The Ohio State University: Basic PPO Plan Coverage Period: 01/01/ /31/2015

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1 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 hr.osu.edu/hrpubs/ben/medicalspd.pdf or by calling or Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? For network providers: $800 person / $2,400 family For out-of-network providers: $1,600 person / $4,800 family Does not apply to prescription drugs, infertility treatment and weight loss surgery. Yes. $1,000 for infertility treatment and $400 for weight loss surgery. There are no other specific deductibles. Yes. For network providers: $3,500 person / $7,000 family For out-of-network providers: $7,000 person / $14,000 family $3,100 person/$6,200 family for prescription drugs. Infertility services, weight management programs, prior authorization penalties, premiums, balance-billed charges and health care this plan doesn t cover. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. 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. Even though you pay these expenses, they don t count toward the out-of-pocket limit. OMB Control Numbers , , and Released on April 23, 2013 (corrected) 1 of 11

2 Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? No. Yes. For a list of network providers see: osuhealthplan.com/search or call No. Yes. Important Questions Answers Why this Matters: The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 8. See your policy or plan document for additional information about excluded services. 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 ) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. 2 of 11

3 If you visit a health care provider s office or clinic If you have a test You Use a You Use an Out -of- Primary care visit to treat an injury or illness 25% coinsurance 45% coinsurance Specialist visit 25% coinsurance 45% coinsurance Other practitioner office visit 25% coinsurance 45% coinsurance Preventive care/screening/immunization No charge 45% coinsurance Some services related to office visits have charges. Out-of-network services subject to deductible and balance Services subject to deductible. Outof-network Acupuncture, chiropractic, and medical massage treatments have a combined maximum benefit of $2,000 per plan year. Services subject to deductible. Out-of-network services subject to balance Age and frequency schedules apply. Out-of-network services subject to balance billing and deductible. Diagnostic test (x-ray, blood work) 25% coinsurance 45% coinsurance Services subject to deductible. Outof-network Imaging (CT/PET scans, MRIs) 25% coinsurance 45% coinsurance 3 of 11

4 The Ohio State University: Basic PPO Plan Coverage Period: 01/01/ /31/2015 If you need drugs to treat your illness or condition More information about prescription drug coverage is available at hr.osu.edu/benefits/h b_prescription.aspx. Generic drugs Formulary brand name drugs You Use a Retail: 30% coinsurance Home Delivery: 30% coinsurance Retail: 40% coinsurance Home Delivery: 40% coinsurance You Use an Out -of- Not covered Not covered Non-formulary brand name drugs 60% coinsurance Not covered Specialty drugs 20% coinsurance (generic and formulary brand name, retail and home delivery) 50% coinsurance (non-formulary brand name, retail and home delivery) Not covered Must use network pharmacy. Covers a 30-day supply (retail), 90-day supply (home delivery). No deductible. $30 maximum (generic, retail) $75 maximum (generic, home delivery) $130 maximum (formulary brand name, retail) $325 maximum (formulary brand name, home delivery) $3,100/person; $6,200 family annual out-of-pocket maximum Certain prescription drugs require prior authorization. Covers a 30-day supply (retail and home delivery) $10 minimum and $44 maximum (generic, retail) $100 maximum (formulary brand name, retail) $9 minimum and $38 maximum (generic, home delivery) $84 maximum (formulary brand name, home delivery) 4 of 11

5 If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs You Use a You Use an Out -of- Facility fee (e.g., ambulatory surgery center) 25% coinsurance 45% coinsurance Services subject to deductible. Outof-network Physician/surgeon fees 25% coinsurance 45% coinsurance Emergency room services 25% coinsurance 25% coinsurance Services subject to deductible. Outof-network Emergency medical transportation 25% coinsurance 25% coinsurance Urgent care 25% coinsurance 45% coinsurance Services subject to deductible. Outof-network Prior authorization is required, expect Facility fee (e.g., hospital room) 25% coinsurance 45% coinsurance emergency admissions must be authorized within one business day. If not obtained, claims may be denied or a penalty applied of 20% of the fee, up to $1,000 per admission or service. Services subject to deductible. Outof-network Physician/surgeon fee 25% coinsurance 45% coinsurance Mental/Behavioral health outpatient services 25% coinsurance 45% coinsurance Services subject to deductible. Outof-network Mental/Behavioral health inpatient services 25% coinsurance 45% coinsurance Prior authorization is required for inpatient and facility-based care, except Substance use disorder outpatient services 25% coinsurance 45% coinsurance emergency admissions must be authorized within one business day. If not obtained, claims may be denied or Substance use disorder inpatient services 25% coinsurance 45% coinsurance a penalty applied of 20% of the fee, up to $1,000 per admission or service. 5 of 11

6 If you are pregnant You Use a You Use an Out -of- Prenatal and postnatal care 25% coinsurance 45% coinsurance Services subject to deductible. Outof-network Prior authorization is required, except Delivery and all inpatient services 25% coinsurance 45% coinsurance emergency admissions must be authorized within one business day. If not obtained, claims may be denied or a penalty applied of 20% of the fee, up to $1,000 per admission or service 6 of 11

7 The Ohio State University: Basic PPO Plan Coverage Period: 01/01/ /31/2015 If you need help recovering or have other special health needs You Use a You Use an Out -of- Home health care 25% coinsurance 45% coinsurance Services subject to deductible. Outof-network Prior authorization is required. If not obtained, claims may be denied or a penalty applied of 20% of the fee, up to $1,000 per admission or service. Rehabilitation services 25% coinsurance 45% coinsurance Services subject to deductible. Out of-network Coverage for occupational and Habilitation services 25% coinsurance 45% coinsurance physical therapy outpatient services is limited to a combined maximum of 45 visits per year. Coverage for speech therapy is limited to 20 visits per year. Skilled nursing care 25% coinsurance 45% coinsurance Services subject to deductible. Outof-network Durable medical equipment 25% coinsurance 45% coinsurance Prior authorization is required, except for durable medical equipment, which Hospice service 25% coinsurance 45% coinsurance requires prior authorization for services over $2,000. If not obtained, claims may be denied or a penalty applied of 20% of the fee, up to $1,000 per admission or service. 7 of 11

8 If your child needs dental or eye care You Use a You Use an Out -of- Eye exam Not covered Not covered none Glasses Not covered Not covered none Dental check-up Not covered Not covered none 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.) Cosmetic surgery Long-term care Private-duty nursing Dental care (Adult & Child) Non-emergency care when traveling outside the U.S. Routine eye care (Adult & Child) 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.) Acupuncture (combined $2,000 annual maximum) Bariatric surgery (paid at 70% after $400 deductible, $25,000 lifetime maximum on weight management programs) Chiropractic care (combined $2,000 annual maximum) Hearing aids (paid at 80% after deductible up to $1,200 every four years) Infertility treatment (paid at 50% after $1,000 deductible, $15,000 lifetime maximum, $25,000 lifetime maximum for grandfathered participants) Routine foot care Weight loss programs (paid at 50%, $1,000 combined annual maximum, $25,000 lifetime maximum on weight management programs) 8 of 11

9 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 BUCKS ( ). You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or 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: NGS CoreSource at or OSU Health Plan at or 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. Does this Coverage Meet the 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: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa , x 987. Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' , x 987. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 9 of 11

10 The Ohio State University: Basic PPO Plan Coverage Examples Coverage Period: 01/01/ /31/2015 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. 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 will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Managing type 2 diabetes (routine maintenance of a well - controlled condition) Amount owed to providers: $7,540 Amount owed to providers: $5,400 Plan pays $4,970 Plan pays $3,260 Patient pays $2,570 Patient pays $2,140 Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 Hospital charges (baby) $900 Office Visits and Procedures $700 Anesthesia $900 Education $300 Laboratory tests $500 Laboratory tests $100 Prescriptions $200 Vaccines, other preventive $100 Radiology $200 Total $5,400 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $800 Patient pays: Copays $0 Deductibles $800 Coinsurance $1,260 Copays $0 Limits or exclusions $80 Coinsurance $1,620 Total $2,140 Limits or exclusions $150 Total $2, of 11

11 Coverage Examples 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. The patient s condition was not an excluded or preexisting condition. 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 innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. 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 predict my own care needs? 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. 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. Are there other costs I should 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-ofpocket 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. 11 of 11

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