|
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, [insert contact information]. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other bolded terms see the Glossary. You can view the Glossary at www.[insert].com or call 1-800-[insert] to request a copy. |
Important Questions |
Answers |
Why This Matters: |
What is the overall deductible? |
$500/person
or
|
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1). The Common Medical Events chart below shows how much you pay for covered services after you meet the deductible. |
Are there other deductibles for specific services? |
Yes. $300 for prescription drug coverage. There are no other specific deductibles. |
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. |
Is there an out-of-pocket limit on my expenses? |
Yes. For participating providers $2,500/person or $5,000/family For non-participating providers $4,000/person or $8,000/family |
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. |
What is not included in the out-of-pocket limit? |
Premiums, balance-billed charges, health care this plan doesn’t cover, [and out-of-network services]. |
Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
Does this plan use a network of providers? |
Yes. See www.[insert].com or call 1-800-[insert] for a list of participating providers. |
If you use an in-network health care provider, this plan will pay some or all of the costs of covered services. Lesser coverage, or no coverage, may be available for out-of-network providers. Be aware, your in-network doctor or hospital may use another out-of-network provider for some services (such as lab work). |
Do I need a referral to see a specialist? |
No. To see a specialist, you don’t need a referral from this plan. |
You can see the specialist you choose without getting permission from this plan. |
Common Medical Event |
Services You May Need |
Your Cost If You Use a Participating Provider |
Your Cost If You Use a Non-Participating Provider |
Limitations & Exceptions |
|
If you visit a health care provider’s office or clinic |
Primary care visit to treat an injury or illness |
$35 copay/visit |
40% coinsurance |
–––––––––––none–––––––––––
|
|
Specialist visit |
$50 copay/visit |
40% coinsurance |
|||
Other practitioner office visit |
20% coinsurance for chiropractor and acupuncture |
40% coinsurance for chiropractor and acupuncture |
|||
Preventive care/screening/immunization |
No charge |
40% coinsurance |
|||
If you have a test |
Diagnostic test (x-ray, blood work) |
$10 copay/test |
40% coinsurance |
–––––––––––none––––––––––– |
|
Imaging (CT/PET scans, MRIs) |
$50 copay/test |
40% coinsurance |
|||
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www. [insert]. |
Generic drugs |
$10 copay/ prescription (retail and mail order) |
40% coinsurance |
Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) |
|
Preferred brand drugs |
20% coinsurance (retail and mail order) |
40% coinsurance |
–––––––––––none–––––––––––
|
||
Non-preferred brand drugs |
40% coinsurance (retail and mail order) |
60% coinsurance |
|||
Specialty drugs |
50% coinsurance |
70% coinsurance |
|||
If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
20% coinsurance |
40% coinsurance |
–––––––––––none––––––––––– |
|
Physician/surgeon fees |
20% coinsurance |
40% coinsurance |
|||
If you need immediate medical attention |
Emergency room services |
20% coinsurance |
20% coinsurance |
–––––––––––none––––––––––– |
|
Emergency medical transportation |
20% coinsurance |
20% coinsurance |
|||
Urgent care |
20% coinsurance |
40% coinsurance |
|||
If you have a hospital stay |
Facility fee (e.g., hospital room) |
20% coinsurance |
40% coinsurance |
–––––––––––none––––––––––– |
|
Physician/surgeon fees |
20% coinsurance |
40% coinsurance |
|||
If you have mental health, behavioral health, or substance abuse needs |
Mental/Behavioral health outpatient services |
$35 copay/office visit; 20% coinsurance/other outpatient services |
40% coinsurance |
–––––––––––none––––––––––– |
|
Mental/Behavioral health inpatient services |
20% coinsurance |
40% coinsurance |
|||
Substance use disorder outpatient services |
$35 copay/office visit; 20% coinsurance/other outpatient services |
40% coinsurance |
|||
Substance use disorder inpatient services |
20% coinsurance |
40% coinsurance |
|||
If you are pregnant |
Prenatal, postnatal care, delivery, and all inpatient services |
20% coinsurance |
40% coinsurance |
–––––––––––none––––––––––– |
|
If you need help recovering or have other special health needs |
Home health care |
20% coinsurance |
40% coinsurance |
–––––––––––none––––––––––– |
|
Rehabilitation services |
20% coinsurance |
40% coinsurance |
|||
Habilitation services |
20% coinsurance |
40% coinsurance |
|||
Skilled nursing care |
20% coinsurance |
40% coinsurance |
|||
Durable medical equipment |
20% coinsurance |
40% coinsurance |
|||
Hospice services |
20% coinsurance |
40% coinsurance |
|||
If your child needs dental or eye care |
Eye exam |
$35 copay/visit |
Not Covered |
Plan coverage limited to one exam/year |
|
Glasses |
20% coinsurance |
Not Covered |
Plan coverage limited to one pair of glasses/year |
||
Dental check-up |
No Charge |
Not Covered |
Plan covers up to $50/year |
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) |
||
|
|
|
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) |
||
|
|
|
Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to continue health coverage after it would otherwise end. For more information, contact us at [insert contact information] or contact: [insert State, HHS, and/or DOL contact information, as applicable]. Other options to continue coverage are available to you too, including individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
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 more information about your rights, this notice, or assistance, contact: [insert applicable contact information from instructions].
Does this Coverage Satisfy the Individual Responsibility Requirement and Meet the Minimum Value Standard?
Yes. This coverage constitutes minimum essential coverage under the Affordable Care Act, so enrolling in this coverage satisfies your obligations under the individual responsibility requirement. In addition, this coverage provides a level of benefits specified in the Affordable Care Act as “minimum value.”
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––
About
these Coverage Examples:
These
examples show how this plan
might cover medical care in a few situations and show how
deductibles,
copayments,
and coinsurance
can add up. Use these examples to see, in general, how much
financial protection a sample patient might get from coverage under
this plan compared to other plans
by comparing the
“Patient
Pays” section for the same example
under each plan’s Summary of Benefits and Coverage.
This
is not a cost estimator.
Don’t use these examples to estimate your actual costs under
this
plan.
Treatments
shown are just examples and your actual costs will be different
depending on the
actual care you receive, the prices your providers
charge,
and many other factors. Also, costs don’t include premiums
you pay to buy coverage under a plan.
Having
a baby
(normal
delivery)
Cost of care $14,150
Plan pays $11,650
Patient
pays
$2,550
Sample care costs:
Hospital charges (mother) |
$6,700 |
Routine obstetric care |
$2,500 |
Hospital charges (baby) |
$2,100 |
Anesthesia |
$1,200 |
Laboratory tests |
$1,000 |
Prescriptions |
$200 |
Radiology |
$200 |
Education |
$200 |
Vaccines, other preventive |
$50 |
Total |
$14,150 |
Patient pays:
Deductibles |
$700 |
Copayments |
$140 |
Coinsurance |
$1660 |
Limits or exclusions |
$0 |
Total |
$2, 500 |
Managing
type 2 diabetes
a
well-controlled condition)
(routine
maintenance of
Cost of care $6,100
Plan pays $4,130
Patient
pays
$1,970
Sample care costs:
Prescriptions |
$3,300 |
Medical Equipment and Supplies |
$1,300 |
Office Visits and Procedures |
$800 |
Education |
$300 |
Laboratory tests |
$200 |
Vaccines, other preventive |
$200 |
Total |
$6,100 |
Patient pays:
Deductibles |
$800 |
Copayments |
$590 |
Coinsurance |
$500 |
Limits or exclusions |
$80 |
Total |
$1,970 |
Note:
The numbers in “Managing type 2 diabetes” assume the
patient is participating in the plan’s 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: [insert].
Simple
fracture
(with
emergency room visit)
Cost of care $2,400
Plan pays $ 1,430
Patient
pays
$ 970
Sample care costs:
Emergency Services |
$1,400 |
Medical Equipment and Supplies |
$400 |
Office Visits and Procedures |
$300 |
Physical Therapy |
$200 |
Laboratory tests |
$90 |
Prescriptions |
$10 |
Total |
$2,400 |
Patient pays:
Deductibles |
$560 |
Copayments |
$100 |
Coinsurance |
$300 |
Limits or exclusions |
$10 |
Total |
$970 |
File Type | application/msword |
Author | Beth Baum |
Last Modified By | Amy Turner |
File Modified | 2014-12-19 |
File Created | 2014-12-19 |