Summary of Benefits Neighborhood Health Plan of Rhode Island

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1 Summary of Benefits Neighborhood Health Plan of Rhode Island Rhode Island Health Benefits Exchange Insurance Market Plans Neighborhood Health Plan of Rhode Island Value (Silver) INDIVIDUAL MARKET (07-13)

2 Important Contacts Telephone numbers, addresses and websites Emergency Care For routine care, always call your Primary Care Physician/Provider (PCP). Do this before seeking care anywhere else. If you have a medical emergency and cannot reach your PCP or their covering provider, seek care at the nearest emergency room. If you need emergency care, you should immediately call 911 or your local emergency responders. Out of Network Care Your plan is based on receiving covered services in Rhode Island. You are only covered outside of the network if you have received prior approval or for emergency services. Calling Member Services Call Member Services at XCHG (9244) for: General questions Help in choosing a Primary Care Physician/Provider (PCP) Benefit questions Eligibility questions Billing questions Hours of Operation: Monday through Friday 8:30 a.m. 5:00 p.m. Services for Hearing Impaired Members Telecommunications Device for the Deaf (Voice TDD) Services for Mental Health and Substance Abuse Neighborhood offers excellent behavioral health benefits, through our partner Beacon Health Strategies (Beacon). If you have any questions, please contact Beacon at This number is also on your Neighborhood member identification card. Beacon is available 24 hours a day, 7 days a week to help you. Our Website Find information about Neighborhood online at Provider Directory What medicines are covered Special programs, and much more Grievance and Appeals If you need to call us about a concern or appeal, please call Member Services at XCHG (9244). To submit an appeal or complaint in writing, please send your letter to: Neighborhood Health Plan of Rhode Island Attn: Grievance and Appeals Unit 299 Promenade Street Providence, RI 02908

3 Translator Services Our plan has free language interpreter services available to answer questions from non- English speaking Members. For information, please call our Member Services Department at XCHG (9244). Preauthorization Neighborhood pays for services that are deemed medically necessary. If a service is not in your Certificate of Coverage, it is not covered. Any services that need preauthorization are marked with an asterisk (*). Medical/Surgical Call Member Services at XCHG (9244) Mental Health and Chemical Dependency Call before having care. Lines are open 24 hours a day, 7 days per week. Your network provider is responsible for obtaining preauthorization for in-network covered services after 12 visits. If you would like to use a non-network provider for nonemergency services, and have us cover those services, your no network provider must request and obtain preauthorization from us first. Please call Member Services at XCHG (9244). Neighborhood s Medical Management Department will review your request for services.

4 AND PHARMACY ES If your plan has cost-sharing, your coverage will include both medical and pharmacy deductibles. There is an individual and if applicable, family deductible. E The Medical deductible is the amount you and if applicable, the enrolled members of your family will need to pay initially for covered Medical Benefits. This amount is paid directly to the provider(s). Once the amount is met, you will pay the applicable costsharing for covered benefits. Your contributions to the deductible will go towards the applicable out-of-pocket maximum described later in this section. A deductible may not apply to all services as noted below. Deductible... $250-$3,000 / Contract Year Family Deductible... $500-$6,000 /Contract Year The Family Medical Deductible applies for all enrolled members of a family. All amounts paid by enrolled members towards their Deductibles go toward the Family Deductible. The Family Medical Deductible is met in a contract year when one or more additional enrolled members in that family have paid toward their Medical Deductibles, a collective amount equal to the balance of the family deductible in any combination. Once the Family Medical Deductible has been met during a contract year, all enrolled members in a family will thereafter have met their Deductibles for the remainder of the contract year. NOTE: The Medical Deductible does NOT apply to preventive services/screenings and any service that takes a copayment. Services that do NOT apply to the Medical Deductible include but are not limited to: Behavioral health and substance abuse services Chiropractic medicine including spinal manipulation Early intervention services Emergency care Habilitative and rehabilitative pulmonary, speech, physical and occupational therapies Obstetrics/gynecological care Outpatient cardiac rehabilitation Pediatric care Primary care Prevention: early detection services, immunizations, tests, screenings Smoking cessation counseling Specialist care Urgent care visits Neighborhood Health Plan of Rhode Island Questions? Call Member Services at XCHG (9244)

5 PHARMACY E The Pharmacy Deductible is the amount you and if applicable, the enrolled members of your family must pay each year for some Covered Pharmacy Services before payments are made. PHARMACY Deductible... $10-$250 / Contract Year Family PHARMACY Deductible... $20-$500 /Contract Year The Family Pharmacy Deductible applies for all enrolled members of a family. All amounts any enrolled Members in a family pay toward their Deductibles go toward the Family Pharmacy Deductible. The Family Deductible is satisfied in a Contract Year when one or more additional enrolled Members in that family have paid toward their Deductibles a collective amount equal to the remaining balance of the family deductible in any combination. Once the Family Deductible is met during a contract year, all enrolled members in a family will have met their Deductibles for the rest of that contract year. Contributions to the deductible will go towards the applicable PHARMACY out-of-pocket maximum. NOTE: Tier 1 drugs do NOT apply to the Pharmacy Deductible. COINSURANCE For those medical covered services in which a coinsurance applies, the Member pays [0-30%] of the allowed amount after their deductible is met. If a member receives prior authorization for a service received outside of the contracted network, the member may be balanced billed and be responsible for the difference between the amount Neighborhood pays and the provider s billed charge. COPAYMENTS For certain benefits, you may pay a flat dollar copayment [$0 - $200] per visit. A deductible does not need to be met if a flat dollar copayment is required. BENEFIT ALLOWANCE The services listed below have a specific dollar ($) benefit allowance that you will pay out-of-pocket to the network provider. You will be responsible for any expenses that exceed the designated benefit allowance. Your costs for these services are not subject to your deductible and are not applied to your out-of-pocket maximum. Services include: Hearing Aids Pediatric Care Low Vision Services including evaluation, vision aid, follow-up care Cranial Prosthetic Neighborhood Health Plan of Rhode Island Questions? Call Member Services at XCHG (9244)

6 AND PHARMACY OUT OF POCKET MAXIMUMS If your plan has cost-sharing, your coverage may include both medical and pharmacy out-of pocket maximums. There is an individual and if applicable, family out-of-pocket maximum. OUT-OF-POCKET MAXIMUM The Medical Out-of-Pocket (OOP) Maximum is the amount of medical expenses that the member pays before Neighborhood assumes all costs for covered benefits for the remainder of the calendar year. Only Medical copayments, deductibles and coinsurance amounts count toward the Medical Out-of-Pocket Maximum. Premiums and any balance billing charges for approved services from non-contracted providers do not count towards the Medical Out-of-Pocket Maximum. The amount of the Medical Out-of-Pocket Maximum is: OOP Max... $750 -$5,000 /contract year Family OOP Max... $1,500-$10,000/ contract year The Family Medical Out-of-Pocket Maximum is satisfied in a Contract Year when one or more additional enrolled Members in that family have paid toward their Medical Out-of-Pocket Maximum a collective amount equal to the remaining balance of the Family Medical Out-of-Pocket Maximum. All amounts any enrolled Members in a family pay toward their Out-of-Pocket Maximums are applied toward the $1,500-$10,000 Family Medical Out-of-Pocket Maximum. Once the Family Out-of-Pocket Maximum has been met during a Contract Year, all enrolled Members in a family will have satisfied their Medical Out-of- Pocket Maximums for the rest of that Contract Year. PHARMACY OUT-OF-POCKET MAXIMUM This certificate of coverage has an individual Pharmacy Out-of-Pocket Maximum of $100-$1,000 per Member per Contract Year for all Covered Services, if applicable. Only member expenses paid through copayments and deductibles count towards the Pharmacy Out-of-Pocket Maximum. The amount of the Pharmacy Out-of-Pocket Maximum for you and the enrolled members of your family (if applicable) each contract year is: PHARMACY OOP Max... $100- $1,000 /contract year Family PHARMACY OOP MAX... $200- $2,000/contract year Neighborhood Health Plan of Rhode Island Questions? Call Member Services at XCHG (9244)

7 The Family Pharmacy Out-of-Pocket Maximum is satisfied in a Contract Year when one or more additional enrolled Members in that family have paid toward their Pharmacy Out-of-Pocket Maximum a collective amount equal to the remaining balance of the Family Pharmacy s Out-of-Pocket Maximum. All amounts any enrolled Members in a family pay toward their Out-of-Pocket Maximums are applied toward the $1,500-$10,000 Family Pharmacy Out-of-Pocket Maximum. Once the Family Out-of-Pocket Maximum has been met during a Contract Year, all enrolled Members in a family will have satisfied their Pharmacy Outof-Pocket Maximums for the rest of that Contract Year. SUMMARY OF BENEFITS The Summary of Benefits provides a high-level overview of covered benefits. For more information on benefits, including an explanation of applicable benefit limits, prior authorization requirements, pharmacy management programs and exclusions, please refer to your Certificate of Coverage. Remember that you must use a network provider for covered services unless it is emergent/urgent care or prior approval has been received. For more information, please call Member Services at XCHG (9244). Neighborhood Health Plan of Rhode Island Questions? Call Member Services at XCHG (9244)

8 NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND VALUE NATIVE AMERICAN 100%- 150% FPL 150%- 200% FPL 200% - 250% FPL BASE PLAN BENEFITS [PA] Prior Authorization required [BL] Benefit Limit applies Emergency & Urgent Care Services $0 Medical Out of Pocket Maximum $0 E & $0 $0 COPAY $750 Medical $250 ECOP AY BEFORE ($) $2,000 Medical $1,000 $4,000 Medical $3,000 $5,000 Medical $3,000 Ambulance Services/Emergency 10% up to 20% up to $50 30% up to $50 30% up to $50 $0 $0 Transportation $50 max per max per trip max per trip max per trip trip Dental Emergencies $0 $0 $25 $25 $200 $200 Treatment in an Emergency Room $0 $0 $25 $25 $200 $200 Urgent Care Centers, Facilities, Provider's Office $0 $0 $10 $10 $50 $50 Outpatient Care / Ambulatory Patient Services Allergy Testing [PA] Chemotherapy [PA] Chiropractic [PA][BL] $0 $0 $10 $10 $50 $50 Clinical Trials [PA] Diabetic Services & Supplies [PA] [BL] Diagnostic Imaging & Machine Tests [PA] Durable Medical Equipment Habilitative Services & Devices [PA] - Occupational Therapy, Physical $0 $0 $10 $10 $50 $50 Therapy, Speech Therapy Hearing Services- Examinations $0 $0 $10 $10 $50 $50 Hearing Aids [PA] [BL] $0 $0 Benefit Allowance. Call Member Services for details. Hearing Services-Screenings Hemodialysis Services Home Health Care [PA] Hospice [PA] Human Leukocyte Antigen Testing or Histocompatibility Locus Antigen 10% 20% 30% 30% Testing [PA] [BL] Infertility Services [PA] [BL] $0 $0 10% 20% 20% 20% Laboratory Services & Tests [PA] Lyme Disease Nutritional Counseling Services [PA] 10% 20% 30% 30% Outpatient Surgery [PA] Pediatric Care (18 and under) to Treat Injury or Illness $5 $5 $25 $25 Pediatric Care (18 and under) Low Vision Services [PA] [BL] $0 $0 Benefit Allowance. Call Member Services for details. Pediatric Care (18 and under) Vision Care - Routine Eye Exam [BL] $10 $10 $50 $50 Pediatric Care (18 and under) Vision Care - Eyeglasses, Contact Lenses, Medically Necessary Contact Lenses [PA][BL] Podiatry Services $0 $0 $10 $10 $50 $50 Primary Care to Treat Injury or Illness Private Duty Nursing [PA] Prosthetic / Orthothic Items [PA] Prosthethic - Cranial Prosthetic [PA] $0 $0 Benefit Allowance. Call Member Services for details. Radiation Therapy [PA] Rehabilitative Services & Devices - Cardiac Rehabilitation [PA][BL] $0 $0 $10 $10 $50 $50 Rehabilitative Services & Devices [PA] - Occupational Therapy, Physical Therapy, Respiratory or Pulmonary Rehabilitation $0 $0 $10 $10 $50 $50 Services, Speech Therapy Specialty Care Services $0 $0 $10 $10 $50 $50 Inpatient Care/Hospitalization Hospital Services [PA] Bariatric Surgery [PA] Inpatient Rehabilitation Services [PA]

9 BENEFITS [PA] Prior Authorization required [BL] Benefit Limit applies NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND VALUE NATIVE AMERICAN 100%- 150% FPL 150%- 200% FPL 200% - 250% FPL BASE PLAN $0 Medical Out of Pocket Maximum $0 E & $0 $0 COPAY $750 Medical $250 $2,000 Medical $1,000 $4,000 Medical $3,000 $5,000 Medical $3,000 Mastectomy Surgery [PA] Reconstructive Surgery / Procedures [PA] Skilled Care in Nursing Facility [PA] Solid Organ & Hematopoietic Stem Cell Transplant [PA] Maternity & Newborn Care (Prenatal & Postnatal Care) Maternity Care/Delivery [PA] Mental Health & Substance Abuse Care Outpatient Mental Health Care [PA - Prior Authorization after initial 12 encounters are used in a calendar year] $0 $0 $5 $5 $25 $25 Inpatient Mental Health Care Services [PA] Outpatient Chemical Dependency Services [PA - Prior Authorization after initial 12 encounters are used in a calendar year] $0 $0 $5 $5 $25 $25 Inpatient Chemical Dependency Services [PA] Preventive Care & Early Detection Services [BL] Annual Physical (Adult & Pediatric) Breast Cancer Screening, Mammography & Prevention [BL] Contraceptive Services & Treatments Early Intervention Services [PA][BL] Gynecology Exam & PAP Smears [BL] Hearing Loss Screening in Newborns Immunizations Lead Screenings Nutritional Counseling as Part of an Obesity Screening [PA] Prenatal Care [PA] Primary Care for Preventive Service Smoking Cessation Well Baby Care & Visits PRESCRIPTION DRUGS* [PA] Prior Authorization required [QL] Quantity Limit applies Tier 1 [PA][QL] NO PHARMACY Deductible & Copay Tier 2 [PA][QL] PHARMACY Deductible & Copay Tier 3 [PA][QL] PHARMACY Deductible & Copay *Contraceptives (under Pharmacy Benefit) NATIVE AMERICAN 100%- 150% FPL 150%- 200% FPL % FPL BASE PLAN $0 PHARMACY $100 PHARMACY $750 PHARMACY $1,000 PHARMACY $0 Copay $2 Copay $2 Copay $10 Copay $10 Copay $0 PHARMACY Deductible $0 Copay $0 PHARMACY Deductible $0 Copay $10 PHARMACY Deductible $50 PHARMACY Deductible $4 Copay $4 Copay $10 PHARMACY Deductible $50 PHARMACY Deductible $6 Copay $6 Copay Deductible $40 Copay Deductible $60 Copay Deductible $40 Copay Deductible $60 Copay

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