EssentialCare. PLAN HIGHLIGHTS. $0 co-pay for preventive care, screenings, and immunizations. No referral needed to see specialist.
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1 EssentialCare. PLAN HIGHLIGHTS $0 co-pay for preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat DoctorsTM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. ESSENTIALCARE is our standard plan offering, aligning with state and federal requirements for deductibles, co-pays, and other benefits, allowing consumers to compare EssentialCare apples to apples with plans from other insurers. Highlights of the EssentialCare plan include set hospital co-pays and low co-pays for visits to specialists. HRINY_CM09_PO.EC_091614
2 EssentialCare. Deductibles and Maximums Platinum Gold Silver Deductible (Single/Family) $0 $600/$1,200 $2,000/$4,000 Max Out of Pocket Limit (Single/Family) $2,000/$4,000 $4,000/$8,000 $5,500/$11,000 High Deductible Plans Bronze Catastrophic* HSA Qualified Yes No Deductible (Single/Family) $3,000/$6,000 $6,600/$13,200 Max Out of Pocket Limit (Single-Incl. Deductible) $6,350/$12,700 $6,600/$13,200 Cost Sharing (All Parameters) 50% 50% Prescription Drugs (After Deductible) $10/$35/$70 0% *Individual Only Cost Sharing-Medical Services After deductible is met Platinum Gold Silver PCP $15 $25 $30 Specialist $35 $40 $50 PT/OT/ST-rehabilitative and habilitative therapies $25 $30 $30 Inpatient/SNF/Hospice-Facility (Per Admission) $500 $1,000 $1,500 Outpatient-Facility $100 $100 $100 Surgeon (Inpatient, Outpatient) $100 $100 $100 ER $100 $150 $150 Ambulance $100 $150 $150 Urgent Care $55 $60 $70 DME/Medical Supplies 10% 20% 30% Outpatient Services After deductible is met Platinum Gold Silver Diagnostic and Routine Lab and Pathology $35 $40 $50 Diagnostic and Routine Imaging $35 $40 $50 Chemotherapy $15 $25 $30 Radiation Therapy $15 $25 $30 Dialysis $15 $25 $30 Mental/Behavioral Healthcare $15 $25 $30 Substance Abuse Disorder Services $15 $25 $30 Home Health Care $15 $25 $30 Hospice $15 $25 $30 Prescription Drugs Platinum Gold Silver Tier I (Selected Generics) $10 $10 $10 Tier II (Other Generics) $30 $35 $35 Tier III (Brand and Specialty) $60 $70 $70 HEALTH REPUBLIC INSURANCE OF NEW YORK 30 Broad St., New York, NY HealthRepublicNY.org
3 PrimarySelect. PLAN HIGHLIGHTS $0 co-pay for visits to a designated primary care physician, even before the deductible is met. $0 co-pay for preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat DoctorsTM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. Health Republic s signature program, PRIMARYSELECT, emphasizes the role of a primary care physician in our members health. After selecting a primary care physician, visits to him or her are free of charge. With low deductibles and $0 copay for selected generics, PrimarySelect is a popular choice among many New Yorkers. HRINY_CM09_PO.PS_091614_REV
4 PrimarySelect. Deductibles and Maximums Platinum Gold Silver Bronze* Deductible (Single/Family) $0 $250/$500 $2,000/$4,000 $5,500/$11,000 Max Out of Pocket (Single/Family) $1,400/$2,800 $3,500/$7,000 $6,350/$12,700 $6,350/$12,700 Cost Sharing (Co-Insurance) 20% 20% 20% 20% Cost Sharing-Medical Services Platinum Gold Silver Bronze* Primary Care (Member Selected) $0 $0 $0 $75 Specialist $75 $75 $75 $75 PT/OT/ST (Co-Pay after Deductible) $30 $30 $30 $75 Inpatient/SNF/Hospice-Facility (Per Admission) Physician/Surgeon Fee (Inpatient) (Co-Pay after Deductible) Outpatient-Facility Surgeon (Outpatient) $100 $150 $150 Individual $100 Group $150 ER (Co-Pay after Deductible is Met) $250 $250 $250 $300 Ambulance (Co-Pay after Deductible is Met) $100 $150 $150 $150 Urgent Care (Co-Pay after Deductible is Met) $100 $100 $100 $100 Outpatient Services Platinum Gold Silver Bronze* Diagnostic and Routine Lab and Pathology $75 $75 $75 $75 Diagnostic and Routine Imaging $75 $75 $75 $75 Mental/Behavioral Healthcare (Selected) $0 $0 $0 $75 Diabetic Care and Supplies $0 $0 $0 $0 Chemotherapy $15 $25 $30 $75 Radiation Therapy $75 Individual $15 Group $75 Individual $25 Group $75 Individual $30 Group Dialysis $15 $25 $30 $75 Home Healthcare (After Deductible) $15 $25 $30 $75 $75 Prescription Drugs Platinum Gold Silver Bronze* Tier I (Selected Generics) Tier II (Other Generics) (After Deductible) Tier III (Brand and Specialty) (After Deductible) $0 Individual $0 Group $30 Individual $35 Group $60 Individual $70 Group $10 Individual $0 Group $10 Individual $0 Group $10 $35 $35 $35 $70 $70 $70 *Individual Only HEALTH REPUBLIC INSURANCE OF NEW YORK 30 Broad St., New York, NY HealthRepublicNY.org
5 PrimarySelect PCMH. Available in the following counties: Bronx, Essex, Hamilton, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk, Westchester. PLAN HIGHLIGHTS $0 co-pay for visits to a designated PCMH primary care physician. $0 co-pay for preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat DoctorsTM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. Similar to PrimarySelect, PRIMARYSELECT PCMH focuses on comprehensive patient care with a specialized network of patient-centered medical homes certified by the National Committee for Quality Assurance (NCQA). Only available at the Silver level, PrimarySelect PCMH is a costfriendly option for those looking to get the most out of their health plan. HRINY_CM09_PO.PSPCMH_091614_REV
6 PrimarySelect PCMH. Deductibles and Maximums Silver Deductible (Single/Family) $2,000/$4,000 Max Out of Pocket (Single/Family) $6,350/$12,700 Cost Sharing (Co-Insurance) 20% Cost Sharing-Medical Services Silver Primary Care (Member Selected) $0 Other Primary Care $30 Specialist $75 PT/OT/ST (Co-Pay after Deductible is Met) $30 Inpatient/SNF/Hospice-Facility (Per Admission) Physician/Surgeon Fee (Inpatient) (Co-Pay after Deductible) Outpatient-Facility Surgeon (Outpatient) $150 Individual/$100 Group ER (Co-Pay after Deductible is Met) $250 Ambulance (Co-Pay after Deductible is Met) $150 Urgent Care (Co-Pay after Deductible is Met) $100 Outpatient Services Silver Diagnostic and Routine Lab and Pathology $75 Diagnostic and Routine Imaging $75 Mental/Behavioral Healthcare (Selected) $0 Diabetic Care and Supplies $0 Chemotherapy $30 Radiation Therapy $75 Individual $30 Group Dialysis $30 Home Healthcare (After Deductible) $30 Prescription Drugs Tier I (Selected Generics) Silver $10 Individual $0 Group Tier II (Other Generics) (After Deductible) $35 Tier III (Brand and Specialty) (After Deductible) $70 HEALTH REPUBLIC INSURANCE OF NEW YORK 30 Broad St., New York, NY HealthRepublicNY.org
7 TotalIndependence. PLAN HIGHLIGHTS The bronze and silver levels offer 2 free visits to a selected primary care physician, even before the deductible is met. The gold level offers 3 free visits to a selected primary care physician, even before the deductible is met. $0 co-pay for in-network preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat DoctorsTM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. TOTALINDEPENDENCE, available to individuals on and off the exchange, is a simplified plan for the next generation of healthcare. This plan offers members the comfort of high-quality healthcare when it s needed, and total independence to achieve their goals. HRINY_CM09_PO.TI_091614_REV
8 TotalIndependence. Deductibles and Maximums Gold Silver Bronze Deductible (Single/Family) $1,950/$3,900 $3,800/$7,600 $6,000/$12,000 Max Out of Pocket Limit (Single/Family) $2,500/$5,000 $4,300/$8,600 $6,500/$13,000 Cost Sharing (Co-Insurance) 50% 50% 50% Cost Sharing-Medical Services Gold Silver Bronze Primary Care (Member Selected) 3 Free 2 Free 2 Free Other Primary Care $0 after deductible $0 after deductible $0 after deductible Specialist $0 after deductible $0 after deductible $0 after deductible PT/OT/ST $0 after deductible $0 after deductible $0 after deductible Inpatient/SNF/Hospice-Facility (Per Admission) $0 after deductible $0 after deductible $0 after deductible Physician/Surgeon Fee (Inpatient) $0 after deductible $0 after deductible $0 after deductible Outpatient-Facility $0 after deductible $0 after deductible $0 after deductible Surgeon (Outpatient) $0 after deductible $0 after deductible $0 after deductible ER $250 $250 $0 after deductible Ambulance $250 $250 $0 after deductible Urgent Care $50 $75 $75 Outpatient Services Gold Silver Bronze Diagnostic and Routine Lab and Pathology $20 $20 $0 after deductible Diagnostic and Routine Imaging $0 after deductible $0 after deductible $0 after deductible Mental/Behavioral Healthcare (Selected) $0 after deductible $0 after deductible $0 after deductible Diabetic Care and Supplies $0 after deductible $0 after deductible $0 after deductible Chemotherapy $0 after deductible $0 after deductible $0 after deductible Radiation Therapy $0 after deductible $0 after deductible $0 after deductible Dialysis $0 after deductible $0 after deductible $0 after deductible Home Health Care $0 after deductible $0 after deductible $0 after deductible Prescription Drugs Gold Silver Bronze Tier I (Selected Generics) $20 $20 $30 Tier II (Other Generics) (After Deductible) $0 after deductible $0 after deductible $0 after deductible Tier III (Brand and Specialty) (After Deductible) $0 after deductible $0 after deductible $0 after deductible HEALTH REPUBLIC INSURANCE OF NEW YORK 30 Broad St., New York, NY HealthRepublicNY.org
Quote Effective: 04/01/ /30/2019 Version Updated: 01/07/2019
Quote Effective: 04/01/2019-06/30/2019 Version Updated: 01/07/2019 Print Package: HIOS ID (Enrollment Code) 78124NY1000265-00 (SON5) Plan Name: Rating Region: Rate Rochester For the Benefits described
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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.avmed.org or by calling 1-800-376-6651. Important Questions
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Anthem BlueCross Classic PPO 250/20/20 / $10/$30/$50/30% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 10/01/2013-09/30/2014 Coverage For: Individual/Family Plan
CARING FOR YOUR SMALL BUSINESS. Off-Exchange 2018 Plans and Services for Groups With Up to 100 Employees
CARING FOR YOUR SMALL BUSINESS Off-Exchange 2018 Plans and Services for Groups With Up to 100 Employees SMALL GROUP PLANS AT A GLANCE EmblemHealth offers small group plans with the needs and budgets of
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Anthem BlueCross Lumenos HSA 1500 (80/50) Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 12/01/2013-11/30/2014 Coverage For: Individual/Family Plan Type:
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Anthem BlueCross Classic PPO 250/20/20 / $10/$30/$50/30% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage For: Individual/Family Plan
Companion Life Insurance Company: New England Culinary Institute Coverage Period: 7/1/14-7/1/15
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.chpstudent.com or by calling 1-800-633-7867. Important
Coverage for: All Coverage Tiers Plan Type: POS. 1 of 9
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.paramounthealthcare.com or by calling 1-800-462-3589.
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Anthem BlueCross BlueShield Blue Access PPO Option 14 / Rx Option AE Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage For: Individual/Family
Coverage for: Individual/Family 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 www.medica.com or by calling 1-855-469-6334. Important Questions
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Anthem BlueCross Value HMO 25/40/20% Select Plus HMO / $10/$30/$45/20% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage For: Individual/Family
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
Anthem BlueCross BlueShield Lumenos HSA Plus Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2013-01/01/2014 Coverage For: Individual/Family Plan Type: CDHP
$0 See the chart starting no 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.healthscopebenefits.com or by calling 1-800-398-0028.
Some of the services this plan doesn t cover are listed on page 6. See your policy or plan Yes. plan doesn t cover?
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.nslijcareconnect.com or by calling 1-855-706-7545. Important
TX Aetna Classic 5000
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.healthreformplansbc.com or by calling 855-632-6274. Important
Anthem Blue Cross CalPERS Exclusive Provider Organization EPO Monterey County Coverage Period: 01/01/ /31/2017
CalPERS Exclusive Organization EPO Monterey County 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.anthem.com/ca/calpers
Schedule of Benefits Phoenix Health Plans, Inc.
Your Policy gives You important information about Your health care benefits. It includes information such as Pre-Authorization requirements. This Schedule of Benefits is issued to You with Your Policy.
Health New England: HNE HMO Bronze A Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Health New England: HNE HMO Bronze A Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Coverage for: Individual + Family Plan Type: HDHP HMO This is only a summary.
Small Group HMO Coverage Period: Beginning on or after 05/01/2013
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.avmed.org. or by calling 1-800-376-6651. Important Questions
Affinity Health Plan: Essential Plan 2 AI/AN plus Dental/Vision 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 schedule of benefits at www.affinityplan.org/ep/member or by calling 1-866-247-5678.
$200 per member / $600 per family in-network. 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.anthem.com or by calling 1-866-627-0705. Important Questions
Nationwide Life Ins. Co.: Cape Cod Academy Coverage Period: 9/1/13-8/31/14
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.chpstudent.com or by calling 1-800-633-7867. Important
Anthem BlueCross BlueShield Blue Access PPO Option 10 / Rx Option 7 Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Anthem BlueCross BlueShield Blue Access PPO Option 10 / Rx Option 7 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 07/01/2015-0 /30/2016 Coverage For: Individual/Family
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
Anthem BlueCross BlueShield Lumenos HSA Plus Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2013-01/01/2014 Coverage For: Individual/Family Plan Type: CDHP
Scott & White Health Plan: ERS Coverage Period: 9/1/2015 8/31/2016 Summary of Benefits and Coverage:
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.ers.swhp.org or by calling (800) 321-7947, TTY (800)
Health Plan Benefits and Coverage Matrix
Health Plan Benefits and Coverage Matrix THIS MATRI IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR
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
Anthem BlueCross BlueShield Lumenos HSA Plus Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2013-01/01/2014 Coverage For: Individual/Family Plan Type: CDHP
Important Questions Answers Why this Matters:
Anthem BlueCross BlueShield Lumenos Health Savings Account POS 11 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 12/01/2013-11/30/2014 Coverage For: Individual/Family
Empire Blue Cross Blue Shield Your Plan: Empire Gold EPO 1000/10%/5000 Your Network: PPO/EPO
Empire Blue Cross Blue Shield Your Plan: Empire Gold EPO 1000/10%/5000 Your Network: PPO/EPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family
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 wwwmvphealthcarecom or by calling 1-888-687-6277 Important
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family
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 wwwmvphealthcarecom or by calling 1-877-742-4181 Important
$1,900 per individual $3,800 per family. Any other deductibles for specific services?
This is only a summary of your benefits. Always refer to the plan document for complete coverage and details. The plan document may be found in the Benefit Office or you may go online. IMPORTANT ANSWERS