Land of Lincoln Health : Family Health Network LLH 3-Tier Bronze PPO Coverage Period: 01/01/ /31/2016

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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 or by calling FHN-4YOU. Important Questions Answers Why this Matters: What is the overall? 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? 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 this plan doesn t cover? Integrated In-Network Tier 1/Tier 2: $5,000 individual / $10,000 family Out-of-Network: $15,000 individual / $30,000 family Doesn t apply to preventive care. No. Yes. For In-Network Tier 1/Tier 2 providers: $6,500 individual / $13,000 family For Out-of-Network providers: Unlimited individual / Unlimited family Premiums, balance-billed charges, and health care this plan doesn t cover. No. Yes. See or call FHN-4YOUfor a list of participating providers. Yes. Yes. You must pay all the costs up to the amount before this plan begins to pay for covered you use. Check your policy or plan document to see when the starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered after you meet the. In-Network Tier 1/Tier 2 is one integrated. It is separate for the Out-of-Network Deductible. You don t have to meet s for specific but see the chart starting on page 2 for other costs for 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. This limit helps you plan for health care expenses. In-Network Tier 1/Tier 2 Annual Outof-Pocket limits are one integrated Out-of-Pocket limit and is separate from Out-of-Network Annual Out-of-Pocket limit. Even though you pay these expenses, they don t count toward the Out-of- Pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered, 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. Be aware, your In-Network doctor or hospital may use an Out-of-Network provider for some. Plans use the term In-Network or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see an FHN specialist for covered with a referral from your FHN PCP. Some of the this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded. 1 of 8

2 Common Medical Event If you visit a health care provider s office or clinic If you have a test Copayments (copay) are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance (coins.) is your share of the costs of a covered service, calculated as a percentage 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. The amount the plan pays for covered 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 In-Network providers by charging you lower s, copayments and coinsurance amounts. Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/ screening/ immunization Diagnostic test (xray, blood work) Imaging (CT/PET scans, MRIs) In- Network Tier 1 No charge In-Network Tier 2 No charge Out-of-Network Limitations & Exceptions To be eligible for the In-Network Tier 1 Benefits, you must choose a Family Health Network (FHN) Primary Care Physician (PCP) at the time of enrollment. For rendered outside of your PCP, a referral from your FHN PCP to an In-Network Tier 1 FHN provider is required to receive the Tier 1 Network benefits. PCP referral required. PCP referral required. Immunizations are excluded except for those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC). PCP referral required. Includes outpatient Lab tests, x-ray, pathology, imaging/diagnostic testing. Genetic testing requires precertification and will only be covered if Medically Necessary as determined by a Physician. 2 of 8

3 Common Medical Event Services You May Need In- Network Tier 1 In-Network Tier 2 Out-of-Network Limitations & Exceptions If you need drugs to treat your illness or condition More information about prescription drug coverage is available at nhealth.org/shop -forplans/formulary If you have outpatient surgery Formulary Low- Cost Generic drugs Formulary Generic drugs Formulary Preferred Brand drugs Formulary Non- Preferred Brand drugs Formulary Specialty Generic & Preferred Brand drugs Formulary Specialty Non-Preferred Brand drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Retail: subject to Retail: subject to Retail: subject to Retail: subject to Retail: subject to Retail: Mail-Order: 50% subject to Retail: subject to Retail: subject to Retail: subject to Retail: subject to Retail: subject to Retail: Mail-Order: 50% subject to Covers up to a 34-day supply (retail prescription); 90-day supply (Mail-Order prescription). Prior Authorization, Step Therapy or Quantity Limits may apply. For a full list of covered drugs (formulary prescriptions) and/or, please contact Member Services, or refer to the Pharmacy formulary at Not all specialty drugs are covered and prior authorization may be required. Specialty drugs must be filled through LLH s specialty drug pharmacy Briova Network. See your policy documents for details. 3 of 8

4 Common Medical Event Services You May Need In- Network Tier 1 In-Network Tier 2 Out-of-Network Limitations & Exceptions 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 Emergency room Emergency medical transportation Urgent care 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 Prenatal and postnatal care Delivery and all inpatient Notification required within 2 business days. None None Based on the semi-private room rate. Excludes patient convenience items. Precertification and PCP referral required. PCP referral required. Precertification not required for office visits for outpatient therapy or medical management. Precertification is required for all other outpatient. See policy for details. PCP referral required. Precertification not required for office visits for outpatient therapy or medical management. Precertification is required for all other outpatient. See policy for details. Notification is required upon confirmation of pregnancy. PCP referral required. 4 of 8

5 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 Home health care Rehabilitation Habilitation Skilled nursing care Durable medical equipment Hospice service In- Network Tier 1 In-Network Tier 2 Eye exam No charge No charge Glasses No charge No charge Dental check-up No charge No charge Excluded Services & Other Covered Services: Out-of-Network Limitations & Exceptions Limited to 45 days per year. These apply to Physical, Occupational, Nutrition and Speech therapies. Precertification and Periodic Review required. PCP referral required. Limited to 45 days per year. Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded.) Abortions except where the pregnancy is the result of rape or incest, or the life of the pregnant woman would be endangered unless an abortion is performed Acupuncture Hearing aids (except for children under age 19) Long-term care Non-medically necessary Cosmetic surgery unless due to Illness or Injury Limited to Insured Persons that have a Terminal Illness with a life expectancy of 1 year or less. Limited to one exam per year for Insured Dependent children under age 19. Limited to one pair of glasses per year for Insured Dependent children under age 19. Limited to one check-up every six months for Insured Dependent children under age 19. Routine eye care (Adult) Routine foot care (Except for Diabetes) Weight loss programs Dental care (Adult) 5 of 8

6 Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered and your costs for these.) Bariatric Surgery Chiropractic Care Infertility Treatment (see policy for details) Non-emergency care when traveling outside the U.S. Private duty nursing 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 in the State You move outside the coverage area For more information on your rights to continue coverage, contact Land of Lincoln Health at FHN-4YOU. You may also contact your state insurance department at: Illinois Department of Insurance Office of Consumer Health Insurance 320 W. Washington Street Springfield, IL Toll Free: 1 (877) 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: Land of Lincoln Mutual Health Insurance Company, 222 S. Riverside Plaza, Suite 1600, Chicago, IL ATTN: APPEALS. 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. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

7 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. Having a baby (normal delivery) Amount owed to providers: $7, Plan pays $2,210 Patient pays $5,330 Sample care costs: Hospital charges (mother) $2, Routine obstetric care $2, Hospital charges (baby) $ Anesthesia $ Laboratory tests $ Prescriptions $ Radiology $ Vaccines, other preventive $40.00 Total $7, Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5, Plan pays $1,760 Patient pays $3,640 Sample care costs: Prescriptions $2, Medical Equipment and Supplies $1, Office Visits and Procedures $ Education $ Laboratory tests $ Vaccines, other preventive $ Total $5, Patient pays: Deductibles $2,420 Patient pays: Copays $0 Deductibles $5,170 Coinsurance $1,140 Limits or exclusions $80 Copays $0 See the next page for Total $3,640 important information about Coinsurance $10 these examples. Limits or exclusions $150 Note: This example was calculated assuming Total $5,330 an individual. Note: This example was calculated assuming an individual. 7 of 8

8 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 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 Tier 2 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 s, 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, s 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. 8 of 8

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