Community HealthEssentials Guide

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1 Community HealthEssentials 2014 Guide

2 Community HealthEssentials - Summary Community HealthEssentials is the new name for Community Health Plan of Washington s (CHPW) individual commercial products offered inside the Washington State Health Benefits Exchange in Open enrollment begins October 1, 2013 and coverage begins January 1, Community HealthEssentials is offered in the 26 counties where Community Health Centers with medical clinics are located in Washington State. The following counties are not included: Asotin, Clallam, Columbia, Garfield, Island, Jefferson, Kittitas, Klickitat, Lincoln, Mason, San Juan, Skamania and Whitman. Community HealthEssentials is offered by Community Health Plan of Washington and administered by First Choice Health. CHPW has partnered with First Choice Health (FCH) to serve as the Preferred Provider Organization (PPO) network and Third Party Administrator (TPA) for Community HealthEssentials commercial products. Administrative services include Customer Service, Utilization Management and Case Management, Claims and Benefits Administration, and Level 1 Appeals. For NCQA and delegation oversight purposes, all Level 2 Appeals will be handled by CHPW. All other plans offered by CHPW will continue to be administered by CHPW and use CHPW s provider network. Customer Service Members and providers can call First Choice Health Customer Service at Monday through Friday between 8:00 AM and 5:00 PM Pacific Time. Members can access the member portal to find specific information about their benefits, claims, and deductibles. They can also download a copy of their Community HealthEssentials ID card from the portal at any time. Providers can access the provider portal for the provider manual, pre-authorization list, provider directory search tool, claim forms, and other information. 1

3 Provider offices can verify eligibility of Community HealthEssentials members by accessing OneHealthPort or by calling First Choice Health Customer Service at Utilization Management and Case Management Community HealthEssentials is a PPO product that allows members the freedom to choose the providers they want to see. Members are not assigned to a Primary Care Provider and no referrals are required for members to see a specialist. Pre-authorizations are required for inpatient admissions and for certain procedures and services. The First Choice Health pre-authorization list is used for Community HealthEssentials members and it is different from the CHPW pre-authorization list. You can find the First Choice Health pre-authorization list at For Pre-authorizations, please call the appropriate number below: Medical: Mental Health/Substance Use: Claims and Benefits Administration Claims for Community HealthEssentials members will be processed and paid by FCH. The Payor ID for electronic claims submission is You can also mail claims to: Community FCH P.O. Box Seattle, WA

4 1 st Level Appeals For appeals questions, please call First Choice Health at Mailing Address for Appeals: Attn: Appeals Coordinator 600 University Street, #1400 Seattle, WA Fax: (206) Member ID Cards Member ID cards will look different from CHPW member ID cards. You will be able to recognize Community HealthEssentials members by the logo on the top left hand corner of the ID card and by the group name Community HealthEssentials. Member ID numbers will start with 87 and have 9 digits. Each member number will be followed by a 2 digit suffix: 01 for subscriber, 02 for spouse, 03 for oldest dependent, and so on. 3

5 What to Expect With Community HealthEssentials Enrollment in the 2014 Exchange Community HealthEssentials Benefit Summaries The following includes an example of the standard Summary of Benefit Coverage (SBC) for Community HealthEssentials Gold, Silver and Bronze plans. Each metal level plan covers the same Essential Health Benefits that are required by Health Care Reform in Please note that although the benefits are the same, there are multiple cost sharing variations that are based on the premium subsidy and level of cost sharing each enrollee qualifies for. SBCs will be available to consumers on October 1, 2013 at in English and Spanish. 4

6 Community HealthEssentials Bronze Summary of Benefits and Coverage: What this Plan Covers & What it Costs

7 Community HealthEssentials Bronze Coverage Period: 01/01/ /31/2014 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 or by calling 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? 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? For network providers: $5,000person/ $10,000 family. For non-network providers: $5,000person/$10,000 family. Doesn t apply to preventive care. Copayments and coinsurance don t count toward the deductible. No. Yes: $6,350person/ $12,700 family. Premiums, balance-billed charges, outof-network coinsurance, and health care this plan doesn t cover No. Yes. See or call for a list of participating providers. No. You don t need a referral to see a specialist Yes. 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. 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. 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-ofpocket limit. The chart starting on page 2 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 2 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 5. See your policy or plan document for additional information about excluded services. 1 of 8

8 Community HealthEssentials Bronze Coverage Period: 01/01/ /31/2014 Co-payments are fixed dollar amounts (for example, $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 for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 30% 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 participating providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your cost if you use a Network Provider Non Network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $45 co-pay/visit 50% co-insurance Network providers not subject to deductible. Specialist visit $75 co-pay/visit 50% co-insurance Network providers not subject to deductible. Network providers not subject to deductible. Limited Other practitioner office $75 co-pay/visit 50% co-insurance to 12 visits per calendar year for acupuncture, and 10 visit visits per calendar year for chiropractic. Preventive care/ screening/immunization No charge 50% co-insurance Network providers not subject to deductible. Diagnostic test (x-ray, blood work) No charge 50% co-insurance none Imaging (CT/PET scans, MRIs) No charge 50% co-insurance none 2 of 8

9 Community HealthEssentials Bronze Coverage Period: 01/01/ /31/2014 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at 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 If you are pregnant Services You May Need Generic drugs Your cost if you use a Network Provider $25 copay/ prescription Non Network Provider Not covered. Preferred brand drugs 50% co-insurance Not covered. Specialty drugs 50% co-insurance Not covered. Limitations & Exceptions Generic drugs not subject to deductible. Covers up to a 30 day supply at retail pharmacies only. Facility fee (e.g., No charge 50% co-insurance ambulatory surgery center) Pre-authorization is required for certain services or claim will be denied. Physician/surgeon fees No charge 50% co-insurance Emergency room services $500 co-pay/visit $500 co-pay/visit none Emergency medical transportation No charge 50% co-insurance none Urgent care $75 co-pay/visit. 50% co-insurance Network providers not subject to deductible. Facility fee (e.g., hospital No charge 50% co-insurance room) Pre-authorization is required or claim will be denied. Physician/surgeon fee No charge 50% co-insurance Mental/Behavioral health outpatient services No charge 50% co-insurance none Mental/Behavioral health No charge Pre-authorization is required or claim will be 50% co-insurance inpatient services denied. Substance use disorder outpatient services No charge 50% co-insurance none Substance use disorder No charge Pre-authorization is required or claim will be 50% co-insurance inpatient services denied. Prenatal and postnatal $75 co-pay/ care pregnancy 50% co-insurance Network providers not subject to deductible. 3 of 8

10 Community HealthEssentials Bronze Coverage Period: 01/01/ /31/2014 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Delivery and all inpatient services Your cost if you use a Network Provider Non Network Provider Limitations & Exceptions No charge 50% co-insurance none Home health care No charge 50% co-insurance Rehabilitation services No charge 50% co-insurance Habilitation services No charge 50% co-insurance Skilled nursing care No charge 50% co-insurance Durable medical equipment No charge 50% co-insurance Hospice service No charge 50% co-insurance Eye exam No charge No charge Glasses No charge No charge Coverage is limited to 130 visits per calendar year. Pre-authorization is required or claim will be denied. Coverage is limited to 30 days per calendar year for inpatient rehabilitation, and 25 visits per calendar year for outpatient rehabilitation. Preauthorization is required for inpatient rehabilitation or claim will be denied. Coverage is limited to 30 days per calendar year for inpatient habilitation, and 25 visits per calendar year for outpatient habilitation. Pre-authorization is required for inpatient habilitation or claim will be denied. Coverage is limited to 60 days per calendar year. Pre-authorization is required or claim will be denied. Pre-authorization required if purchase over $2,000 or rental over $500/month, or claim will be denied. Coverage for respite care is limited to 14 days lifetime maximum. Pre-authorization required or claim will be denied. Coverage is limited to 1 exam per calendar year. Not subject to deductible. Coverage is limited to one pair of lenses and one pair of frames per calendar year. Not subject to deductible. Dental check-up Not covered Not covered none 4 of 8

11 Community HealthEssentials Bronze Coverage Period: 01/01/ /31/2014 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.) Bariatric surgery Cosmetic surgery Dental care (Adult and child) 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.) Acupuncture Chiropractic care Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at (800) You may also contact your state insurance department at (800) 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 the Washington State Office of the Insurance Commissioner at (800) 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. 5 of 8

12 Community HealthEssentials Bronze Coverage Period: 01/01/ /31/2014 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. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

13 Community HealthEssentials Bronze Coverage Period: 01/01/ /31/2014 Coverage Examples 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) Amount owed to providers: $7,540 Plan pays $2,320 Patient pays $5,220 Sample care costs: 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 Patient pays: Deductibles $5,000 Co-pays $20 Co-insurance $0 Limits or exclusions $200 Total $5,220 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,420 Patient pays $1,980 Sample care costs: 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 Patient pays: Deductibles $100 Co-pays $1,800 Co-insurance $0 Limits or exclusions $80 Total $1,980 7 of 8

14 Community HealthEssentials Bronze Coverage Period: 01/01/ /31/2014 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 co-insurance 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 co-payments, deductibles, and co-insurance. 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. 8 of 8

15 Community HealthEssentials Silver Summary of Benefits and Coverage: What this Plan Covers & What it Costs

16 Community HealthEssentials Silver Coverage Period: 01/01/ /31/2014 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 or by calling 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? 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? For network providers: $2,000person/ $4,000 family. For non-network providers: $5,000person/$10,000 family. Doesn t apply to preventive care. Copayments and coinsurance don t count toward the deductible. No. Yes: $6,350person/ $12,700 family. Premiums, balance-billed charges, outof-network coinsurance, and health care this plan doesn t cover No. Yes. See or call for a list of participating providers. No. You don t need a referral to see a specialist Yes. 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. 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. 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-ofpocket limit. The chart starting on page 2 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 2 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 4. See your policy or plan document for additional information about excluded services. 1 of 8

17 Community HealthEssentials Silver Coverage Period: 01/01/ /31/2014 Co-payments are fixed dollar amounts (for example, $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 for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 30% 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 participating providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your cost if you use a Network Provider Non Network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $30 co-pay/visit 50% co-insurance Network providers not subject to deductible. Specialist visit $55 co-pay/visit 50% co-insurance Network providers not subject to deductible. Network providers not subject to deductible. Limited Other practitioner office $55 co-pay/visit 50% co-insurance to 12 visits per calendar year for acupuncture, and 10 visit visits per calendar year for chiropractic. Preventive care/ screening/immunization No charge 50% co-insurance Network providers not subject to deductible. Diagnostic test (x-ray, blood work) 30% co-insurance 50% co-insurance none Imaging (CT/PET scans, MRIs) 30% co-insurance 50% co-insurance none 2 of 8

18 Community HealthEssentials Silver Coverage Period: 01/01/ /31/2014 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at 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 If you are pregnant Services You May Need Generic drugs Preferred brand drugs Your cost if you use a Network Provider $15 copay/ prescription $50 copay/ prescription Non Network Provider Not covered. Not covered. Specialty drugs 50% co-insurance Not covered. Limitations & Exceptions Generic drugs not subject to deductible. Covers up to a 30 day supply at retail pharmacies only. Facility fee (e.g., 30% co-insurance 50% co-insurance ambulatory surgery center) Pre-authorization is required for certain services or claim will be denied. Physician/surgeon fees 30% co-insurance 50% co-insurance Emergency room services $250 co-pay/visit $250 co-pay/visit Not subject to deductible. Emergency medical transportation 30% co-insurance 50% co-insurance none Urgent care $55 co-pay/visit. 50% co-insurance Network providers not subject to deductible. Facility fee (e.g., hospital 30% co-insurance 50% co-insurance room) Pre-authorization is required or claim will be denied. Physician/surgeon fee 30% co-insurance 50% co-insurance Mental/Behavioral health outpatient services 30% co-insurance 50% co-insurance none Mental/Behavioral health Pre-authorization is required or claim will be 30% co-insurance 50% co-insurance inpatient services denied. Substance use disorder outpatient services 30% co-insurance 50% co-insurance none Substance use disorder Pre-authorization is required or claim will be 30% co-insurance 50% co-insurance inpatient services denied. Prenatal and postnatal $55 co-pay/ care pregnancy 50% co-insurance Network providers not subject to deductible. 3 of 8

19 Community HealthEssentials Silver Coverage Period: 01/01/ /31/2014 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Delivery and all inpatient services Your cost if you use a Network Provider Non Network Provider Limitations & Exceptions 30% co-insurance 50% co-insurance none Home health care 30% co-insurance 50% co-insurance Rehabilitation services 30% co-insurance 50% co-insurance Habilitation services 30% co-insurance 50% co-insurance Skilled nursing care 30% co-insurance 50% co-insurance Durable medical equipment 30% co-insurance 50% co-insurance Hospice service 30% co-insurance 50% co-insurance Eye exam No charge No charge Glasses No charge No charge Coverage is limited to 130 visits per calendar year. Pre-authorization is required or claim will be denied. Coverage is limited to 30 days per calendar year for inpatient rehabilitation, and 25 visits per calendar year for outpatient rehabilitation. Preauthorization is required for inpatient rehabilitation or claim will be denied. Coverage is limited to 30 days per calendar year for inpatient habilitation, and 25 visits per calendar year for outpatient habilitation. Pre-authorization is required for inpatient habilitation or claim will be denied. Coverage is limited to 60 days per calendar year. Pre-authorization is required or claim will be denied. Pre-authorization required if purchase over $2,000 or rental over $500/month, or claim will be denied. Coverage for respite care is limited to 14 days lifetime maximum. Pre-authorization required or claim will be denied. Coverage is limited to 1 exam per calendar year. Not subject to deductible. Coverage is limited to one pair of lenses and one pair of frames per calendar year. Not subject to deductible. Dental check-up Not covered Not covered none 4 of 8

20 Community HealthEssentials Silver Coverage Period: 01/01/ /31/2014 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.) Bariatric surgery Cosmetic surgery Dental care (Adult and child) 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.) Acupuncture Chiropractic care Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at (800) You may also contact your state insurance department at (800) 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 the Washington State Office of the Insurance Commissioner at (800) 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. 5 of 8

21 Community HealthEssentials Silver Coverage Period: 01/01/ /31/2014 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. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

22 Community HealthEssentials Silver Coverage Period: 01/01/ /31/2014 Coverage Examples 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) Amount owed to providers: $7,540 Plan pays $4,460 Patient pays $3,080 Sample care costs: 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 Patient pays: Deductibles $2,000 Co-pays $80 Co-insurance $800 Limits or exclusions $200 Total $3,080 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,020 Patient pays $1,380 Sample care costs: 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 Patient pays: Deductibles $100 Co-pays $1,200 Co-insurance $0 Limits or exclusions $80 Total $1,380 7 of 8

23 Community HealthEssentials Silver Coverage Period: 01/01/ /31/2014 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 co-insurance 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 co-payments, deductibles, and co-insurance. 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. 8 of 8

24 Community HealthEssentials Gold Summary of Benefits and Coverage: What this Plan Covers & What it Costs

25 Community HealthEssentials Gold Coverage Period: 01/01/ /31/2014 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 or by calling 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? 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? For network providers: $500person/ $1,000 family. For non-network providers: $5,000person/$10,000 family. Doesn t apply to preventive care. Copayments and coinsurance don t count toward the deductible. No. Yes: $4,800person/ $9,600 family. Premiums, balance-billed charges, outof-network coinsurance, and health care this plan doesn t cover No. Yes. See or call for a list of participating providers. No. You don t need a referral to see a specialist Yes. 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. 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. 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-ofpocket limit. The chart starting on page 2 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 2 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 5. See your policy or plan document for additional information about excluded services. 1 of 8

26 Community HealthEssentials Gold Coverage Period: 01/01/ /31/2014 Co-payments are fixed dollar amounts (for example, $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 for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance 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 participating providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your cost if you use a Network Provider Non Network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $30 co-pay/visit 50% co-insurance Network providers not subject to deductible. Specialist visit $40 co-pay/visit 50% co-insurance Network providers not subject to deductible. Network providers not subject to deductible. Limited Other practitioner office $40 co-pay/visit 50% co-insurance to 12 visits per calendar year for acupuncture, and 10 visit visits per calendar year for chiropractic. Preventive care/ screening/immunization No charge 50% co-insurance Network providers not subject to deductible. Diagnostic test (x-ray, blood work) 20% co-insurance 50% co-insurance none Imaging (CT/PET scans, MRIs) 20% co-insurance 50% co-insurance none 2 of 8

27 Community HealthEssentials Gold Coverage Period: 01/01/ /31/2014 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at 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 If you are pregnant Services You May Need Generic drugs Preferred brand drugs Your cost if you use a Network Provider $10 copay/ prescription $40 copay/ prescription Non Network Provider Not covered. Not covered. Specialty drugs 50% co-insurance Not covered. Limitations & Exceptions Generic drugs not subject to deductible. Covers up to a 30 day supply at retail pharmacies only. Facility fee (e.g., 20% co-insurance 50% co-insurance ambulatory surgery center) Pre-authorization is required for certain services or claim will be denied. Physician/surgeon fees 20% co-insurance 50% co-insurance Emergency room services $250 co-pay/visit $250 co-pay/visit Not subject to deductible. Emergency medical transportation 20% co-insurance 50% co-insurance none Urgent care $40 co-pay/visit. 50% co-insurance Network providers not subject to deductible. Facility fee (e.g., hospital 20% co-insurance 50% co-insurance room) Pre-authorization is required or claim will be denied. Physician/surgeon fee 20% co-insurance 50% co-insurance Mental/Behavioral health outpatient services 20% co-insurance 50% co-insurance none Mental/Behavioral health Pre-authorization is required or claim will be 20% co-insurance 50% co-insurance inpatient services denied. Substance use disorder outpatient services 20% co-insurance 50% co-insurance none Substance use disorder Pre-authorization is required or claim will be 20% co-insurance 50% co-insurance inpatient services denied. Prenatal and postnatal $40 co-pay/ care pregnancy 50% co-insurance Network providers not subject to deductible. 3 of 8

28 Community HealthEssentials Gold Coverage Period: 01/01/ /31/2014 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Delivery and all inpatient services Your cost if you use a Network Provider Non Network Provider Limitations & Exceptions 20% co-insurance 50% co-insurance none Home health care 20% co-insurance 50% co-insurance Rehabilitation services 20% co-insurance 50% co-insurance Habilitation services 20% co-insurance 50% co-insurance Skilled nursing care 20% co-insurance 50% co-insurance Durable medical equipment 20% co-insurance 50% co-insurance Hospice service 20% co-insurance 50% co-insurance Eye exam No charge No charge Glasses No charge No charge Coverage is limited to 130 visits per calendar year. Pre-authorization is required or claim will be denied. Coverage is limited to 30 days per calendar year for inpatient rehabilitation, and 25 visits per calendar year for outpatient rehabilitation. Preauthorization is required for inpatient rehabilitation or claim will be denied. Coverage is limited to 30 days per calendar year for inpatient habilitation, and 25 visits per calendar year for outpatient habilitation. Pre-authorization is required for inpatient habilitation or claim will be denied. Coverage is limited to 60 days per calendar year. Pre-authorization is required or claim will be denied. Pre-authorization required if purchase over $2,000 or rental over $500/month, or claim will be denied. Coverage for respite care is limited to 14 days lifetime maximum. Pre-authorization required or claim will be denied. Coverage is limited to 1 exam per calendar year. Not subject to deductible. Coverage is limited to one pair of lenses and one pair of frames per calendar year. Not subject to deductible. Dental check-up Not covered Not covered none 4 of 8

29 Community HealthEssentials Gold Coverage Period: 01/01/ /31/2014 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.) Bariatric surgery Cosmetic surgery Dental care (Adult and child) 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.) Acupuncture Chiropractic care Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at (800) You may also contact your state insurance department at (800) 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 the Washington State Office of the Insurance Commissioner at (800) 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. 5 of 8

30 Community HealthEssentials Gold Coverage Period: 01/01/ /31/2014 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. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

31 Community HealthEssentials Gold Coverage Period: 01/01/ /31/2014 Coverage Examples 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) Amount owed to providers: $7,540 Plan pays $5,890 Patient pays $1,650 Sample care costs: 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 Patient pays: Deductibles $500 Co-pays $50 Co-insurance $900 Limits or exclusions $200 Total $1,650 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,320 Patient pays $1,080 Sample care costs: 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 Patient pays: Deductibles $100 Co-pays $900 Co-insurance $0 Limits or exclusions $80 Total $1,080 7 of 8

32 Community HealthEssentials Gold Coverage Period: 01/01/ /31/2014 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 co-insurance 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 co-payments, deductibles, and co-insurance. 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. 8 of 8

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