,
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?
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 www.centralpateamsters.com or by calling 1-800-422-8330 (PA)
this plan begins to pay. If you have other family members on the plan each family member deductible?
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning On or After 1/1/2018 Platinum 90 PPO Coverage for: Individual + Family Plan Type:
Important Questions Answers Why this Matters: What is the overall deductible?
This is only a summary. If you want more detail about your medical coverage and costs, you can get the complete terms in the policy or plan document at www.teamsters-hma.com or by calling 1-877-384-2875.
No You don t have to meet deductibles for specified services, but see the chart starting on page 2 for other costs for services this plan covers.
Molina Healthcare of Utah, Inc.: Molina Silver 150 Plan Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family
Important Questions Answers Why this Matters:
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 www.landoflincolnhealth.org or by calling 1-888-858-9130.
Important Questions Answers Why this Matters:
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 www.crystalrunhp.com or by calling 1-844-638-6506. Important
Health First Insurance : Large Group C2 PPO OOP 1500/80/60 w Co-pa
Health First Insurance : Large Group C2 PPO 3000 50 50 6350 OOP 1500/80/60 w Co-pa Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: On or after 01/01/2015 Coverage
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 through 12/31/2018
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 through 12/31/2018 Community Value HMO (Silver) - 94% CSR Coverage for: Individual
Highlights of your Health Care Coverage Washington Counties Insurance Fund
Highlights of your Health Care Coverage Washington Counties Insurance Fund Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible. Medical Benefits apply after
$ 0 Does not apply to Vision benefit. Important Questions Answers Why this Matters: What is the overall deductible?
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 www.vsp.com or by calling 1-800-877-7195. Important Questions