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 questions about your rights, this notice, or assistance, you can contactParamount Insurance Co. Member Service Department at (000) 000-0000 or Toll Free at 1(800) 462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Single/Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered heath care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. For general definitions of common terms such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? $300 Single (Paramount Ohio HMO Network.) $600 Family (Paramount Ohio HMO Network.) Does not apply to preventive care or covered services requiring a copayment. 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, preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there otherdeductibles for specific services? No (Paramount Ohio HMO Network.) You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2000 Single (Paramount Ohio HMO Network.) $4000 Family(Paramount Ohio HMO Network.) 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 includedin the out-of-pocket limit? Premiums 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 ifyou use a network provider? Yes. See xxx.xxxxxxxxxxxxxxxxxxx.xxx/XxxxXXxxxxxxx or call 0-000-000-0000 for a list of Paramount Ohio HMO 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 (a balance bill). 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 areferral to see a specialist? No You can see the specialist you choose without a referral. 50
Appears in 2 contracts
Samples: Negotiated Agreement, Negotiated Agreement
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 questions about your rights, this notice, or assistance, you can contactParamount Insurance Co. Member Service Department at (000) 000-0000 or Toll Free at 1(800) 462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Single/Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered heath care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. For general definitions of common terms such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? $300 Single (Paramount Ohio HMO Network.) $600 Family (Paramount Ohio HMO Network.) Does not apply to preventive care or covered services requiring a copayment. 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, preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there otherdeductibles for specific services? No (Paramount Ohio HMO Network.) You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2000 Single (Paramount Ohio HMO Network.) $4000 Family(Paramount Ohio HMO Network.) 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 includedin the out-of-pocket limit? Premiums 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 ifyou use a network provider? Yes. See xxx.xxxxxxxxxxxxxxxxxxx.xxx/XxxxXXxxxxxxx or call 0-000-000-0000 for a list of Paramount Ohio HMO 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 (a balance bill). 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 areferral to see a specialist? No You can see the specialist you choose without a referral. 50All 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 If you visit a health care provider's office or clinic Primary Care visit to treat an injury or illness $25.00 Co-pay/visit. Not covered. –––––––––––none––––––––––– Specialist visit $35.00 Co-pay/visit. Not covered. –––––––––––none––––––––––– 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) 15% Co-Insurance. Not covered. –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) 15% Co-Insurance. Not covered. –––––––––––none––––––––––– If you need drugs to treat your illness or condition More information about prescription drug coverage is available xxxxx.xxxxxxxxxxxxxxxxxxx.xxx/Xxxxxxxxx- PharmacyResources-CommercialDrugBenefits Prescription Drug Coverage Not Covered By Paramount. Not Covered By Paramount. Not Covered By Paramount. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 15% Co-Insurance. Not covered. –––––––––––none––––––––––– Physician/surgeon fees 15% Co-Insurance. Not covered. –––––––––––none––––––––––– If you need immediate medical attention Emergency room care $100.00 Co-pay/visit. Payable under HMO network of benefits. –––––––––––none––––––––––– Emergency medical transportation 15% Co-Insurance. Payable under HMO network of benefits. –––––––––––none––––––––––– Urgent care $15.00 Co-pay/visit. Payable under HMO network of benefits. –––––––––––none––––––––––– If you have a hospital stay Facility fee (e.g., hospital room) 15% Co-Insurance. Not covered. –––––––––––none––––––––––– Physician/surgeon fees 15% Co-Insurance. Not covered. –––––––––––none––––––––––– If you need mental health, behavioral health, or substance abuse services Outpatient services $25.00 Co-pay/visit. Not covered. –––––––––––none––––––––––– Inpatient services 15% Co-Insurance. Not covered. –––––––––––none––––––––––– If you are pregnant Office visits $35.00 Co-pay/visit. Not covered. Deductible does not apply. Cost sharing does not apply for preventive services. 40 *For more information about limitations and exceptions, see the plan or policy document at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx. PLAN 2 If you are pregnant Childbirth/delivery professional services 15% Co-Insurance. Not covered. –––––––––––none––––––––––– Childbirth/delivery facility services 15% Co-Insurance. Not covered. –––––––––––none––––––––––– If you need help recovering or have other special health needs Home health care 15% Co-Insurance. Not covered. –––––––––––none––––––––––– Rehabilitation services 15% Co-Insurance. Not covered. Inpatient Rehabilitation is limited to 60 days per calendar year. Outpatient physical, occupational and speech therapy limited to 30 visits combined. Habilitation services 15% Co-Insurance. Not covered. Inpatient Habilitation is limited to 60 days per calendar year. Outpatient physical, occupational and speech therapy limited to 30 visits combined. Skilled nursing care 15% Co-Insurance. Not covered. Unliimited days. Durable medical equipment No charge. Not covered. Subject to Medicare part B Guidelines. Hospice services 15% Co-Insurance. Not covered. –––––––––––none––––––––––– If your child needs dental or eye care Children's eye exam No charge. Not covered. Limited to one (1) routine vision exam every twelve (12) months. Children's glasses Not covered. Not covered. –––––––––––none––––––––––– Children's dental check-up Not covered. Not covered. –––––––––––none––––––––––– 41 Services Your Plan Generally Does NOT cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Dental care (Adult) • Private-duty nursing • Bariatric Surgery • Long-term care • Routine foot care • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please check your plan document. • Chiropractic care • Routine eye care (Adult) • Hearing Aids ($700 toward the purchase of hearing aid(s) every 36 months) • Infertility treatment (Excludes infertility drugs) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration, 1-866-444-EBSA (3272), xxx.xxx.xxx/xxxx/xxxxxxxxxxxx
Appears in 1 contract
Samples: Negotiated Agreement
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 questions about your rights, this notice, or assistance, you can contactParamount Insurance Co. Member Service Department at (000) 000-0000 or Toll Free at 1(8000(000) 462000-35890000, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Single/Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered heath care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. For general definitions of common terms such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? $300 Single (Paramount Ohio HMO Network.) $600 Family (Paramount Ohio HMO Network.) Does not apply to preventive care or covered services requiring a copayment. 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, preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there otherdeductibles for specific services? No (Paramount Ohio HMO Network.) You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2000 Single (Paramount Ohio HMO Network.) $4000 Family(Paramount Ohio HMO Network.) 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 includedin the out-of-pocket limit? Premiums 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 ifyou use a network provider? Yes. See xxx.xxxxxxxxxxxxxxxxxxx.xxx/XxxxXXxxxxxxx or call 0-000-000-0000 for a list of Paramount Ohio HMO 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 (a balance bill). 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 areferral to see a specialist? No You can see the specialist you choose without a referral. 50
Appears in 1 contract
Samples: Negotiated Agreement
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 questions about your rights, this notice, or assistance, you can contactParamount Insurance Co. Member Service Department at (000) 000-0000 or Toll Free at 1(800) 462-3589, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Single/Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered heath care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, contact Paramount at 0-000-000-0000 or xxx.xxxxxxxxxxxxxxxxxxx.xxx/xxxxxx-xxxxxxxxx. For general definitions of common terms such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx or call 0-000-000-0000 to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? $300 Single (Paramount Ohio HMO Network.) $600 Family (Paramount Ohio HMO Network.) Does not apply to preventive care or covered services requiring a copayment. 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, preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there otherdeductibles for specific services? No (Paramount Ohio HMO Network.) You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2000 Single (Paramount Ohio HMO Network.) $4000 Family(Paramount Ohio HMO Network.) 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 includedin the out-of-pocket limit? Premiums 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 ifyou use a network provider? Yes. See xxx.xxxxxxxxxxxxxxxxxxx.xxx/XxxxXXxxxxxxx or call 0-000-000-0000 for a list of Paramount Ohio HMO 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 (a balance bill). 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 areferral to see a specialist? No You can see the specialist you choose without a referral. 50
Appears in 1 contract
Samples: Negotiated Agreement
