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HomeMy WebLinkAboutAETNA HDHP SBCCITY OF GEORGETOWN : Aetna Choice® POS II : Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy. 070300-090020-031420 1 of 8 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.HealthReformPlanSBC.com or by calling 1-888-982-3862. Important Questions Answers Why this Matters: What is the overall deductible? For each Calendar Year, Network: Individual $3,000 / Family $6,000. Out-of-Network: Individual $6,000 / Family $12,000. Does not apply to preventive care in-network. 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 2 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 2 for other costs for services this plan covers. Is there an out-of-pocket limit on my expenses? Yes. Network: Individual $4,000 / Family $8,000. Out-of-Network: Individual $12,000 / Family $24,000. 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, penalties for failure to obtain pre-authorization for service, and health care this plan does not 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 2 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. See www.aetna.com or call 1-888-982-3862 for a list of network 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 2 for how this plan pays different kinds of providers. Do 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. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. CITY OF GEORGETOWN : Aetna Choice® POS II : Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy. 070300-090020-031420 2 of 8 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a 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 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 to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments, and coinsurance amounts. Common Medical Event Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use an Out–of–Network Provider Limitations & Exceptions If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness 10% coinsurance 50% coinsurance Includes Internist, General Physician, Family Practitioner or Pediatrician. Specialist visit 10% coinsurance 50% coinsurance –––––––––––none––––––––––– Other practitioner office visit 10% coinsurance 50% coinsurance Coverage is limited to 40 visits per calendar year for Chiropractic care combined with rehabilitation services. Preventive care/ screening/ immunization No charge, except hearing exams not covered 50% coinsurance, except hearing exams not covered Age and frequency schedules may apply. If you have a test Diagnostic test (x-ray, blood work) 10% coinsurance 50% coinsurance –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) 10% coinsurance 50% coinsurance –––––––––––none––––––––––– CITY OF GEORGETOWN : Aetna Choice® POS II : Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy. 070300-090020-031420 3 of 8 Common Medical Event Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use an Out–of–Network Provider Limitations & Exceptions If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.aetna.com/ pharmacy-insurance/ individuals-families Generic drugs After deductible: $10 copay/ prescription (retail), $30 copay/ prescription (mail order) After deductible: 30% coinsurance after $10 copay/ prescription (retail) Covers up to a 30 day supply (retail prescription), 31-90 day supply (mail order prescription). Includes contraceptive drugs and devices obtainable from a pharmacy, oral fertility drugs. No charge for formulary generic FDA-approved women's contraceptives in-network. Precertification required. Your cost will be higher for choosing Brand over Generics unless prescribed Dispense as Written. Preferred brand drugs After deductible: $40 copay/ prescription (retail), $120 copay/ prescription (mail order) After deductible: 30% coinsurance after $40 copay/ prescription (retail) Non-preferred brand drugs After deductible: $70 copay/ prescription (retail), $210 copay/ prescription (mail order) After deductible: 30% coinsurance after $70 copay/ prescription (retail) Specialty drugs Applicable cost as noted above for generic or brand drugs. Not covered –––––––––––none––––––––––– If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 10% coinsurance 50% coinsurance –––––––––––none––––––––––– Physician/surgeon fees 10% coinsurance 50% coinsurance –––––––––––none––––––––––– If you need immediate medical attention Emergency room services 10% coinsurance 10% coinsurance No coverage for non-emergency use. Emergency medical transportation 10% coinsurance 50% coinsurance –––––––––––none––––––––––– Urgent care 10% coinsurance 50% coinsurance No coverage for non-urgent use. If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 50% coinsurance Pre-authorization required for out-of-network care. Physician/surgeon fee 10% coinsurance 50% coinsurance –––––––––––none––––––––––– CITY OF GEORGETOWN : Aetna Choice® POS II : Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy. 070300-090020-031420 4 of 8 Common Medical Event Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use an Out–of–Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services 10% coinsurance 50% coinsurance –––––––––––none––––––––––– Mental/Behavioral health inpatient services 10% coinsurance 50% coinsurance Pre-authorization required for out-of-network care. Substance use disorder outpatient services 10% coinsurance 50% coinsurance –––––––––––none––––––––––– Substance use disorder inpatient services 10% coinsurance 50% coinsurance Pre-authorization required for out-of-network care. If you are pregnant Prenatal and postnatal care No charge 50% coinsurance –––––––––––none––––––––––– Delivery and all inpatient services 10% coinsurance 50% coinsurance Includes outpatient postnatal care. Pre-authorization may be required for out-of-network care. If you need help recovering or have other special health needs Home health care 10% coinsurance 50% coinsurance Coverage is limited to 60 visits per calendar year. Pre-authorization required for out-of-network care. Rehabilitation services 10% coinsurance 50% coinsurance Coverage is limited to 40 visits per calendar year for Physical, Occupational, Speech Therapy, and Chiropractic care combined. Habilitation services Not covered Not covered Not covered. Skilled nursing care 10% coinsurance 50% coinsurance Coverage is limited to 60 days per calendar year. Pre-authorization required for out-of-network care. Durable medical equipment 10% coinsurance 50% coinsurance –––––––––––none––––––––––– Hospice service 10% coinsurance 50% coinsurance Pre-authorization required for out-of-network care. If your child needs dental or eye care Eye exam Not covered Not covered Not covered. Glasses Not covered Not covered Not covered. Dental check-up Not covered Not covered Not covered. CITY OF GEORGETOWN : Aetna Choice® POS II : Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy. 070300-090020-031420 5 of 8 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.) Acupuncture Habilitation services Routine eye care (Adult & Child) Bariatric surgery Hearing aids Routine foot care Cosmetic surgery Long-term care Weight loss programs Dental care (Adult & Child) Non-emergency care when traveling outside the Glasses (Child) 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.) Chiropractic care - Coverage is limited to 40 visits Infertility treatment - Coverage is limited to the Private-duty nursing - Coverage is limited to 70 - 8 per calendar year combined with rehabilitation diagnosis and treatment of underlying medical hour shifts per calendar year. services. condition. Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-888-982-3862. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. 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 contact us by calling the toll free number on your Medical ID Card. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file an appeal. Contact information is at http://www.aetna.com/individuals-families-health-insurance/rights-resources/complaints-grievances-appeals/index.html Does this Coverage Provide Minimum Essential Coverage? 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. CITY OF GEORGETOWN : Aetna Choice® POS II : Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy. 070300-090020-031420 6 of 8 Does this Coverage Meet Minimum Value Standard? 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. Language Access Services: Para obtener asistencia en Español, llame al 1-888-982-3862. 1-888-982-3862. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-982-3862. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-982-3862. -------------------To see examples of how this plan might cover costs for a sample medical situation, see the next page.------------------- Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy. 070300-090020-031420 7 of 8 CITY OF GEORGETOWN : Aetna Choice® POS II : Coverage Period: 01/01/2015 - 12/31/2015 Coverage Examples Coverage for: Individual + Family | Plan Type: POS Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $3,000 Copays $200 Coinsurance $90 Limits or exclusions $80 Total $3,370 Deductibles $3,000 Copays $20 Coinsurance $220 Limits or exclusions $150 Total $3,390 Amount owed to providers: $7,540 Amount owed to providers: $5,400 Plan pays: $4,150 Plan pays: $2,030 Patient pays: $3,390 Patient pays: $3,370 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) Sample care costs: Managing type 2 diabetes (routine maintenance of a well-controlled condition) Sample care costs: This is not a cost estimator. Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be different. See the next page for important information about these examples. Patient pays: Patient pays: Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy. 070300-090020-031420 8 of 8 CITY OF GEORGETOWN : Aetna Choice® POS II : Coverage Period: 01/01/2015 - 12/31/2015 Coverage Examples Coverage for: Individual + Family | Plan Type: POS Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited. Does the Coverage Example Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides. The patient's condition was not an excluded or preexisting condition. predict my own care needs? Are there other costs I should All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. No. Treatments shown are just examples. The care you would receive for this condition could be different, based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.