UnitedHealthcare: Choice Plus HRA Coverage Period: 01/01/ /31/2015 Summary of Benefits and Coverage

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1 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific 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? For participating providers $1,000 person / $2,000 family. For non-participating providers $2,000 person / $4,000 family. Doesn t apply to preventive care No. Yes. For participating providers $2,000 person / $4,000 family. For non-participating providers $4,000 person / $8,000 family Premiums, balance-billed charges, and health care this plan doesn t cover. No. Yes. See or call for a list of participating providers. No. You don t need a referral to see a specialist. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Member copayments do not accumulate towards the deductible. The deductible is calculated on a calendar year basis. See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. Only the hospital copay counts; and the annual deductible is included in the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered Be aware, your in-network doctor or hospital may use an out-of-network provider for some Plans use the term in-network, preferred, or participating for providers in their network. See the chart 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 at the end of page 5. See your policy or plan document for additional information about excluded 1 of 6

2 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service, after you have met your deductible. 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 If you have a test (nonpreventative care) If you need drugs to treat your illness or condition Please visit or call for more information about prescription drug coverage. Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/immunization Outpatient diagnostic test (x-ray, blood work, lab) Outpatient major diagnostic test (CT, PET, MRI and Nuclear Medicine) Tier 1 Tier 2 Tier 3 Your Cost If You Use a Participating Provider No charge Your Cost If You Use a Non-Participating Provider Limitations & Exceptions 30% coinsurance 30% coinsurance 30% coinsurance $10 copay/ $25 copay/ prescription (mail order). $30 copay/ $75 copay/ prescription (mail order). $50 copay/ $125 copay/ prescription (mail order). $10 copay/ $30 copay/ $50 copay/ Covers up to a 31-day supply for retail prescription and a 90-day supply for mail order prescription. Only certain prescription drugs are available through mail order. An ancillary charge may apply when a covered prescription drug is dispensed at your [or your provider s] request and there is another drug that is chemically the same available at a lower tier. 2 of 6

3 If you need an ambulance 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 If you have a neurobiological disorder mental health services for autism spectrum disorders Outpatient pharmaceutical products Emergency and non-emergency ambulance Physician/surgeon and facility fees (e.g., ambulatory surgery center) Emergency room services (outpatient) 30% coinsurance No charge after deductible has been met. No charge after participating provider deductible has been met. This includes medications administered in an outpatient setting, in the physician s office, and by a home health agency. Pre-service notification may be required. 30% coinsurance No charge after deductible has been met. *No charge after participating provider * Pre-service notification may be required. deductible has been met. See If you need an ambulance. Emergency medical transportation Urgent care 30% coinsurance Facility fee (e.g., hospital room) *30% coinsurance Physician/surgeon fee 30% coinsurance Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient Inpatient services Outpatient services per visit. per per visit. per per per visit. *30% coinsurance *30% coinsurance If you are pregnant Delivery and all inpatient Prenatal and postnatal care. Depending upon where the covered health service is provided, benefits will be the same as those stated under each covered health service category in this benefit summary. 3 of 6

4 If you need help recovering or have other special health needs If you need a transplant If you need a part of your body fixed If you need a scopic procedure Rehabilitation services Outpatient therapy and manipulative treatment. For services provided in the Physician s Office, a copayment will only apply to the initial office visit. Pre-service notification is required if inpatient stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery. *30% coinsurance Benefits are limited as follows: 20 visits of physical therapy 20 visits of occupational therapy 20 visits of manipulative treatment 20 visits of speech therapy 20 visits of pulmonary rehabilitation 36 visits of cardiac rehabilitation 30 visits of post-cochlear implant aural therapy Home health care (limited to 60 visits per year) Skilled nursing care (limited to 60 **Pre-service notification is required for days per year) equipment in excess of $1,000. Hospice care Durable medical equipment **30% coinsurance per Transplantation services *30% coinsurance For participating provider benefits, services must be received at a designated facility. Depending upon where the covered health service is provided, benefits will be the same as those stated under each covered health service category in this benefit summary. Reconstructive procedures Pre-service notification is required for certain non-participating provider Prosthetic devices 30% coinsurance Outpatient diagnostic and therapeutic. e.g colonoscopy; 30% coinsurance sigmoidoscopy; endoscopy. 4 of 6

5 If you have hearing problems If you need dental or eye care Hearing aids 30% coinsurance Limited to $5,000 per year and to a single purchase (including repair/replacement) per hearing impaired ear every three years. Eye exam Not Covered Limited to one exam every two years Dental services (accident only) $3,000 maximum per year No charge after No charge after $900 maximum per tooth deductible has been participating provider Pre-service notification is required for certain met. deductible has been met. services Excluded Services: Services Your Plan Does NOT Cover (This IS NOT a complete list. Check your policy or plan document for other excluded ) Nutritional or cosmetic therapy Infertility treatment Alternative treatments Non-emergency care when traveling outside the U.S. Vision and hearing services(except those described above) Routine foot care Cosmetic surgery Weight loss programs 5 of 6

6 Your Rights to Continue Coverage: ** Individual health insurance sample Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at You may also contact your state insurance department at OR ** Group health coverage sample 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: 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. 6 of 6