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 work) X-ray: $5 copay/service Lab: $5 copay/service Not Covered Member pays for cost of services if prior authorization is not obtained. Imaging (CT/PET scans, MRIs) PET Scan: $10 copay/service MRI: $10 copay/service CT: $10 copay/service Not Covered If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.healthplanofnevada .com Tier 1 $25 copay/prescription (retail) $62.50 copay/prescription (mail) Not Covered You have a 3-Tier pharmacy plan. Covers up to a 30-day retail supply or up to a 90-day mail order supply. Member pays for cost of services if prior authorization or step therapy is not obtained. Tier 2 $50 copay/prescription (retail) $125 copay/prescription (mail) Not Covered Tier 3 $75 copay/prescription (retail) $187.50 copay/prescription (mail) Not Covered Tier 4 Not Covered Not Covered Not Applicable. 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 have outpatient surgery Facility fee (e.g., ambulatory surgery center) $75 copay/admit Not Covered Member pays for cost of services if prior authorization is not obtained. Physician/surgeon fees $20 copay/surgery Not Covered If you need immediate medical attention Emergency room care ER Physician: No charge ER Facility: $500 copay/visit ER Physician: No charge ER Facility: $500 copay/visit You may be balance billed from Non-Plan Providers. Emergency medical transportation $50 copay/trip $50 copay/trip Urgent care $20 copay/visit $20 copay/visit You may be balance billed from Non-Plan Providers. If you have a hospital stay Facility fee (e.g., hospital room) $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. Physician/surgeon fees No charge Not Covered If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/visit Not Covered Member pays for cost of services if prior authorization is not obtained. Inpatient services $350 copay/day $1750 max/admit Not Covered If you are pregnant Office visits No charge Not Covered Routine prenatal care obtained from a Plan Provider is covered at no charge. Maternity care may include tests and services described elsewhere in the SBC (i.e. Lab). Childbirth/delivery professional services Surgical: No charge Anesthesia: No charge Not Covered Childbirth/delivery professional services includes Anesthesia and Physician Surgical Services; each service has a separate cost- share. Member pays for cost of services if prior authorization is not obtained. Childbirth/delivery facility services $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. 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 need help recovering or have other special health needs Home health care No charge Not Covered Does not include Specialty Prescription Drugs. Member pays for cost of services if prior authorization is not obtained. Rehabilitation services $5 copay/visit Not Covered Coverage is limited to a combined Inpatient and Outpatient benefit of 120 days/visits per year. Member pays for cost of services if prior authorization is not obtained. Habilitation services $5 copay/visit Not Covered Coverage is limited to a combined Inpatient and Outpatient benefit of 120 days/visits per year. Member pays for cost of services if prior authorization is not obtained. Skilled nursing care $250 copay/admit Not Covered Coverage is limited to 100 days. Member pays for cost of services if prior authorization is not obtained. Durable medical equipment No charge Not Covered For purchase or rental at HPN's option. Purchases are limited to a single type of DME, including repair and replacement, every 3 years. Member pays for cost of services if prior authorization is not obtained. Hospice services $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. If your child needs dental or eye care Children's eye exam Not Covered Not Covered Your plan may include certain vision and/or dental services. Please refer to your plan documents for more information. Children's glasses Not Covered Not Covered Children's dental check-up Not Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Abortion (except for rape, incest, life at risk) Acupuncture Cosmetic surgery Dental care (Adult) Long-term care Non-emergency care when traveling outside the U.S. Routine eye care (Adult) Routine foot care Weight loss programs Bariatric surgery - One (1) per Lifetime Hearing aids - One (1) every three (3) years (including repair/replace) Chiropractic care - 20 visits per calendar year Limited infertility treatment Your Rights to Continue Coverage: Private-duty nursing There are agencies that can help if you want to continue your coverage after it ends. For group health coverage subject to ERISA, contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.
Appears in 1 contract
Samples: Group Enrollment Agreement
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. Some of the services this plan doesn't cover are listed on page 5. See xxx.xxxxxxxxxxxxxxxxxx.xxx/Xxxxxx/Xxxxxx- or-Provider your policy or call 0-000-000-0000 plan document for a list of Plan Providersadditional information about excluded services. 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 Your Cost 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. Limitations & Exceptions Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information HMO In-Network Provider (You will pay the least) NonOut-Plan of-Network 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 20% co-insurance 30% co-insurance ---------- none -------- Specialist visit $40 copay/20% co-insurance 30% co-insurance ---------- none -------- Other practitioner office visit Not Covered Member pays 20% co-insurance for cost of chiropractor 30% co-insurance Coverage for Chiropractic services if prior authorization is not obtained. Plan Providers seen without a referral $50 copay/visitlimited to 12 days annual max. Preventive care/ screening/ Care Screening/immunization Adult routine physical exam 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. No charge 30% co-insurance 50% co-insurance ---------- none -------- ---------- none -------- If you have a test Diagnostic test (x-ray, blood work) X20% co-ray: $5 copay/service Lab: $5 copay/service Not Covered Member pays for cost of services if prior authorization is not obtained. insurance 30% co-insurance ---------- none -------- Imaging (CT/PET scans, MRIs) PET Scan: 20% co-insurance 30% co-insurance ---------- none -------- Co-payments are fixed dollar amounts (for example, $10 copay/service MRI: 15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health plan's allowed amount for an overnight hospital stay is $10 copay/service CT: 1,000, your co-insurance payment of 20% would be $10 copay/service Not Covered 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 charge is $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 in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Your Cost if you use an Limitations & Exceptions Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.healthplanofnevada .com Tier 1 xxx.xxXxxxx.xxx Generic drugs $25 copay10 co-pay/prescription (retailretail 30 days) $62.50 copay20 co-pay/prescription (mailretail and home delivery 90 days) 30% co-insurance/prescription (30 day retail) Not Covered You have (home delivery) Coverage is limited up to a 3-Tier pharmacy plan. Covers 90- day supply (retail and home delivery); up to a 30-day retail supply or up to (retail) and a 9090¬day supply (home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. Preferred brand drugs $30 co-day mail order supply. Member pays for cost of services if prior authorization or step therapy is not obtained. Tier 2 $50 copaypay/prescription (retailretail 30 days) $125 copay60 co-pay/prescription (mailretail and home delivery 90 days) 30% co-insurance/prescription (30 day retail) Not Covered Tier 3 (home delivery) Non-preferred brand drugs $75 copay60 co-pay/prescription (retailretail 30 days) $187.50 copay120 co-pay/prescription (mailretail and home delivery 90 days) 30% co-insurance/prescription (30 day retail) Not Covered Tier 4 Not Covered Not Covered Not Applicable. 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 mosthome delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) $75 copay/admit Not Covered Member pays for cost of services if prior authorization is not obtained. 20% co-insurance 30% co-insurance -----------none-------- Physician/surgeon fees $20 copay/surgery Not Covered 20% co-insurance 30% co-insurance -----------none-------- If you need immediate medical attention Emergency room care ER Physician: No charge ER Facility: services $500 copay200 co-pay/visit ER Physician: No charge ER Facility: $500 copay200 co-pay/visit You may be balance billed from NonPer visit co-Plan Providers. pay is waived if admitted Emergency medical transportation $50 copay/trip $50 copay/trip 20% co-insurance 20% co-insurance -----------none-------- Urgent care $20 copay35 co-pay/visit $20 copay35 co-pay/visit You may be balance billed from NonPer visit co-Plan Providers. pay is waived if admitted If you have a hospital stay Facility fee (e.g., hospital room) $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. 20% co-insurance 30% co-insurance -----------none-------- Physician/surgeon fees No charge Not Covered 20% co-insurance 20% co-insurance -----------none-------- Common Medical Event Services You May Need Your Cost if you use an Limitations & Exceptions If you need have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services Outpatient 20% co-insurance 30% co-insurance -----------none-------- Mental/Behavioral health inpatient services $10 copay/visit Not Covered Member pays for cost of 20% co-insurance 30% co-insurance -----------none-------- Substance use disorder outpatient services if prior authorization is not obtained. Inpatient 20% co-insurance 30% co-insurance -----------none-------- Substance use disorder inpatient services $350 copay/day $1750 max/admit Not Covered 20% co-insurance 30% co-insurance -----------none-------- If you are pregnant Office visits No charge Not Covered Routine prenatal Prenatal and postnatal care obtained from a Plan Provider is covered at no charge. Maternity care may include tests 20% co-insurance 30% co-insurance -----------none-------- Delivery and all inpatient services described elsewhere in the SBC (i.e. Lab). Childbirth/delivery professional services Surgical: No charge Anesthesia: No charge Not Covered Childbirth/delivery professional services includes Anesthesia and Physician Surgical Services; each service has a separate cost- share. Member pays for cost of services if prior authorization is not obtained. Childbirth/delivery facility services $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information HMO Provider (You will pay the least) Non20% co-Plan Provider (You will pay the most) insurance 30% co-insurance -----------none-------- If you need help recovering or have other special health needs Home health care No charge 20% co-insurance 30% co-insurance -----------none-------- Rehabilitation services 20% co-insurance 30% co-insurance Coverage for Physical Therapy services is limited to 40 days annual max, Speech Therapy is limited to 20 days annual max and Occupational Therapy, Pulmonary Rehabilitation and Cognitive Therapy are limited to 20 days annual max. Cardiac Rehabilitation services are limited to 36 days annual max. Habilitation services Not Covered Does not include Specialty Prescription Drugs. Member pays for cost of services if prior authorization is not obtained. Rehabilitation services $5 copay/visit Not Covered -----------none-------- Skilled nursing care 20% co-insurance 30% co-insurance Coverage is limited to a combined Inpatient and Outpatient benefit of 120 days/visits per year. Member pays for cost of services if prior authorization is not obtained. Habilitation services $5 copay/visit Not Covered Coverage is limited to a combined Inpatient and Outpatient benefit of 120 days/visits per year. Member pays for cost of services if prior authorization is not obtained. Skilled nursing care $250 copay/admit Not Covered Coverage is limited to 100 days. Member pays for cost of services if prior authorization is not obtained. days annual max Durable medical equipment No charge Not Covered For purchase or rental at HPN's option. Purchases are limited to a single type of DME, including repair and replacement, every 3 years. Member pays for cost of services if prior authorization is not obtained. 20% co-insurance 30% co-insurance -----------none-------- Hospice services $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. 20% co-insurance 30% co-insurance -----------none-------- If your child needs dental or eye care Children's eye exam Eye Exam Not Covered Not Covered Your plan may include certain vision and/or dental services. Please refer to your plan documents for more information. Children's glasses -----------none-------- Glasses Not Covered Not Covered Children's dental -----------none-------- Dental check-up Not Covered Not Covered -----------none-------- Excluded Services & Other Covered Services: Services Services Your Plan Generally Does NOT Cover (This isn't a complete list. Check your policy or plan document for more information and a list of any other excluded services.) Abortion (except for rape, incest, life at risk) Acupuncture Cosmetic surgery Dental care (Adult) Long Habilitation services Private-term care Non-emergency care when traveling outside the U.S. duty nursing Routine eye care (Adult) Routine foot care Weight loss programs Cosmetic surgery Hearing aids Dental care (Adult) Infertility treatment Dental care (Children) Long-term care Eye care (Children) Non-emergency care when traveling outside the U.S. 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.) Bariatric surgery - One (1) per Lifetime Hearing aids - One (1) every three (3) years (including repair/replace) Chiropractic care - 20 visits per calendar year Limited infertility treatment Your Rights to Continue Coverage: Private-duty nursing There are agencies that can help if you want to continue your coverage after it ends. For group health coverage subject to ERISA, contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.care
Appears in 1 contract
Samples: Negotiated Agreement
Important Questions Answers Why This Matters. What is the overall deductible? $0 250/single,$500/family Network $500/single,$1,000/family Non-Network Doesn't apply to coinsurance, copays and network preventive care 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 Common Medical Events chart below starting on page 2 for your costs how much you pay for covered services this plan covers. Are there services covered before after you meet your the deductible? Not Applicable Not Applicable . Are there other deductibles for specific services? No You don't n’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. What is the Is there an out-of-pocket limit for this planon my expenses? Yes, Coinsurance Limit: $6,8501,000/Member and single,$2,000/family Network $13,7002,000/Family single,$4,000/family Non-Network Out-of-pocket Limit: $6,600/single,$13,200/family Network Unlimited/single,Unlimited/family Non-Network The out-of-pocket limit is the most you could pay in during a year coverage period (usually one year) for your share of the cost of covered services. If This limit helps you have other family members plan for health care expenses. The coinsurance limit is included in this plan, they have to meet their own the out-of-pocket limits until the overall family out-of-pocket limit has been metlimit. What is not included in the out-of-pocket limit? Penalties for not obtaining any required prior authorization, premiumsPremiums, balance-billing charges, billed charges and health care this plan doesn't cover. Even though you pay these expenses, they don't n’t count toward the out-of- –of–pocket limit. Will you Is there an overall annual limit on what the insurer pays? No The chart starting on page 2 describes any limits on what the plan will pay less if you for specific covered services, such as office visits. Does this plan use a network providerof providers? Yes. , See xxx.xxxxxxxxxxxxxxxxxx.xxx/Xxxxxx/Xxxxxx- or-Provider XxxXxxxxx.xxx/XXX or call 0-000-000-0000 000.000.0000 for a list of Plan Providersparticipating 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 If you use an out-ofin-network doctor or other health care provider, and you might receive a xxxx from a provider for this plan will pay some or all of the difference between the provider's charge and what your plan pays (balance billing)costs of covered services. Be aware aware, your in-network provider might doctor or hospital may use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. 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. Do you I need a referral to see a specialist? No You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes See your policy or plan document for additional information about excluded services. Questions: Call 000.000.0000 or visit us at XxxXxxxxx.xxx/XXX. If you aren’t clear about any of the underlined terms in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a copy. 882859801 BEN1611683108853-00020 APPENDIX M (continued) LERC : Plan 6 Vermilion Coverage Period: 07/01/2016 – 06/30/2017 Summary of Benefits and Coverage: What This plan will Plan Covers & What it Costs Coverage for: Single or Family / Plan Type: PPO •Copayments are fixed dollar amounts (for example, $15) you pay some or all for covered health care, usually when you receive the service. •Coinsurance is your share of the costs to see of a specialist 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 but only 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 a referral before to pay the $500 difference. (This is called balance billing.) •This plan may encourage you see the specialistto use Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need What Your Cost if You Will Pay Limitations, Exceptions & Other Important Information HMO Use a Network Provider (Your Cost if You will pay the least) Use a Non-Plan Network Provider (You will pay the most) Limitations and Exceptions If you visit a health care provider's ’s office or clinic Primary care visit to treat an injury or illness $20 15 copay/visit Not Covered None 30% coinsurance -----none----- Specialist visit $40 15 copay/visit 30% coinsurance -----none----- Other practitioner office visit (Chiropractic) 10% coinsurance 30% coinsurance -----none----- Other practitioner office visit (Acupuncture) Not Covered Member pays for cost of services if prior authorization is not obtained. Plan Providers seen without a referral $50 copay/visit. Excluded Service Preventive care/ screening/ 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. 50% coinsurance -----none----- If you have a test Diagnostic test (x-ray, ) 10% coinsurance 30% coinsurance -----none----- Diagnostic test (blood work) X-ray: $5 copay/service Lab: $5 copay/service Not Covered Member pays for cost of services if prior authorization is not obtained. 10% coinsurance 30% coinsurance -----none----- Imaging (CT/PET scans, MRIs) PET Scan: $10 copay/service MRI: $10 copay/service CT: $10 copay/service Not Covered If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.healthplanofnevada .com Tier 1 $25 copay/prescription (retail) $62.50 copay/prescription (mail) Not Covered You have a 3-Tier pharmacy plan. Covers up to a 10% coinsurance 30-day retail supply or up to a 90-day mail order supply. Member pays for cost of services if prior authorization or step therapy is not obtained. Tier 2 $50 copay/prescription (retail) $125 copay/prescription (mail) Not Covered Tier 3 $75 copay/prescription (retail) $187.50 copay/prescription (mail) Not Covered Tier 4 Not Covered Not Covered Not Applicable. 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) % coinsurance -----none----- If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) $75 copay/admit Not Covered Member pays for cost of services if prior authorization is not obtained. 10% coinsurance 30% coinsurance -----none----- Physician/surgeon fees $20 copay/surgery Not Covered If you need immediate medical attention Emergency room care ER Physician(Outpatient) 10% coinsurance 30% coinsurance -----none----- Questions: No charge ER Facility: $500 copay/Call 000.000.0000 or visit ER Physician: No charge ER Facility: $500 copay/visit You may be balance billed from Non-Plan Providers. Emergency medical transportation $50 copay/trip $50 copay/trip Urgent care $20 copay/visit $20 copay/visit You may be balance billed from Non-Plan Providersus at XxxXxxxxx.xxx/XXX. If you have aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a hospital stay Facility fee (e.g., hospital room) $350 copay/day $1750 max/admit Not Covered Member pays for cost copy. 882859801 BEN1611683108853-00020 APPENDIX N LERC : Plan 21 Coverage Period: 07/01/2016 – 06/30/2017 Summary of services if prior authorization Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Single or Family / Plan Type: PPO This is not obtainedonly a summary. Physician/surgeon fees No charge Not Covered If you need mental healthwant more detail about your coverage and costs, behavioral health, or substance abuse services Outpatient services $10 copay/visit Not Covered Member pays for cost of services if prior authorization is not obtained. Inpatient services $350 copay/day $1750 max/admit Not Covered If you are pregnant Office visits No charge Not Covered Routine prenatal care obtained from a Plan Provider is covered at no charge. Maternity care may include tests and services described elsewhere can get the complete terms in the SBC (i.e. Lab). Childbirth/delivery professional services Surgical: No charge Anesthesia: No charge Not Covered Childbirth/delivery professional services includes Anesthesia and Physician Surgical Services; each service has a separate cost- share. Member pays for cost of services if prior authorization is not obtained. Childbirth/delivery facility services $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. 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 need help recovering or have other special health needs Home health care No charge Not Covered Does not include Specialty Prescription Drugs. Member pays for cost of services if prior authorization is not obtained. Rehabilitation services $5 copay/visit Not Covered Coverage is limited to a combined Inpatient and Outpatient benefit of 120 days/visits per year. Member pays for cost of services if prior authorization is not obtained. Habilitation services $5 copay/visit Not Covered Coverage is limited to a combined Inpatient and Outpatient benefit of 120 days/visits per year. Member pays for cost of services if prior authorization is not obtained. Skilled nursing care $250 copay/admit Not Covered Coverage is limited to 100 days. Member pays for cost of services if prior authorization is not obtained. Durable medical equipment No charge Not Covered For purchase or rental at HPN's option. Purchases are limited to a single type of DME, including repair and replacement, every 3 years. Member pays for cost of services if prior authorization is not obtained. Hospice services $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. If your child needs dental or eye care Children's eye exam Not Covered Not Covered Your plan may include certain vision and/or dental services. Please refer to your plan documents for more information. Children's glasses Not Covered Not Covered Children's dental check-up Not Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded servicesat XxxXxxxxx.xxx/XXX or by calling 000.000.0000.) Abortion (except for rape, incest, life at risk) Acupuncture Cosmetic surgery Dental care (Adult) Long-term care Non-emergency care when traveling outside the U.S. Routine eye care (Adult) Routine foot care Weight loss programs Bariatric surgery - One (1) per Lifetime Hearing aids - One (1) every three (3) years (including repair/replace) Chiropractic care - 20 visits per calendar year Limited infertility treatment Your Rights to Continue Coverage: Private-duty nursing There are agencies that can help if you want to continue your coverage after it ends. For group health coverage subject to ERISA, contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.
Appears in 1 contract
Samples: Negotiations Agreement
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. Some of the services this plan doesn't cover are listed on page 5. See xxx.xxxxxxxxxxxxxxxxxx.xxx/Xxxxxx/Xxxxxx- or-Provider your policy or call 0-000-000-0000 plan document for a list of Plan Providersadditional information about excluded services. 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 Your Cost 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. Limitations & Exceptions Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information HMO In-Network Provider (You will pay the least) NonOut-Plan of-Network 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 20% co-insurance 30% co-insurance ---------- none -------- Specialist visit $40 copay/20% co-insurance 30% co-insurance ---------- none -------- Other practitioner office visit Not Covered Member pays 20% co-insurance for cost of chiropractor 30% co-insurance Coverage for Chiropractic services if prior authorization is not obtained. Plan Providers seen without a referral $50 copay/visitlimited to 12 days annual max. Preventive care/ screening/ Care Screening/immunization Adult routine physical exam 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. No charge 30% co-insurance 50% co-insurance ---------- none -------- ---------- none -------- If you have a test Diagnostic test (x-ray, blood work) X20% co-ray: $5 copay/service Lab: $5 copay/service Not Covered Member pays for cost of services if prior authorization is not obtained. insurance 30% co-insurance ---------- none -------- Imaging (CT/PET scans, MRIs) PET Scan: 20% co-insurance 30% co-insurance ---------- none -------- • Co-payments are fixed dollar amounts (for example, $10 copay/service MRI: 15) you pay for covered health care, usually when you receive the service. • Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health plan's allowed amount for an overnight hospital stay is $10 copay/service CT: 1,000, your co-insurance payment of 20% would be $10 copay/service Not Covered 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 charge is $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 in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Your Cost if you use an Limitations & Exceptions Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.healthplanofnevada .com Tier 1 xxx.xxXxxxx.xxx Generic drugs $25 copay10 co-pay/prescription (retailretail 30 days) $62.50 copay20 co-pay/prescription (mailretail and home delivery 90 days) 30% co-insurance/prescription (30 day retail) Not Covered You have (home delivery) Coverage is limited up to a 3-Tier pharmacy plan. Covers 90- day supply (retail and home delivery); up to a 30-day retail supply or up to (retail) and a 9090¬day supply (home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. Preferred brand drugs $30 co-day mail order supply. Member pays for cost of services if prior authorization or step therapy is not obtained. Tier 2 $50 copaypay/prescription (retailretail 30 days) $125 copay60 co-pay/prescription (mailretail and home delivery 90 days) 30% co-insurance/prescription (30 day retail) Not Covered Tier 3 (home delivery) Non-preferred brand drugs $75 copay60 co-pay/prescription (retailretail 30 days) $187.50 copay120 co-pay/prescription (mailretail and home delivery 90 days) 30% co-insurance/prescription (30 day retail) Not Covered Tier 4 Not Covered Not Covered Not Applicable. 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 mosthome delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) $75 copay/admit Not Covered Member pays for cost of services if prior authorization is not obtained. 20% co-insurance 30% co-insurance -----------none-------- Physician/surgeon fees $20 copay/surgery Not Covered 20% co-insurance 30% co-insurance -----------none-------- If you need immediate medical attention Emergency room care ER Physician: No charge ER Facility: services $500 copay200 co-pay/visit ER Physician: No charge ER Facility: $500 copay200 co-pay/visit You may be balance billed from NonPer visit co-Plan Providers. pay is waived if admitted Emergency medical transportation $50 copay/trip $50 copay/trip 20% co-insurance 20% co-insurance -----------none-------- Urgent care $20 copay35 co-pay/visit $20 copay35 co-pay/visit You may be balance billed from NonPer visit co-Plan Providers. pay is waived if admitted If you have a hospital stay Facility fee (e.g., hospital room) $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. 20% co-insurance 30% co-insurance -----------none-------- Physician/surgeon fees No charge Not Covered 20% co-insurance 20% co-insurance -----------none-------- Common Medical Event Services You May Need Your Cost if you use an Limitations & Exceptions If you need have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services Outpatient 20% co-insurance 30% co-insurance -----------none-------- Mental/Behavioral health inpatient services $10 copay/visit Not Covered Member pays for cost of 20% co-insurance 30% co-insurance -----------none-------- Substance use disorder outpatient services if prior authorization is not obtained. Inpatient 20% co-insurance 30% co-insurance -----------none-------- Substance use disorder inpatient services $350 copay/day $1750 max/admit Not Covered 20% co-insurance 30% co-insurance -----------none-------- If you are pregnant Office visits No charge Not Covered Routine prenatal Prenatal and postnatal care obtained from a Plan Provider is covered at no charge. Maternity care may include tests 20% co-insurance 30% co-insurance -----------none-------- Delivery and all inpatient services described elsewhere in the SBC (i.e. Lab). Childbirth/delivery professional services Surgical: No charge Anesthesia: No charge Not Covered Childbirth/delivery professional services includes Anesthesia and Physician Surgical Services; each service has a separate cost- share. Member pays for cost of services if prior authorization is not obtained. Childbirth/delivery facility services $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information HMO Provider (You will pay the least) Non20% co-Plan Provider (You will pay the most) insurance 30% co-insurance -----------none-------- If you need help recovering or have other special health needs Home health care No charge 20% co-insurance 30% co-insurance -----------none-------- Rehabilitation services 20% co-insurance 30% co-insurance Coverage for Physical Therapy services is limited to 40 days annual max, Speech Therapy is limited to 20 days annual max and Occupational Therapy, Pulmonary Rehabilitation and Cognitive Therapy are limited to 20 days annual max. Cardiac Rehabilitation services are limited to 36 days annual max. Habilitation services Not Covered Does not include Specialty Prescription Drugs. Member pays for cost of services if prior authorization is not obtained. Rehabilitation services $5 copay/visit Not Covered -----------none-------- Skilled nursing care 20% co-insurance 30% co-insurance Coverage is limited to a combined Inpatient and Outpatient benefit of 120 days/visits per year. Member pays for cost of services if prior authorization is not obtained. Habilitation services $5 copay/visit Not Covered Coverage is limited to a combined Inpatient and Outpatient benefit of 120 days/visits per year. Member pays for cost of services if prior authorization is not obtained. Skilled nursing care $250 copay/admit Not Covered Coverage is limited to 100 days. Member pays for cost of services if prior authorization is not obtained. days annual max Durable medical equipment No charge Not Covered For purchase or rental at HPN's option. Purchases are limited to a single type of DME, including repair and replacement, every 3 years. Member pays for cost of services if prior authorization is not obtained. 20% co-insurance 30% co-insurance -----------none-------- Hospice services $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. 20% co-insurance 30% co-insurance -----------none-------- If your child needs dental or eye care Children's eye exam Eye Exam Not Covered Not Covered Your plan may include certain vision and/or dental services. Please refer to your plan documents for more information. Children's glasses -----------none-------- Glasses Not Covered Not Covered Children's dental -----------none-------- Dental check-up Not Covered Not Covered -----------none-------- Excluded Services & Other Covered Services: Services Services Your Plan Generally Does NOT Cover (This isn't a complete list. Check your policy or plan document for more information and a list of any other excluded services.) Abortion (except for rape, incest, life at risk) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental care (Children) Eye care (Children) • Habilitation services • Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine eye care (Adult) • Routine foot care • Weight loss programs 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.) • Bariatric surgery - One (1) per Lifetime Hearing aids - One (1) every three (3) years (including repair/replace) • Chiropractic care - 20 visits per calendar year Limited infertility treatment Your Rights to Continue Coverage: Private-duty nursing There are agencies that can help if you want to continue your coverage after it ends. For group health coverage subject to ERISA, contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.care
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Samples: Negotiated Agreement
