Round Lake Area Schools District 116 Benefits Open Enrollment May 14 May 25 September 2012 2013 Benefit Summary
Table of Contents Eligibility... 3 Benefits Overview 2012 2013... 4 Insurance Premiums... 5 Medical Benefits... 6 Dental Insurance... 8 Life Insurance and AD&D... 9 Vision Insurance... 10 Flexible Spending Account... 11 Contact Information... 12 Your Benefits... 13 Medicare/Retirement... 14 Required Proof Documents for Dependent Coverage... 15 Glossary of Health Insurance and Medical Terms... 16 Notes... 18 This document is an outline of the coverage proposed by the carrier(s), based on information provided by Round Lake Area Schools District 116. It does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Policy forms for your reference will be made available upon request. The intent of this document is to provide you with general information regarding the status of, and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your general counsel or an attorney who specializes in this practice area. 2
Eligibility Benefits Overview 2012-2013 The goal is to provide you with the most comprehensive health benefits possible while remaining good stewards with our fiscal commitments and obligations. Benefits Offered Medical Insurance Dental Insurance Life Insurance Accidental Death & Dismemberment (AD&D) Insurance Vision Insurance Flexible Spending Account (FSA) Who Is Eligible? All full time employees are eligible for the benefits listed above. The plan allows coverage for a Round Lake Area Schools District 116 employee s legal spouse and/or child(ren), biological, adopted, step or foster, covered from birth to age 26; to age 30 for honorably discharged veterans. Active eligible employees, regardless of age, are eligible for benefits under the Round Lake Area Schools District 116 Health Plan. 3
Benefits Overview 2012 2013 The Who s Who of Your Round Lake Area Schools District 116 Medical Plans Blue Cross and Blue Shield of Illinois is the claims administrator for the PPO and HMO plans. They determine if you and your dependents are eligible for benefits and process your claims. Contact Blue Cross for questions concerning eligibility, plan benefits, or status of claim payments. Blue Cross PPO Customer Service can be reached at 800.458.6024, between 8:30 a.m. and 6:00 p.m., CST, Monday through Friday. Blue Cross HMO Customer Service can be reached at 800.892.2803. Blue Cross Website is both user friendly and informative. You can locate doctors and hospitals participating in the network. The Blue Access site allows you to email customer service with questions, check the status of a claim, print a medical claim form, print a temporary ID card and request a duplicate ID Card. You can also review BCBS discounts on vision care and other services. Their web address for members is www.bcbsil.com. Blue Cross is your PPO (preferred provider organization) Network. This means a group of select hospitals, clinics, physicians, and medical services that provide quality healthcare at a reduced rate. Contact Blue Cross to determine if your healthcare provider is part of the network. Call them at 800.458.6024 from 8:30 a.m. to 6:00 p.m., CST, Monday through Friday, or visit their website at www.bcbsil.com. Blue Cross Medical Services Advisory is your utilization review contact. They work with your doctor to ensure you are getting the most appropriate care, in the appropriate setting for hospital stays. Contact them at 800.826.8551, 7:00 a.m. to 7:00 p.m., CST, Monday through Friday. Medco is your PPO Prescription Benefit Manager. Retail and Mail Prescription Services for PPO plans are administered through Medco. Retail prescriptions can be obtained through participating pharmacies by presenting your Medco ID Card. Mail program brochures can be obtained on the Medco website www.medcohealth.com. You can also view the formulary program, locate a participating pharmacy, order refill, etc. on the website. If you have specific questions or issues, please call 800.711.0917. Prime Therapeutics is your HMO Prescription Benefit Manager. The Retail and Mail Prescription Services for HMO plans are administered through Prime Therapeutics. Retail prescriptions can be obtained through participating pharmacies by presenting your Blue Cross ID Card. Mail program brochures can be obtained on the Blue Cross website www.bcbsil.com. You can also view the formulary program, locate a participating pharmacy, order refills, etc., on the website. If you have specific questions or issues, please call the Blue Cross Prescription Drug Inquiry Unit at 800.423.1973. 4
Insurance Premiums Insurance Payroll Deduction 2012 Monthly Employee Share 2012 Monthly District Share 2012 Employee 24 checks Blue Adv. HMO Single $0 $610.61 $0 Single + Spouse $431.70 $610.61 $215.85 Single + Child(ren) $379.58 $610.61 $189.79 Family $822.56 $610.61 $411.28 HMO Illinois Single $0 $676.89 $0 Single + Spouse $478.56 $676.89 $239.28 Single + Child(ren) $420.78 $676.89 $210.39 Family $911.85 $676.89 $455.93 PPO Plan 250 Single $0 $768.97 $0 Single + Spouse $580.55 $768.97 $290.28 Single + Child(ren) $513.07 $768.97 $256.54 Family $1,086.63 $768.97 $543.32 PPO Plan 350 Single $0 $676.51 $0 Single + Spouse $510.72 $676.51 $255.36 Single + Child(ren) $451.38 $676.51 $225.69 Family $955.96 $676.51 $477.98 PPO Plan 500 Single $0 $676.51 $0 Single + Spouse $510.72 $676.51 $255.36 Single + Child(ren) $451.38 $676.51 $225.69 Family $955.96 $676.51 $477.98 PPO Vision Single $5.28 $0 $2.64 Family $14.92 $0 $7.46 HMO Vision Single $6.00 $0 $3.00 Family $16.57 $0 $8.29 PPO Dental Single $0 $32.07 $0 Family $63.60 $32.07 $31.80 HMO Dental Single $0 $17.11 $0 Family $28.09 $17.11 $14.05 5
Medical Benefits BCBS Healthcare Plan Administrator Blue Cross Blue Shield continues to be our healthcare provider. As always, you can go to their website www.bcbsil.com to learn more. Deductible 1 PPO Plan 250** PPO Plan 350 In-Network Out-of-Network In-Network Out-of-Network Individual $250 $250 $350 $1,050 Family $500 $500 $700 $2,100 Coinsurance 90% 70% 90% 70% Out-of-pocket limit (includes deductible) Individual $1,000 $2,000 $2,500 $5,000 Family $2,000 $4,000 $5,000 $10,000 Lifetime Maximum Unlimited Unlimited Covered Expenses Hospital Inpatient Services 90%* 70%* $300 per admission 90%* 70%* Outpatient Services 90%* 70%* 90%* 70%* Emergency Room $100 copay & 100%* Copay Waived If Admitted $75 copay & 90%* Copay Waived If Admitted Physician Inpatient Surgery 90%* 70%* 90%* 70%* Outpatient Surgery 90%* 70%* 90%* 70%* Primary Care Office Visits $10 copay 2 70%* $20 copay 2 70%* Specialist Office Visits $10 copay 2 70%* $40 copay 2 70%* Wellcare/Physical Exam 100% 90%* 100% 70%* Other X-ray and Lab 90%* 70%* 90%* 70%* Chiropractic 3 (annual 40-visit limit) 90%* 70%* 90%* 70%* Therapy Services (Speech, Occupational, Physical) 90%* 70%* 90%* 70%* Acupuncture 4 ($3,000 annual benefit) 90%* 70%* 90%* 70%* Prescription Drugs 5 Retail Pharmacy (30-day supply) Mail Order (90-day supply) $10 Generic, $25 Formulary Brand, $40 Non-Formulary Brand $25 Generic, $62.50 Formulary Brand, $100 Non-Formulary Brand $15 Generic, $30 Formulary Brand, $50 Non-Formulary Brand $30 Generic, $60 Formulary Brand, $100 Non-Formulary Brand VSP Vision Exam (annual) $10 copay Reimbursed to $45 $10 copay Reimbursed to $45 Dependent Age To age 26, to age 30 if military veteran To age 26, to age 30 if military veteran 6 *Subject to deductible and coinsurance. 1 Deductibles are based on calendar year. 2 Copays do not apply towards the out-of-pocket limit or annual deductible. Copays apply only to office visit charge, not to misc. expense incurred during visit. **The PPO Plan 250 is only available to staff enrolled in the plan prior to August 8, 2011. 3 Chiropractic care that is medically necessary is covered; maintenance care is not covered. 4 Please see plan booklet or contact BCBS for approved providers. 5 See Plan Document for further details on the prescription drug program.
In-Network PPO Plan 500 HMO 10 Illinois HMO Blue Advantage Out-of-Network $500 $1,500 N/A N/A $1,000 $3,000 N/A N/A 90% 70% 100% 100% $2,500 $5,500 $1,500 $1,500 $5,000 $11,000 $3,000 $3,000 Unlimited Unlimited Unlimited 90%* 70%* 100% 100% 90%* 70%* 100% 100% $75 copay & 90%* Copay Waived If Admitted $75 copay Copay Waived If Admitted $75 copay Copay Waived If Admitted 90%* 70%* 100% 100% 90%* 70%* $10 copay $10 copay $20 copay 2 70%* $10 copay $10 copay $40 copay 2 70%* $20 copay $20 copay 100% 70%* $10 copay $10 copay 90%* 70%* 100% 100% 90%* 70%* Only if referred through PCP Only if referred through PCP 90%* 70%* Only if referred through PCP, then copay. Only if referred through PCP, then copay 90%* 70%* Only if referred through PCP Only if referred through PCP $13 Generic, $25 Formulary Brand, $40 Non-Formulary Brand $26 Generic, $50 Formulary Brand, $80 Non-Formulary Brand $10 copay Reimbursed to $45 To age 26, to age 30 if military veteran $7 Generic $25 Formulary Brand $40 Non-Formulary Brand $17.50 Generic $62.50 Formulary Brand $100 Non-Formulary Brand To age 26, to age 30 if military veteran $7 Generic $25 Formulary Brand $40 Non-Formulary Brand $17.50 Generic $62.50 Formulary Brand $100 Non-Formulary Brand To age 26, to age 30 if military veteran Note: The Comparisons are outlines of the benefit schedules. This exhibit in no way replaces the plan document of coverage, which outlines all the plan provisions and legally governs the operation of the plans. 7
Dental Insurance Dental Round Lake Area Schools recognizes that different individuals have varying comfort levels and needs in regards to insurance. It is important that you analyze a variety of factors to determine where you and your family need expanded coverage (e.g., risk factors, age, wellness, and medical history). Semi-annual dental checkups are important, no matter your age. Dependent dental eligibility now covered to age 26 and to age 30 for honorably discharged veterans. Guardian PPO Dental Plan offers the luxury and convenience of choice. You choose which dental professionals you and your family see. You can find a provider and look up additional information at www.guardianlife.com. If you have any questions regarding claims information, please call 866.302.4542. Dental Plan Benefits Benefit Network Non-Network Annual Benefit $1,250 $1,250 Annual Deductible (3X Family) Per Person $50 $50 Diagnostic 100% 90% Preventive (cleanings & exams) 100% 90% Basic Services (minor perio) 80% 70% Major Restorative (major perio, oral surgery, endodontics) 50% 40% Orthodontics 50% 50% Orthodontics Lifetime Limit $1,000 $1,000 First Commonwealth (HMO) Under this plan, you pay only the patient copayment amount listed in the Schedule of Dental Benefits. There are no deductibles, no annual benefit maximums and no claim forms to complete. How the Dental HMO Works The panel dentist you select when you enroll in this DeltaCare plan will provide all routine dental care for you and your family. If specialty care is required, your To make a change to your medical or dental benefits or flexible spending account, you must experience a qualified life event in accordance with the Flexible Spending Account plan document. panel dentist will refer you to a specialist who is also a member of the First Commonwealth Network. You will need a written referral in order to visit a specialist. If you have questions Customer service is available at 866.494.4542. 8
Life Insurance and AD&D ING Life Insurance and AD&D Round Lake Area Schools pays 100% of your basic term life insurance premiums. Round Lake Area Schools provides its eligible employees with Group Life and Accidental Death and Dismemberment Insurance (AD&D). Features included in your Life coverage include: Right to Convert Provision Portability of Insurance (Basic Life Coverage and Optional Life) Waiver of Premium Accelerated Benefit for the Terminally Ill ING Voluntary Life Insurance Employees may elect to purchase additional insurance at their expense up to a maximum of $500,000 in $10,000 increments. Spouse optional insurance can be purchased in $10,000 increments, not to exceed 100% of employee s coverage or $250,000. Employees can also purchase optional child life insurance coverage; either $5,000 or $10,000. Employees are guaranteed up to $100,000 of Voluntary Life Insurance, no medical questions asked. Employees can cover their spouses up to $20,000 of Voluntary Life Insurance, no medical questions asked. Monthly Premium Rates For Employee and Spouse Per $1,000 of Life Insurance. For additional information, please contact Kristi McCaulou at 847.270.9005. Age (last birthday as of the anniversary date) Rate Under age 20 $.04 20-24 $.04 25-29 $.04 30-34 $.06 35-39 $.08 40-44 $.10 45-49 $.15 50-54 $.23 55-59 $.41 60-64 $.57 65-69 $1.04 70-74 $1.68 75+ $2.73 Dependent Children (6 months to age 26 benefit) Rate Per Month $5,000 $1.25 $10,000 $2.50 *Newborn children automatically become insured at 14 days of age if you insure other dependent children. 9
Vision Insurance VSP Vision Benefit Doctor Network: You will find the VSP choice provider who s right for you at www.vsp.com or by calling 800.877.7195. Our doctors offer flexible hours, a variety of office settings, and eyewear choices you ll love. Value and Savings: You ll get great savings on your eye exam and eyewear, and discounts on laser vision correction. Your Coverage With a VSP Choice Provider WellVision Exam focuses on your eye health and overall wellness $10 copay Every 12 months Prescription Eyewear Buy-up options. The following coverage applies if you have purchased the prescription eyewear buy-up option. Prescription Glasses $25 copay Lenses Every 12 months; Single vision, lined bifocal, and lined trifocal lenses; Polycarbonate lenses for dependent children Frames Every 24 months; $130 allowance for frame of your choice; 20% off the amount over your allowance Or No copay Every 12 months; $130 allowance for contacts and the contact lens exam (fitting and evaluation). Contact Lens Care Current soft contact lens wearers may qualify for a special program that includes a contact lens exam and initial supply of replacement lenses. Extra Discounts and Savings Average 20% 25% savings on all non-covered lens options. Glasses and Sunglasses 20% off additional glasses and sunglasses, including lens options, from any VSP doctor within 12 months of your last WellVision Exam. Contacts 15% off cost of contact lens exam (fitting and evaluation). Laser Vision Correction Average 15% off the regular price or 5% off the promotional price. Discounts only available from contracted facilities. Employee Only Employee + Family Employee Only Employee + Family $5.28 monthly $14.92 monthly $6.00 monthly $16.57 monthly PPO Member Contribution Non-PPO Member Contribution Your Coverage With Other Providers If you see a provider other than a VSP choice provider, your coverage is listed below. You have 6 months to submit a claim to VSP for reimbursement. Visit www.vsp.com for details. Exam Up to $45 Single Vision Lenses Up to $30 Lined Bifocal Lenses Up to $50 Lined Trifocal Lenses Up to $65 Frame Up to $70 Contacts Up to $105 VSP guarantees service from VSP doctors only. In the event of a conflict between this information and your organization s contract with VSP, the terms of the contract will prevail. 10 Davis Vision Discount Programs As a member of BCBS, you are eligible to participate in a vision discount program that offers discounts on eye exams, contact lenses, frames, lenses and lens add-ons. In order to receive this vision discount, you will need to present your BCBS medical ID card at the time of service. The vision discount program is administered by Davis Vision, Inc. Davis Vision contracts with more than 26,000 national providers, including Visionworks, ForEyes, and EyeMasters. To locate a provider, call Davis Vision at 877.393.8844.
Flexible Spending Account What is an FSA? An FSA is a Flexible Spending Account that allows you to set aside money for eligible expenses on a pretax basis. There are two types of Flexible Spending Accounts available a healthcare account and a dependent day care account. A healthcare account reimburses you for out-of-pocket medical, dental, prescription or vision services, such as deductibles, copays, coinsurance and over-the-counter (OTC) items. Starting January 1, 2011, certain OTC medicines and drugs will be considered ineligible unless you have a written prescription from your doctor. A dependent day care account reimburses you for expenses, such as day care, before- and afterschool programs, nursery school or preschool, summer day camp and even adult day care. What you need to know about FSAs You may only sign up for an FSA during open enrollment or when you first become eligible. Round Lake Area School s FSA open enrollment will be held in the fall. Once you establish your plan year contribution, you may only change it if you experience a change in status. This may include a change in one of the following conditions:» Legal marital status (marriage, divorce, legal separation, annulment or death of a spouse).» Number of tax dependents (birth, adoption or death).» Employment status that affects eligibility.» Dependent satisfying or ceasing to satisfy coverage requirements (reaching limiting age, gain/ loss of student status, marriage).» To apply for a change, you must complete a change-in-election form through your employer's Human Resources/Benefits department within 30 days of the date of the event. Your employer offers a grace period, you will be allowed an additional 2 months after the end of your plan year to use your FSA dollars. For example: if your plan year ends on December 31, your employer will allow expenses to be incurred through March 15. Any claims that were incurred during the plan year must be submitted for reimbursement by the end of your run out period. This date is established by your employer and is generally 90 or 120 days after the end of your plan year. Any amount left in your healthcare and/or dependent day care FSA at the end of the plan year will be forfeited. Healthcare: Individual/Family maximum is $2,000 Dependent care: Individual/Family maximum is $5,000 $2,500 for married employees filing separate returns For questions, contact: horacemann.healthhub.com Customer Service at 877.533.0220 11
Contact Information Important Contact Information If you would like to further research your benefit options, find a provider, or ask detailed questions about your benefit coverage, you may contact the insurance companies/service provider directly. Listed below are toll-free phone numbers and websites for those that provide insurance services. Benefit Administrator Phone Website/email Medical PPO BCBS 800.458.6024 www.bcbsil.com Medical HMO BCBS 800.892.2803 www.bcbsil.com Dental PPO Guardian Life 866.302.4542 www.guardianlife.com Dental HMO First Commonwealth 866.494.4542 www.guardianlife.com Flexible Spending Account (FSA) Horace Mann 877.533.0220 horacemann.healthhub.com Vision VSP 800.877.7195 www.vsp.com If you have questions regarding the enrollment process, your payroll deductions, or need general benefit information, please contact Kristi McCaulou at 847.270.9005 or kmccaulou@rlas-116.org. 12
Your Benefits Coordination of Benefits This Coordination of Benefits (COB) provision applies when a person has healthcare coverage under more than one Plan. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the Primary plan. The Primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the Primary plan is the Secondary plan. If the plan is secondary, the total payment from all plans cannot be more than what it would normally pay in benefits if it was the primary plan. The Secondary plan may reduce the benefits it pays so that payments from all Plans do not exceed 100% of the total Allowable expense. In addition, if the plan is Secondary, it will pay for expenses only covered by our plan. If the other, Primary, plan covers a service that we do not cover, we will not coordinate benefits on that particular expense. If the employee is married to a spouse that has group medical insurance elsewhere and the couple has children, the parent whose birthday month and day falls before the others will provide the Primary plan for the children and the parent whose birthday month and day falls after will provide the Secondary plan. The district plan is the Primary plan for all active employees. Maximize Your Benefits The following are helpful hints designed to help you get the most out of your health plans. Using the Blue Cross and Blue Shield of Illinois PPO Network Services Before going to a Blue Cross hospital, call Blue Cross s PPO info line at 800.458.6024 or visit their website www.bcbsil.com to ensure the hospital is part of the network. Present your insurance ID card to your healthcare provider at your appointment. This informs providers where they need to send your claims and identifies you as a Blue Cross member. Blue Cross participating providers will forward claims directly to Blue Cross before requesting any necessary deductible or coinsurance payments from you so the appropriate discount can be applied. An office copay may be required. Hospital Precertification Program for the Round Lake Area Schools Program You, your doctor, or a family member must call Medical Services Advisory for any hospital stay. You must call 72 hours (3 days) before a planned hospital admission or the next business day after an emergency admission. If you fail to precertify your stay, it will result in a $500 penalty! Medical Services Advisory can be reached at 800.826.8551. Predetermination: Members are encouraged to always obtain prior approval when using nonnetwork providers. Predetermination will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. 13
Medicare/Retirement Medicare/Retirement Medicare and Group Health Plan Coverage When you turn 65, you have a number of important decisions to make. These may include whether to enroll in Medicare Part B, join a Medicare Prescription Drug Plan, buy a Medigap policy, and/or keep employer or retiree coverage. Understanding your choices may help you avoid paying more than you need to for Medicare Part B and other insurance, and get the coverage that s best for you. You can visit www.medicare.gov and select Compare Medicare Prescription Drug Plans and Compare Health Plans and Medigap Policies in Your Area. You can also call your State Health Insurance Assistance Program. To get their telephone number, call 1.800.MEDICARE (1.800.633.4227). TTY users should call 1.877.486.2048. Medicare Part B benefits are optional and are available to all beneficiaries when they become entitled to Medicare Part A. Medicare Part B may be purchased by most persons age 65 and over. Although participation in Medicare Part B is optional, Round Lake Area Schools health plans will pay as if Medicare Part B has been elected when Medicare is primary. See chart below to determine when Medicare is primary. Failure to purchase Medicare Part B when Medicare is primary will drastically affect an individual s ability to recover any costs incurred for physician services and other Medicare Part B covered items. Medicare Part D (prescriptions) Those eligible for Medicare are provided a letter of creditable coverage by the district. The letter states that the prescription drug program currently provided by Round Lake Area Schools Healthcare Plan meets or exceeds Medicare Part D. Medicare participants were advised that they could select the Round Lake Area Schools prescription drug plan instead of Medicare Part D. The letter permits Medicare eligible persons to join Medicare Part D at a later date, if they choose, without paying a late entrant penalty. This letter will be provided annually each fall. Who Pays First? If You Situation Pays First Pays Second Are 65 or older and covered by a group health plan because you or your spouse is still working Have an employer group health plan after you retire and are 65 or older Entitled to Medicare The employer has 20 or more employees Entitled to Medicare Group Health Plan Medicare Medicare Retiree Coverage 14
Required Proof Documents for Dependent Coverage Legal Marriage Marriage certificate Civil Union certificate Biological Child One of the following:» Birth certificate of biological child» Documentation on hospital letterhead indicating the birth date of child(ren) under 6 months old If you are enrolling dependents in the Healthcare Plan, proof documents are required. Please see proof document list for each category that is applicable to you. Adopted Child One of the following:» Official court/agency papers (initial stage)» Official Court Adoption Agreement (mid-stage)» Birth certificate (final stage) Foster Child Official court or agency placement papers Stepchild Child s Birth Certificate showing the child s parent is the employee s spouse Marriage Certificate showing legal marriage between the employee and the child s parent Court document showing that your spouse has custody of the child or is required to cover child Other Child Court papers demonstrating legal guardianship, including the person named as legal guardian Court-Ordered Medical Coverage One of the following:» Qualified Medical Child Support Order (QMCSO)» National Medical Support Notice (NMSN) Child Age 26 or Older Certified Handicapped Child/Disabled Student Attending Physician Statement signed by the employee and the child s attending physician DD-214 military documents showing honorable discharge from military branches 15
Glossary of Health Insurance and Medical Terms Allowed Amount. Maximum amount on which payment is based for covered healthcare services. This may be called eligible expense, payment allowance or negotiated rate. If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.) Balance Billing. When a provider bills you for the difference between the provider s charge and the allowed amount. For example, if the provider s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you. Brand: Medications are marketed under a trademarkprotected name and are often available from only one manufacturer. Coinsurance. Your share of the costs of a covered healthcare service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan s allowed amount for an office visit is $100 and you ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. Copayment. A fixed amount (for example, $15) you pay for a covered healthcare service, usually when you receive the service. The amount can vary by the type of covered healthcare service. Deductible. The amount you owe for healthcare services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won t pay anything until you ve met your $1000 deductible for covered healthcare services subject to the deductible. The deductible may not apply to all services. Emergency Services. Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. Formulary: A list of commonly prescribed medications that are preferred by your plan because they are safe, effective alternatives to other generics or brands that may be more expensive. The formulary has a wide selection of generic and brand-name medications. Health Insurance. A contract that requires your health insurer to pay some or all of your healthcare costs in exchange for a premium. Hospitalization. Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care. Hospital Outpatient Care. Care in a hospital that usually doesn t require an overnight stay. In-network Coinsurance. The percent (for example, 20%) you pay of the allowed amount for covered healthcare services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance. In-network Copayment. A fixed amount (for example, $15) you pay for covered healthcare services to providers who contract with your health insurance or plan. Innetwork copayments usually are less than out-ofnetwork copayments. Network. The facilities, providers and suppliers your health insurer or plan has contracted with to provide healthcare services. Non-Preferred Provider. A provider who doesn t have a contract with your health insurer or plan to provide services to you. You ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Out-of-network Coinsurance. The percent (for example, 40%) you pay of the allowed amount for covered healthcare services to providers who do not contract with your health insurance or plan. Out-ofnetwork coinsurance usually costs you more than innetwork coinsurance. Out-of-network Copayment. A fixed amount (for example, $30) you pay for covered healthcare services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments. 16
Out-of-Pocket Limit. The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or healthcare your health insurance or plan doesn t cover. Some health insurance or plans don t count all of your copayments, deductibles, coinsurance payments, out-of-network payments or other expenses toward this limit. Physician Services. Healthcare services a licensed medical physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) provides or coordinates. Plan. A benefit your employer, union or other group sponsor provides to you to pay for your healthcare services. Preauthorization. A decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn t a promise your health insurance or plan will cover the cost. Preferred Provider. A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also participating providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more. Premium. The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. Primary Care Physician. A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) who directly provides or coordinates a range of healthcare services for a patient. Primary Care Provider. A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of healthcare services. Provider. A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), healthcare professional or healthcare facility licensed, certified or accredited as required by state law. Rehabilitation Services. Healthcare services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speechlanguage pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. Specialist. A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of healthcare. Urgent Care. Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. VEBA. Voluntary Employee s Beneficiary Association. An association providing for the payment of life, sick, accident or other benefits to the members of the association, their dependents or beneficiaries; it enjoys tax-exempt status, provided that certain conditions are met. Prescription Drug Coverage. Health insurance or plan that helps pay for prescription drugs and medications. Prescription Drugs. Drugs and medications that by law require a prescription. 17
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Q:\2012\GBS\Round Lake Area Schools\RLASD116.indd