Arise Health Plan: Silver 6850 Summary of Benefits and Coverage: What this Plan Covers & What it Costs

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1 Arise Health Plan: Silver 6850 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/ /31/2016 Coverage for: Single/Family Plan Type: HMO 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: For participating providers: $6850 Person/$13700 Family. Doesn t apply to preventive care What is the overall, injections, glasses for deductible? children, or prescription drugs purchased at a pharmacy. Copays don t count toward the deductible. Are there other deductibles 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? No. Yes. For participating providers: $6850 Person/$13700 Family Premiums, balance-billed charges, health care this plan doesn t cover, and penalties for failure to obtain prior authorization. No. Yes. See or call for a list of participating providers. No. You don t need a referral to see a participating specialist. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered 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 after you meet the deductible. You don t have to meet deductibles 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. 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, 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 participating specialist you choose without permission from this plan. Some of the this plan doesn t cover are listed on page 6. See your policy or plan document for additional information about excluded. 1 of 8

2 Arise Health Plan: Silver 6850 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/ /31/2016 Coverage for: Single/Family Plan Type: HMO Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered 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, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic Services You May Need Your Cost If You Use a Your Cost If You Use a Non- Limitations & Exceptions The copayment does not apply to your first three visits Primary care visit to treat an $30 copay/visit with a primary care physician. Deductible waived for injury or illness participating providers. Specialist visit $60 copay/visit Deductible waived for participating providers. Other practitioner office visit $10 copay/visit for convenient care clinic $0 copay/visit for telehealth visits Deductible waived for participating providers. If you have a test Preventive care/ screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) chiropractor No charge Coverage is limited to provided by a participating provider. 0% coinsurance Deductible waived for participating providers. 0% coinsurance All imaging (CT/PET scans, MRIs) require prior obtain prior authorization. 2 of 8

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Wisconsin.com. If you have outpatient surgery If you need immediate medical attention Services You May Need Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Your Cost If You Use a $20 copay/prescription (retail) $50 copay/prescription (home delivery) $50 copay/prescription (retail) $125 copay/prescription (home delivery) $75 copay/prescription (retail) $187.5 copay/prescription (home delivery) 25% coinsurance up to prescription out-ofpocket maximum of $500/prescription Your Cost If You Use a Non- Limitations & Exceptions Selected generic drugs will be no charge. Covers up to a 30-day supply retail/90-day supply home delivery. Drugs provided by other than a pharmacy require prior authorization. Covers up to a 30-day supply retail/90-day supply home delivery. If brand dispensed when generic available, you are responsible for dollar amount difference between brand and generic. Drugs provided by other than a pharmacy require prior authorization. Covers up to a 30-day supply retail/90-day supply home delivery. If brand dispensed when generic available, you are responsible for dollar amount difference between brand and generic. Drugs provided by other than a pharmacy require prior authorization. Covers up to a 30-day supply. If brand dispensed when generic available, you are responsible for dollar amount difference between brand and generic. Drugs provided by other than a pharmacy require prior authorization Facility fee (e.g., ambulatory surgery center) 0% coinsurance none Physician/surgeon fees 0% coinsurance none Emergency room $250 copay/visit $250 copay/visit Emergency medical transportation Copay applies to fee billed by facility for use of a hospital emergency room. Physician charges and miscellaneous hospital expenses will be subject to the participating provider coinsurance. Deductible waived. 0% coinsurance 0% coinsurance none Urgent care $250 copay/visit $250 copay/visit Copay applies to fee billed by facility for urgent care. All other expenses for urgent care will be subject to the participating provider coinsurance. Deductible waived. 3 of 8

4 Common Medical Event 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 Facility fee (e.g., hospital room) Your Cost If You Use a Your Cost If You Use a Non- 0% coinsurance Physician/surgeon fee 0% coinsurance Mental/Behavioral health outpatient Mental/Behavioral health inpatient Substance use disorder outpatient Substance use disorder inpatient office visits 0% coinsurance for other outpatient 0% coinsurance office visits 0% coinsurance for other outpatient 0% coinsurance Limitations & Exceptions obtain prior authorization. obtain prior authorization. Deductible waived for office visits by participating providers. obtain prior authorization. Deductible waived for office visits by participating providers. obtain prior authorization Prenatal and postnatal care 0% coinsurance none Delivery and all inpatient 0% coinsurance obtain prior authorization 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 Your Cost If You Use a Your Cost If You Use a Non- Limitations & Exceptions Home health care 0% coinsurance Coverage is limited to 60 visits per calendar year. Rehabilitation office 0% coinsurance for outpatient hospital Coverage is limited to 20 visits for physical therapy and massage therapy; 20 visits for occupational therapy; and 20 visits for speech therapy. Habilitation office 0% coinsurance for outpatient hospital Skilled nursing care 0% coinsurance Durable medical equipment 0% coinsurance Coverage is limited to 20 visits for physical therapy and massage therapy; 20 visits for occupational therapy; and 20 visits for speech therapy. Coverage is limited to 30 days per confinement in a skilled nursing facility. All non-emergent admissions require prior authorization. Benefits will not be payable if you fail to obtain prior authorization. Coverage is limited to a single purchase of a type of durable medical equipment every three years. Purchases over $1,000, rentals over $750 per month, and all CPAP purchases and rentals require prior authorization. Benefits will not be payable if you fail to obtain prior authorization. Hospice service 0% coinsurance none Eye exam No charge Coverage is limited to one eye exam per calendar year and must be provided by a participating provider. Coverage is limited to one pair of frames and one set of Glasses No charge lenses per calendar year from a selection of frames and lenses and must be provided by a participating provider. Dental check-up No coverage for dental check-ups. 5 of 8

6 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.) Abortions (except in cases of rape, incest or Dental care (Adult) Private duty nursing when the life of the mother is endangered) Dental check-up Routine eye care (Adult ) Acupuncture Infertility treatment Routine foot care Bariatric surgery Long-term care Weight loss programs Cosmetic surgery Non-emergency care when traveling outside the U.S. Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered and your costs for these.) Chiropractic care Hearing aids 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 the insurer at You may also contact your state insurance department at 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 Arise Health Plan at You may also contact your state insurance department at 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 Arise Health Plan: Silver 6850 Coverage Examples Coverage Period: 1/1/ /31/2016 Coverage for: Single/Family Plan Type: HMO About these Coverage Examples: Having a baby (normal delivery) Managing type 2 diabetes (routine maintenance of a well-controlled condition) 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. Amount owed to providers: $7,540 Plan pays $1240 Patient pays $6300 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 $6160 Copays $110 Coinsurance $0 Limits or exclusions $30 Total $6300 Amount owed to providers: $5,400 Plan pays $3400 Patient pays $2000 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 $140 Copays $1860 Coinsurance $0 Limits or exclusions $0 Total $ of 8

8 Arise Health Plan: Silver 6850 Coverage Examples Coverage Period: 1/1/ /31/2016 Coverage for: Single/Family Plan Type: HMO 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 innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8