PPO Student Health Plan

Transcription

1 SUMMARY OF BENEFITS PPO Student Health Plan Academic Year Northeastern University Student Health Plan Be advised that you may be eligible for coverage under a group health plan of a parent s employer or under a parent s individual health insurance policy if you are under the age of 26. Contact the plan administrator of the parent s employer plan or the parent s individual health insurance issuer for more information. Self-funded student health plans, such as the NUSHP, are not subject to regulation under the Patient Protection and Affordable Care Act (ACA). NUSHP is voluntarily including in its program benefits that are designed to meet or exceed requirements that would otherwise apply to fully insured student health insurance programs. This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect as of January 1, 2014, as part of the Massachusetts Health Care Reform Law. An Association of Independent Blue Cross and Blue Shield Plans

2 Your Choice Know How to Receive the Highest Level of Coverage. You receive the highest level of benefits under this plan when you choose preferred providers. These are called your in-network benefits. You can also choose a non-preferred provider, usually at a lower level of benefits. These are called your out-of-network benefits. With this health care plan, you can go almost anywhere for health care. However, your costs are lower if you use the services of preferred providers in our network. When You Choose Preferred Providers. After a $250 per-admission copayment, you pay 10 percent coinsurance for most inpatient hospital, physician, and other provider-covered services. You also pay 10 percent coinsurance for some outpatient services, and for some outpatient services you pay a $25 copayment for each visit. You pay a $20 copayment for services received at Fenway Health. The copayment does not apply to preventive care services (see chart on opposite and back pages). Please note: If a preferred provider refers you to another provider for covered services (such as a lab or specialist), make sure the provider is a preferred provider in order to receive benefits at the in-network level. If the provider you use is not a preferred provider, you re still covered, but your benefits, in most situations, will be covered at the out-of-network level, even if the preferred provider refers you. How to Find a Preferred Provider. There are several ways to find a preferred provider: Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card. Visit the Blue Cross Blue Shield of Massachusetts website at Call our Physician Selection Service at When You Choose Non-Preferred Providers. You must meet a deductible for all out-of-network services each plan year before you can receive coverage for benefits under this plan. Your deductible is calculated on a plan-year basis. Your plan year begins on September 1 and ends on August 31 of each year. Your deductible is the first $250 of covered charges per member each plan year. After your deductible has been met, you pay 20 percent coinsurance for most out-of-network covered services. deductible and/or your coinsurance). Your Out-of-Pocket Maximum. Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your out-of-pocket maximum for medical benefits is $3,500 per member (or $7,000 per family) for in-network services and $7,000 per member (or $14,000 per family) services. Your out-of-pocket maximum for prescription drug benefits is $1,000 per member (or $2,000 per family). Emergency Room Services. In an emergency, such as a suspected heart attack, stroke, or poisoning, you should go directly to the nearest medical facility or call 911 (or the local emergency phone number). You pay a $50 copayment, plus 10 percent coinsurance, for in-network or out-of-network emergency room services. There is no deductible for these services. Utilization Review Requirements. You must follow the requirements of Utilization Review, which are Pre-Admission Review, Pre-Service Approval for certain outpatient services, Concurrent Review and Discharge Planning, and Individual Case Management. If you need non-emergency or non-maternity hospitalization, you or someone on your behalf must call the number on your ID card for pre-approval. Information concerning Utilization Review is detailed in your Benefit Description and riders. If you do not notify Blue Cross Blue Shield and receive pre-approval, your benefits may be reduced or denied. Dependent Benefits. You may purchase this health care plan for your spouse and/or unmarried dependent children until age 26. Please visit or NUSHP@neu.edu for additional information. Enrollment forms are available on our website. Northeastern University Health and Counseling Services (UHCS)-Forsyth Building. Eligible* students have full use of the services offered at Northeastern University s Health and Counseling Services (UHCS) whether they waive or enroll in NUSHP. There is no charge for office visits at UHCS for eligible students. For more information about UHCS, visit the website at or call For benefit questions regarding NUSHP, please NUSHP@neu.edu. For more information about enrollment in or waiver of NUSHP, visit the website at For more information about BCBSMA coverage, call or visit the website at UHCS is not affiliated with Blue Cross Blue Shield of Massachusetts. Information regarding UHCS was provided by Northeastern University for UHCS. * Undergraduate day and law students (with no additional fee); eligible graduate and College of Professional Studies students who pay the annual UHCS fee of $225. Pediatric Dental Benefits. Your medical plan coverage includes a separate dental policy that covers pediatric dental benefits for members under age 19 as required under the federal Patient Protection and Affordable Care Act. You must meet a plan-year deductible for certain covered dental services. Your deductible is $50 per member (no more than $150 for three or more members under age 19 enrolled under the same family membership). Your out-of-pocket maximum is the most that you could pay during a plan year for deductible and coinsurance for covered dental services. Your out-of-pocket maximum is $350 per member (no more than $700 for two or more members under age 19 enrolled under the same family membership). To find participating dental providers, visit the Blue Cross Blue Shield of Massachusetts website at or call our Physician Selection Service at

3 Your Medical Benefits Plan Specifics Your Cost In-Network Your Cost Out-of-Network Plan-year deductible None $250 per member Plan-year out-of-pocket maximum Covered Services Preventive Care Well-child care visits, including related tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Routine adult physical exams, including related tests, for members age 19 or older (one per plan year) $3,500 per member $7,000 per family Nothing Nothing $7,000 per member $14,000 per family after deductible after deductible Routine GYN exam (one per plan year), including related lab tests Nothing after deductible Routine hearing exam Nothing after deductible Family planning services office visits Nothing after deductible Other Outpatient Care Emergency room visits $50 per visit (waived if admitted or for observation stay), plus 10% coinsurance $50 per visit (waived if admitted or for observation stay), plus 10% coinsurance, no deductible Medical care visits for infertility services $25 per visit* after deductible Clinic visits; physicians, podiatrists, and office visits for medical care services $25 per visit* after deductible Chiropractic medical care services (up to 12 visits per plan year) $25 per visit after deductible Short-term rehabilitation therapy - physical & occupational (up to 60 visits per plan year**) $25 per visit after deductible Allergy injections $25 per visit after deductible Speech, hearing, and language disorder treatment (see below for benefits for diagnostic X-rays and lab tests) $25 per visit after deductible Diagnostic X-rays, lab tests, and other tests 10% coinsurance after deductible Home health care, including hospice care 10% coinsurance after deductible Durable medical equipment (such as wheelchairs, crutches, hospital beds) and repairs 10% coinsurance*** after deductible Prosthetic devices and repairs 10% coinsurance after deductible Oxygen and equipment for its administration 10% coinsurance after deductible Surgery and related anesthesia (including infertility services) Ambulatory surgical facility Office setting Mental Health and Substance Abuse Treatment Biologically based conditions Inpatient admissions in a general or mental hospital, or substance abuse facility Outpatient visits Non-biologically based mental conditions Inpatient admissions in a general hospital Inpatient admissions in a mental hospital Outpatient visits Vision Care Benefits at Fenway Health Routine vision exam (one per plan year) Contact lens fitting (one per plan year) $50 per admission, plus 10% coinsurance 10% coinsurance $250 per admission, plus 10% coinsurance $25 per visit* $250 per admission, plus 10% coinsurance $250 per admission, plus 10% coinsurance $25 per visit* Nothing $40 per visit after deductible after deductible after deductible after deductible after deductible after deductible after deductible * You pay a $20 copayment when this service is performed at Fenway Health. ** No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. *** In-network cost share waived for one breast pump per birth You pay a $100 copayment for surgeon fees plus 10% coinsurance for removal of impacted teeth (except in an office setting you pay only the10% coinsurance). There is $2,500 plan-year benefit maximum for removal of impacted teeth (inpatient and outpatient combined). No coverage is provided when these services are performed at a facility other than Fenway Health.

4 Covered Services Your Cost In-Network Your Cost Out-of-Network Inpatient care (including maternity care) General or chronic disease hospital care (as many days as medically necessary) $250 per admission, plus 10% coinsurance after deductible Surgical services $200 copayment, plus 10% coinsurance* after deductible Care in a skilled nursing facility (up to 100 days per plan year) $250 per admission, plus 10% coinsurance after deductible Care in a rehabilitation hospital (up to 60 days per plan year) $250 per admission, plus 10% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum At designated retail pharmacies (up to a 30-day formulary supply for each prescription/refill or supply) At Fenway Health retail pharmacy (up to a 30-day formulary supply for each prescription/refill or supply) Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $1,000 per member $2,000 per family $10 for Tier 1 *** $20 for Tier 2 $30 for Tier 3 $5 for Tier 1 *** $10 for Tier 2 $15 for Tier 3 $30 for Tier 1 $60 for Tier 2 $90 for Tier 3 Not covered Not covered Not covered * You pay a $100 copayment for surgeon fees plus 10% coinsurance for removal of impacted teeth. There is $2,500 plan-year benefit maximum for removal of impacted teeth (inpatient and outpatient combined). ** Cost share waived for certain orally-administered anticancer drugs. *** You pay nothing for Tier 1 oral contraceptives and contraceptive devices from a designated retail pharmacy or Fenway Health retail pharmacy. Pediatric Dental Benefits for Members under age 19* Plan-year deductible for Group 2 and Group 3 services Plan-year out-of-pocket maximum Group 1 Preventive and Diagnostic Services: oral exams, X-rays, and routine dental care Group 2 Basic Restorative Services: fillings, root canals, stainless steel crowns, periodontal care, oral surgery, and dental prosthetic maintenance Group 3 Major Restorative Services: tooth replacement, resin crowns, and occlusal guards Orthodontic Services: medically necessary orthodontic care pre-authorized for a qualified member Your Cost In-Network** $50 per member $150 for three or more members $350 per member $700 for two or more members Nothing, no deductible 25% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance, no deductible * All services are limited to an age-based schedule and/or frequency. For a complete list of covered services or additional information, refer to your benefit description. ** Out-of-network benefits are not provided for dental services. Get the Most from Your Plan. Visit us at or call to learn about discounts, savings, resources, and special programs like those listed below that are available to you. A Fitness Benefit toward membership at a health club or for fitness classes This fitness benefit applies for fees paid to: privately owned or privately sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) A Weight Loss Program Benefit toward participation in a qualified weight loss program This weight loss program benefit applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) Blue Care Line SM A 24-hour nurse line to answer your health care questions call BLUE (2583) Reimbursement for membership fees for up to 3 consecutive months of one annual family or individual membership at a health club or 10 fitness classes, per individual or family per calendar year Reimbursement for up to 3 months participation fees per individual or family per calendar year No additional charge Questions? Call For questions about Blue Cross Blue Shield of Massachusetts, visit the website at Interested in receiving information from Blue Cross Blue Shield of Massachusetts via ? Go to to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. The benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; hearing aids; most dental care; and any services covered by workers compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. Please note: Blue Cross and Blue Shield of Massachusetts, Inc., administers claims payment only and does not assume financial risk for claims. Registered Marks of the Blue Cross and Blue Shield Association. SM Service Marks of the Blue Cross and Blue Shield Association. SM Service Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield HMO Blue, Inc Blue Cross and Blue Shield of Massachusetts, Inc BS (6/15) TBD JB

5 PPO Student Health Plan Northeastern University Student Health Plan Coverage Period: Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: PPO 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 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? 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? $0 in-network; $250 per member out-of-network. Does not apply to innetwork prenatal care; emergency room, emergency transportation. No. Yes. For medical benefits $3,500 member / $7,000 family in-network, $7,000 member / $14,000 family outof-network; and for prescription drug benefits $1,000 member / $2,000 family. Premiums, balance-billed charges, and health care this plan doesn't cover. Yes. See or call for a list of network providers. No. Yes. Why this Matters: 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-of-pocket limit. 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 8. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association 1 of 11

6 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 (or provider s charge if it is less than the allowed amount) for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000 (and it is less than the provider s charge), 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 billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. (If you are eligible to elect a Health Reimbursement Account (HRA), Flexible Spending Account (FSA) or you have elected a Health Savings Account (HSA), you may have access to additional funds to help cover certain out-of-pocket expenses such as copayments, coinsurance, deductibles and costs related to services not otherwise covered.) Common Medical Event Services You May Need Your cost if you use In-Network Out-of-Network Limitations & Exceptions If you visit a health care provider s office or clinic If you have a test Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit $20 / visit at Fenway Health Center; $25 / visit for other covered providers $20 / visit at Fenway Health Center; $25 / visit for other covered providers $25 / chiropractor visit / chiropractor visit Preventive care/screening/immunization No charge Diagnostic test (x-ray, blood work) 10% coinsurance Imaging (CT/PET scans, MRIs) 10% coinsurance for out-of-network; limited to 12 visits per plan year for out-of-network; limited to age-based schedule and / or frequency 2 of 11

7 Common Medical Event Services You May Need Your cost if you use In-Network Out-of-Network Limitations & Exceptions If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) $5 / retail supply at Fenway Health Center; $10 / retail supply at other covered pharmacies or $30 mail service supply $10 / retail supply at Fenway Health Center; $20 / retail supply at other covered pharmacies; or $60 mail service supply $15 / retail supply at Fenway Health Center; $30 / retail supply at other covered pharmacies; or $90 mail service supply Applicable cost share (generic, preferred, nonpreferred) $50 / admission, coinsurance Not covered Not covered Not covered Not covered Physician/surgeon fees 10% coinsurance Up to 30-day retail (90-day mail service) supply; cost share may be waived for certain covered drugs and supplies; pre-authorization required for certain drugs Up to 30-day retail (90-day mail service) supply; cost share may be waived for certain covered drugs and supplies; pre-authorization required for certain drugs Up to 30-day retail (90-day mail service) supply; cost share may be waived for certain covered drugs and supplies; pre-authorization required for certain drugs When obtained from a designated specialty pharmacy; pre-authorization required for certain drugs 3 of 11

8 Common Medical Event Services You May Need Your cost if you use In-Network Out-of-Network Limitations & Exceptions If you need immediate medical attention If you have a hospital stay Emergency room services $50 / admission, coinsurance $50 / admission, coinsurance Copayment waived if admitted or for observation stay Emergency medical transportation $200 / day $200 / day none Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee $20 / visit at Fenway Health Center; $25 / visit for other covered providers $250 / admission, coinsurance $200 / admission, coinsurance; $100 / admission coinsurance for removal of impacted wisdom teeth ; pre-authorization required ; pre-authorization required 4 of 11

9 Common Medical Event Services You May Need Your cost if you use In-Network Out-of-Network Limitations & Exceptions Mental/Behavioral health outpatient services $20 / visit at Fenway Health Center; $25 / visit for other covered providers If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health inpatient services Substance use disorder outpatient services $250 / admission, coinsurance $20 / visit at Fenway Health Center; $25 / visit for other covered providers ; pre-authorization required Substance use disorder inpatient services $250 / admission, coinsurance ; pre-authorization required If you are pregnant Prenatal and postnatal care Delivery and all inpatient services No charge for prenatal care; 10% coinsurance for postnatal care $250 / admission, coinsurance for out-of-network 5 of 11

10 Common Medical Event Services You May Need Your cost if you use In-Network Out-of-Network Limitations & Exceptions If you need help recovering or have other special health needs Home health care 10% coinsurance Rehabilitation services $25 / visit Habilitation services $25 / visit Skilled nursing care $250 / admission, coinsurance Durable medical equipment 10% coinsurance Hospice service 10% coinsurance for out-of-network; pre-authorization required for out-of-network; limited to 60 visits per plan year (other than for home health care, autism and speech therapy) for out-of-network; rehabilitation therapy coverage limits apply; coverage limit waived for early intervention services for eligible children for out-of-network; limited to 100 days per plan year; pre-authorization required for out-of-network; in-network cost share waived for one breast pump per birth for out-of-network; pre-authorization required for certain services 6 of 11

11 Common Medical Event Services You May Need Your cost if you use In-Network Out-of-Network Limitations & Exceptions If your child needs dental or eye care Eye exam Glasses No charge at Fenway Health Center; not covered for other providers $40 for contact lens fitting at Fenway Health center; not covered for other providers Not covered Dental check-up No charge Not covered Limited to one exam per plan year Not covered none Limited to members under age 19, twice in 12 months 7 of 11

12 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.) Acupuncture Children's glasses Cosmetic surgery Dental care (adult) Hearing aids Long-term care Private-duty nursing 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.) Bariatric surgery Chiropractic care (12 visits per plan year) Infertility treatment Non-emergency care when traveling outside the U.S. Routine eye care - covered at Fenway Health Center only (one exam per plan year) Routine foot care (only for patients with systemic circulatory disease) Weight loss programs (three months in qualified program(s) per contract per calendar year) 8 of 11

13 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 your plan sponsor. Note: A plan sponsor is usually the member s employer or organization that provides group health coverage to the member. 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 the Member Service number listed on your ID card or contact your plan sponsor. Note: A plan sponsor is usually the member s employer or organization that provides group health coverage to the member. 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. Disclaimer: This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and the policy, the terms and conditions of the policy will govern. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 9 of 11

14 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 $6,366 Patient pays $1,174 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 $0 Copays $270 Coinsurance $754 Limits or exclusions $150 Total $1,174 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,160 Patient pays $1,240 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 $0 Copays $1,150 Coinsurance $10 Limits or exclusions $80 Total $1, of 11

15 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 in-network 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-of-pocket 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. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. Registered Marks of the Blue Cross and Blue Shield Association Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc BS (7/15) PDF JI 11 of 11

16 MCC Compliance This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect as of January 1, 2014, as part of the Massachusetts Health Care Reform Law. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. #139512BS (6/14) 150M

17 Pediatric Dental Your health plan coverage includes a dental policy that covers pediatric dental services as required under the federal Patient Protection and Affordable Care Act. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc (9/14) 10M