Anthem Blue Cross Select HMO: B3 Coverage Period: 01/01/ /31/2015

Transcription

1 This is only a summary. Please read the FEHB Plan brochure (RI )) that contains the complete terms of this plan. All benefits are subject to the definitions, limitations, and exclusions set forth in the FEHB Plan brochure. Benefits may vary if you have other coverage, such as Medicare. You can get the FEHB Plan brochure at or by calling Important Questions Answers Why this Matters: What is the overall deductible? $0 Are there other deductibles for specific services? No 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 Is there an out of pocket limit on my expenses? What is not included in the out of pocket 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? Yes $3,000 Self Only $6,000 Self and Family Infertility services No Yes. For a list of network providers, see or call Yes, your primary care doctor must refer you. 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. 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-ofnetwork provider for some services. We use the terms preferred or participating for providers in our 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 this plan s FEHB brochure for additional information about excluded services. If you aren t clear about any of the underlined terms used in this form, see the Glossary. 1 of 8

2 Common Medical Event Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. If you visit a health care provider s office or clinic Services You May Need Your Cost If You Use a Network Your Cost If You Use a Non- Participating (plus you may be balance billed) Limitations & Exceptions Primary care visit to treat an injury or illness $25 per visit You must use network providers. Specialist visit $40 per visit Specialty care is by referral only. Other practitioner office visit $15 per Chiropractic Limited to 20 visits and must be provided visit, by an American Specialty Health Plans of $40 per California, Inc. (ASH Plans) provider. Acupuncture visit Acupuncture care is by referral only. Preventive care/screening/immunization No charge You must use network providers. Diagnostic test (x-ray, blood work) No charge You must use network providers. If you have a test Imaging (CT/PET scans, MRIs) $100 per test You must use network providers and the services are performed in a doctor s office, radiology center, or outpatient department of a hospital or ambulatory surgical center. If you aren t clear about any of the underlined terms used in this form, see the Glossary. 2 of 8

3 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 Low cost preferred drugs that may be generic, single or multi-source brand name drugs Higher cost preferred drugs that may be generic, single or multisource brand name drugs Higher cost non-preferred drugs that may be generic, single or multisource brand name drugs Specialty drugs Your Cost If You Use a Network $5 per prescription retail, $12.50 per prescription 90-day mail order $40 per prescription retail, $90 per prescription 90-day mail order $70 per prescription retail, $150 per prescription 90-day mail order $125 per prescription for 30 day supply $250 per outpatient surgery admission Your Cost If You Use a Non- Participating (plus you may be balance billed) $5 per prescription plus 50% of maximum allowed amount for retail only. $40 per prescription plus 50% of maximum allowed amount for retail only. $70 per prescription plus 50% of maximum allowed amount for retail only. Limitations & Exceptions Must use plan mail order program for 90 day supply. Must use plan mail order program for 90 day supply. Must use plan mail order program for 90 day supply. Must utilize Specialty Pharmacy Program provider. Facility fee (e.g., ambulatory surgery center) Must use network provider. Physician/surgeon fees No charge Must use network provider Emergency room services $125 per visit $125 per visit None Emergency medical transportation $100 per trip $100 per trip None Urgent care $40 per visit $40 per visit None Facility fee (e.g., hospital room) $250 per day up maximum of 4 days Physician/surgeon fee No charge If you aren t clear about any of the underlined terms used in this form, see the Glossary. 3 of 8

4 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Your Cost If You Use a Network $25 per office visit/ No charge for other outpatient services. $250 per day up maximum of 4 days $25 per office visit/ No charge for other outpatient services. $250 per day up maximum of 4 days Your Cost If You Use a Non- Participating (plus you may be balance billed) Limitations & Exceptions Substance use disorder inpatient services Prenatal and postnatal care $25 per visit Delivery and all inpatient services Nothing Home health care $40 per visit 100 visit limit for care provided by a Home Health Agency Rehabilitation services $40 per visit Limited to a 60 day period of care. Must use network providers. Limited to a 60 day period of care. Must Habilitation services $40 per visit If you need help use network providers.. recovering or have Limited to 100 days per calendar year Skilled nursing care No charge other special health when confined in a skilled nursing facility. needs Must be ordered by your primary care physician, used only for a health problem, Durable medical equipment 50% coinsurance used only by the person who needs the equipment or supply and made only for medical use. Hospice service No charge For conditions that may lead to death. Your primary care physician will work with the hospice to develop a treatment plan that will be reviewed every 30 days. If you aren t clear about any of the underlined terms used in this form, see the Glossary. 4 of 8

5 If your child needs dental or eye care Eye exam No charge Glasses Dental check-up Excluded Services & Other Covered Services: Included a visit check by your primary care physician to see if it is medically necessary for you to have a complete vision exam by a vision specialist. If approved by your primary care physician, this may include an exam with diagnosis, a treatment program and refractions. Services Your Plan Does NOT Cover (This isn t a complete list. Check this plan s FEHB brochure for other excluded services.) Cosmetic surgery except as approved by the Plan Dental care (Adult) Glasses Long-term care Non-emergency care when traveling outside the U.S. Non-network providers Private-duty nursing Routine foot care Specialty services that have not been approved Weight loss programs Other Covered Services (This isn t a complete list. Check this plan's FEHB brochure for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care provided by American Specialty Health Plans, Inc. providers Hearing aids Infertility treatment Routine eye care (Adult) Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending on the circumstances, you may be eligible for a 31-day free extension of coverage, to convert to an individual policy, and to receive temporary continuation of coverage (TCC). Your TCC rights will 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. An individual policy may also provide different benefits than you had while covered under the plan. Other limitations on your rights to continue coverage may also apply. If you aren t clear about any of the underlined terms used in this form, see the Glossary. 5 of 8

6 For more information on your rights to continue coverage, see the FEHB Plan brochure, contact your HR office/retirement system, contact your plan at or visit Your Appeal Rights: If you are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal. For information about your appeal rights please see Section 3, How you get care, and Section 8 The disputed claims process, in your plan's FEHB brochure. If you need assistance, you can contact: Anthem Blue Cross Select HMO at 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. Coverage under this plan qualifies as 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). The health coverage of this plan does meet the minimum value standard for the benefits the plan 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. If you aren t clear about any of the underlined terms used in this form, see the Glossary. 6 of 8

7 Coverage Examples Coverage for: Self Only -or- Self and Family PlanType: 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 $6,515 Patient pays $ 1,025 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 $1,025 Coinsurance $0 Limits or exclusions $0 Total $1,025 These numbers assume the patient has given notice of her pregnancy to the plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information, please contact: Managing type 2 diabetes (routine maintenance of a well - controlled condition) Amount owed to providers: $5,400 Plan pays $4,680 Patient pays $ 675 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 $25 Coinsurance $650 Limits or exclusions $0 Total $675 Note: These numbers assume the patient is participating in our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may be higher. For more information about the diabetes wellness program, please contact If you aren t clear about any of the underlined terms used in this form, see the Glossary. 7 of 8

8 Coverage Examples Coverage for: Self Only -or- Self and Family PlanType: HMO 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. If you aren t clear about any of the underlined terms used in this form, see the Glossary. 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. 8 of 8