Important Questions Answers Why This Matters. What is the overall deductible? Out-of-Network: $200 individual, $600 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: $6,350 individual, $12,700 family Out-of-Network: $6,350 per individual, $12,700 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx or by calling 1- 800-639-2227or (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary car...
Important Questions Answers Why This Matters. What is the overall deductible? For Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. 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 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. 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 and health care this plan doesn't cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. 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-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan does...
Important Questions Answers Why This Matters. What is the overall deductible? $0 See the Common Medical Events chart below for your costs for services this plan covers. Are there services covered before you meet your deductible? Not Applicable Not Applicable Are there other deductibles for specific services? No You don't have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $6,850/Member and $13,700/Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Penalties for not obtaining any required prior authorization, premiums, balance-billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of- pocket limit. Will you pay less if you use a network provider? Yes. See xxx.xxxxxxxxxxxxxxxxxx.xxx/Xxxxxx/Xxxxxx- or-Provider or call 0-000-000-0000 for a list of Plan Providers. This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a xxxx from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? Yes This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information HMO Provider (You will pay the least) Non-Plan Provider (You will pay the most) If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness $20 copay/visit Not Covered None Specialist visit $40 copay/visit Not Covered Member pays for cost of services if prior authorization is not obtained. Plan Providers seen without a referral $50 copay/visit. Preventive care/ screening/ immunization No charge Not Covered You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood ...
Important Questions Answers Why This Matters. What is the overall deductible? $0 See the Common Medical Events chart below for your costs for services this plan covers. Are there services covered before you meet your deductible? No. You will have to meet the deductible before the plan pays for any services. Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? For in-network providers $6,350/individual or $12,700/family Combined medical/behavioral and pharmacy out-of-pocket limit The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
Important Questions Answers Why This Matters. Will you pay less if you use a network provider? Yes.
