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1 Important Questions (Massachusetts ) (New England ) (National ) What is the overall $0.00 Are there other s for specific? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Yes. For medical benefits, $2,000 member / $4,000 family; and for prescription drug benefits, $1,000 member / $2,000 family. $500 member / $1,000 family. Does not apply to preventive care, prenatal care, emergency room, prescription drugs, most office s, mental health, emergency transportation, home health care, and hospice. $250 member -- $500 family Does not apply to in- preventive and prenatal care, most office s, therapy s, mental health s; prescription drugs, emergency room, emergency transportation No No No Yes. For medical benefits, $2,000 member / $4,000 family; and for prescription drug benefits, $1,000 member / $2,000 family. Yes. For medical benefits, $2,000 member / $4,000 family; and for prescription drug benefits, $1,000 member / $2,000 family. 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. Does this plan use a of providers? Do I need a referral to see a specialist? Are there this plan does not cover? Yes, for all plans, see or call for a list of providers. Uses a MASSACHUSETTS based Uses a NEW ENGLAND based ME, VT, NH, MA, CT, RI Uses a NATIONAL Yes Yes No Yes Please see the complete Summary of Benefits & Coverage and the plan document for details This is not a complete list: Acupuncture Children s glasses Cosmetic Surgery Dental Care (adult) Long-term Care Non-emergency care when traveling outside of the US Private Duty nursing Acupuncture Children s glasses Cosmetic Surgery Dental Care (adult) Long-term Care Non-emergency care when traveling outside of the US Private Duty nursing Acupuncture Children s glasses Cosmetic Surgery Dental Care (adult) Long-term Care Private Duty nursing Page 1 of 11

2 If you a health care provider s office or clinic If you have a test PCP to treat an injury or illness In $15.00 Specialist Visit $25.00 Other Practitioner office Preventive Care / screening / immunization Diagnostic Test (x-ray, blood work) Imaging (CT/PET scans, MRIs) $25/ chiropractor $75.00 (Massachusetts ) (New England ) In $20.00 $30.00 GYN exam limited to 1 exam per calendar yr Copay applies per category of test/day; some. $30/ chiropractor (National ) In $15.00 $15.00 GYN exam limited to 1 exam per calendar yr $15/ chiropractor to out of to out of to out of for out of ; limited to age based frequency and/or schedule Page 2 of 11

3 If you need drugs to treat your illness or condition More info about prescription drug coverage is available at ma.com Generic drugs Preferred Brand Drugs Non-preferred Brand Drugs Specialty Drugs (Massachusetts ) In $10 retail $20 mail $30 retail $60 mail $50 retail $100 mail Applicable cost share (generic, preferred, non preferred) Up to 30 day retail (90 day mail ) ; cost share waived for birth control and orally administered anti-cancer drugs; drugs. When obtained from designated specialty pharmacy; drugs. (New England ) In $10 retail $20 mail $30 retail $60 mail $50 retail $100 mail Applicable cost share (generic, preferred, non preferred) Up to 30 day retail (90 day mail ) ; cost share waived for birth control and orally administered anti-cancer drugs; drugs. When obtained from designated specialty pharmacy; drugs. (National ) In $10 retail $20 mail $30 retail $60 mail $50 retail $100 mail Applicable cost share (generic, preferred, non preferred) Up to 30 day retail (90 day mail ) ; cost share waived for birth control and orally administered anti-cancer drugs; drugs. When obtained from designated specialty pharmacy; drugs. Page 3 of 11

4 If you have outpatient surgery If you need immediate medical attention Facility fee (e.g. ambulatory surgery center) Physician / surgeon fees Emergency Room Services Emergency medical transportation Urgent Care In $150 per (colonoscopies not subject to copay) $75.00 per (Massachusetts ) $75.00 per Copayment waived if admitted or for observation stay (New England ) In (colonoscopies not subject to ) (colonoscopie s not subject to ) $ per $ per Copayment waived if admitted or for observation stay No Charge No Charge $25.00 per $25.00 per coverage limited to out of area $30.00 per $30.00 per coverage limited to out of area (National ) In $250 per (colonoscopies not subject to copay) $ per 10% coinsurance $15.00 per $ per 10% coinsurance Copayment waived if admitted or for observation stay for out of Page 4 of 11

5 If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs Facility Fee (e.g. hospital room) Physician / surgeon fee Mental / Behavioral health outpatient Mental / Behavioral health inpatient Substance use disorder outpatient Substance use disorder inpatient In $250 per $15.00 per $250 per $15.00 per $ per (Massachusetts ) (New England ) In $20.00 per $20.00 per (National ) In $15.00 per $15.00 per for out of for out of Page 5 of 11

6 If you are pregnant Prenatal and Postnatal care Delivery and all inpatient Home health care (Massachusetts ) In $250 per and no charge for delivery (New England ) In (National ) In for prenatal care; 10% coinsurance for postnatal care 20% coinsurance for prenatal care; 30% coinsurance for postnatal care for in- postnatal care and out-of prenatal and postnatal care applies; If you need help recovering or have other special health needs Rehabilitation $25 per $15 per for speech therapy Limit 60 s per calendar yr (other than for autism, home health care and speech therapy); $30 per limited to 60 s per calendar year (other than for autism, home health care, and speech therapy); $15 per for out of ; limited to 100 s per calendar year (other than for autism, home health care, and speech therapy) Page 6 of 11

7 If you need help recovering or have other special health needs Habilitation Skilled Nursing care (Massachusetts ) In $25 per $15 per for speech therapy Rehabilitation therapy coverage limits apply; cost share and coverage limits waived for early intervention for eligible children; pre-authorization. Limited to 100 days per calendar year; (New England ) In $30 per, rehabilitation therapy coverage limits apply; cost share and coverage limits waived for early intervention for eligible children; limited to 100 days per calendar year; (National ) In $15 per for out of ; rehabilitation therapy coverage limits apply; cost share and coverage limits waived for early intervention for eligible children limited to 100 days per calendar year; Page 7 of 11

8 Services You May Need In (Massachusetts ) (New England ) In (National ) In If you need help recovering or have other special health needs Durable medical equipment Hospice Service Cost share waived for one breast pump per birth. cost share waived for one breast pump per birth Pre-authorization 40% coinsurance in cost share waived for one breast pump per birth (20% co-insurance for out of applies;. If your child needs dental or eye care Eye exam Glasses Dental Check up Limited to one exam per calendar year Limited to children under age 12 (one exam every 6 months) and under age 18 with a cleft palate/ cleft lip condition. Limited to one exam per calendar year Limited to members under age 12 (one exam every 6 months); and members under age 18 with a cleft palate / cleft lip condition. for members with a cleft palate / cleft lip condition for members with a cleft palate / cleft lip condition for out of ; limited to one exam per calendar year. Limited to members under age 18; for out of. Page 8 of 11

9 Other (This isn t a complete list. Check the policy or plan document for other and your costs for these (Massachusetts ) Bariatric surgery Chiropractic care Hearing aids ($2,000 per ear every 36 months for members age 21 and younger) Infertility treatment Routine eye care (one exam per calendar year) Routine foot care (only for patients with systemic circulatory disease) Weight loss programs ($150 per calendar year per policy) (New England ) Bariatric surgery Chiropractic care Hearing aids ($2,000 per ear every 36 months for members age 21 and younger) Infertility treatment Routine eye care (one exam per calendar year) Routine foot care (only for patients with systemic circulatory disease) Weight loss programs ($150 per calendar year per policy) (National ) Bariatric surgery Chiropractic care Hearing aids ($2,000 per ear every 36 months for members age 21 and younger) Infertility treatment Routine eye care (one exam per calendar year) Routine foot care (only for patients with systemic circulatory disease) Weight loss programs ($150 per calendar year per policy) Non-emergency care when traveling outside the U.S. Page 9 of 11

10 Women s Health and Cancer Rights Act of 1998: All of the Mount Holyoke College group health insurance plans provide benefits for mastectomy related including surgery, reconstruction, prostheses and treatment of physical complications. Please contact your health insurance provider for details. Premium Assistance under Medicaid and the Children s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, you can contact the Department of Labor electronically at or by calling toll-free EBSA (3272). If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of January 31, You should contact your State for further information on eligibility. Page 10 of 11

11 MAINE Medicaid Website: Phone: Medicaid Website: dmahs/clients/medicaid/ Medicaid Phone: CHIP Website: CHIP Phone: Website: Phone: TTY NEW HAMPSHIRE Medicaid Website: Phone: MASSACHUSETTS Medicaid and CHIP NEW YORK Medicaid Website: Phone: Website: Phone: NEW YORK Medicaid Website: Phone: RHODE ISLAND Medicaid WASHINGTON Medicaid Website: Phone: Website: pages/index.aspx Phone: ext Website: Phone: , HMS Third Party Liability VERMONT Medicaid Website: Phone: To see if any more States have added a premium assistance program since January 31, 2014, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services EBSA (3272) , Menu Option 4, Ext OMB Control Number (expires 10/31/2016) Website: Phone: Page 11 of 11

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