Georgia Plan Guide

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Georgia Plan Guide The health of business, well planned. Plans effective November 1, 2012 For businesses with eligible employees GA (6/12)

2 Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 2 to 100 employees. Health/Dental benefits and health/dental insurance plans are offered, underwritten or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). 2

3 You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. We are committed to helping employers build healthy businesses. In today s rapidly changing economy, we recognize the need for less expensive, less complex health plan choices. Now, we offer a variety of newly streamlined medical and dental benefits and insurance plans to provide more affordable options and to help simplify plan selection and administration. In this guide: 5 Small business commitment 5 Benefits for every stage of life 6 Provider network 7 Medical overview 14 Medical plan options 28 Dental overview 30 Dental plan options 42 Life & disability overview 45 Life & disability plan options 47 Underwriting guidelines 55 Product specifications 63 Limitations and exclusions 66 Group enrollment checklist 3

4 You and your employees can benefit from Affordable plan options Online self-service tools and capabilities Enhanced services for consumer-directed health plans 24-hour access to Employee Assistance Program services Preventive care covered 100% Aetna disease management and wellness programs With Aetna, we know it s about... Options We provide a variety of health plan options to help meet your employees needs, including medical, dental, disability, and life insurance. And, with access to a wide network of health care providers, you can be sure that employees have options in how they access their health care. Medical plans 100% plans Traditional plans HSA-compatible plans Consumer-directed health plans Compass plans MC National POS plans PPO plans Indemnity Dental plans DMO PPO PPO Max Freedom-of-Choice plan design Preventive Simplicity We know that the health of your business is your top priority. Our streamlined plans and variety of services make it easier for you to focus on your business by simplifying administration and management. We make it easy to manage health insurance benefits with simplified enrollment, billing, and claims processing so you can focus on what matters most. Trust We work hard to provide health plan solutions you can trust. Our account executives, underwriters, and customer service representatives are committed to providing businesses and their employees with service they can trust. Aetna resources are designed to fortify the health of your business Members can track medical claims and take advantage of online services with our secure Aetna Navigator member website. It features automated enrollment, personal health records, and printable temporary member ID cards. Get real cost and health information to help make the right care decision with an online Cost of Care Estimator. Manage health records online with the Personal Health Record. Use of the Aetna Health Connections SM Disease Management Program, which provides personal support to members to help them manage their conditions. Get 24/7 access to a nurse to help with personal health-related questions. Help members work toward health goals with wellness initiatives, such as the Simple Steps to a Healthier Life online program. Take advantage of discount programs for vision, dental, and general health care that encourage use of plan offerings. Life and disability plans Basic life Supplemental life AD&D Ultra Dependent life Short-term disability Long-term disability 4

5 We are committed to the health of your business At Aetna, we understand that your business has unique needs. That s why we have streamlined our plan options for employers with 2 to 100 employees. We are committed to providing you with value and quality you can count on. Our variety of products and services allows you to focus on the health of your business. Our health plan options are designed with the health of your business in mind Basic plans Provide basic benefits for your employees Limit the expense to your business Allow employees to buy up and share more of the cost --Simply Savings plans Value plans Encourage employees to make responsible health care decisions Provide tools and resources to support consumerism Provide an innovative plan design --HSA-compatible plans --Simply Savings --Compass plans Traditional plans Provide traditional benefits plans Limit the financial impact on employees --Traditional plans --100% plans Health insurance benefits for every stage of life For young individuals and couples without children Lower monthly payments Modest out-of-pocket costs Quality preventive care Prescription drug coverage Financial protection --Consumer-directed health plans --HSA-compatible plans --Compass plans For married couples and single parents with teens and college-aged children Checkups and care for injuries and illness Preventive care and screenings that promote a healthy lifestyle National network of health care providers --Consumer-directed health plans --Traditional plans --100% plans --MC National POS plans For married couples and single parents with young children or teens Lower fees for office visits Lower monthly payments Caps on out-of-pocket expenses Quality preventive care for the entire family --Traditional plans --100% plans For men and women 55 years of age and over with no children at home Financial security Quality prescription drug coverage Hospital inpatient/outpatient services Emergency care --Consumer-directed health plans --HSA-compatible plans 5

6 6 Georgia Provider Network* *Network subject to change. All Plans MC and PPO Plans Only Appling Atkinson Bacon Baker Banks Ben Hill Berrien Bleckley Brantley Brooks Calhoun Candler Carroll (PPO Only) Catoosa Charlton Chattooga Clay Clinch Coffee Colquitt Cook Crisp Dade Decatur Dodge Dooly Dougherty Early Echols Edgefield Elbert Emanuel Evans Fannin Franklin Gilmer Grady Harbersham Hart Irwin Jasper Jeff Davis Jenkins Johnson Lanier Laurens Lee Lowndes Lumpkin Macon Marion Meriwether Miller Mitchell Montgomery Murray Pierce Quitman Rabun Randolph Schley Screven Seminole Stephens Stewart Sumter Talbot Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Turner Union Walker Ware Wayne Webster Wheeler White Whitfield Wilcox Worth Baldwin Barrow Bartow Bibb Bryan Bulloch Burke Butts Camden Chatham Chattahoochee Cherokee Clarke Clayton Cobb Columbia Coweta Crawford Dawson Dekalb Douglas Effingham Fayette Floyd Forsyth Fulton Glascock Glynn Gordon Greene Gwinnett Hall Hancock Haralson Harris Heard Henry Houston Jackson Jefferson Jones Lamar Liberty Lincoln Long Madison McDuffie McIntosh Monroe Morgan Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pike Polk Pulaski Putnam Richmond Rockdale Spalding Taliaferro Troup Twiggs Upson Walton Warren Washington Wilkes Wilkinson

7 Aetna Medical Overview We are committed to putting the member at the center of everything we do. You can count on us to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. 7

8 Medical Overview Product information Product Name Product Description PCP Required Referrals Required Network Health Network Only Health Network Option Open Access Managed Choice (OA MC) PPO Indemnity A health maintenance organization (HMO) uses a network of participating providers. Each family member may select a primary care physician (PCP) participating in the Aetna network to provide routine and preventive care and help coordinate the member s total health care. Members never need a referral when visiting a participating specialist for covered services. Only services rendered by a participating provider are covered, except for emergency or urgently needed care. Health Network Option is a two-tiered product that allows members to access care in or out of network. Members have lower out-of-pocket costs when they use the in-network tier of the plan. Member cost sharing increases if members decide to go out of network. Members may go to their PCP or directly to a participating specialist without a referral. It is their choice, each time they seek care. Managed Choice members can access any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. PPO plan members can access any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. The indemnity plan option is available for employees who live outside the plan s network service area. Members coordinate their own health care and may access any recognized provider for covered services without a referral. Optional No Aetna Health Network Only SM (Open Access) Optional No Aetna Health Network Option SM (Open Access) Optional No Managed Choice POS (Open Access) No No Open Choice PPO No No N/A 8

9 Wellness on Us SM Wellness for employees means a healthier business for employers. Our business health benefits and insurance plans in Georgia offer $0 copays for in-network eye exams and $0 copay for in-network preventive care. It s one more way to help employees get a step closer to better health. Preventive Care Benefits: Immunizations $0 copay Routine physicals $0 copay Child wellness visits $0 copay Routine mammogram $0 copay Routine OB/GYN visits $0 copay No Cost Health Incentive Credit* Members can earn $50 in just a few simple steps Members earn a $50 credit towards their out-of-pocket expenses when they: Complete or update their health assessment on Simple Steps To A Healthier Life, and Complete one Online Wellness Program If the employee s spouse is covered under the plan, he or she is also eligible for the same incentive credit. So a family could save $100 in out-of-pocket expenses each year. Incentive rewards will be credited towards the deductible and maximum out-of-pocket limit. This program is included at no additional cost on all plans except the HSA-compatible plans. Simple Steps* Help employees take a step in the right direction Simple Steps To A Healthier Life (Simple Steps) is an interactive online health and wellness program that can help you enhance the health and productivity of your employees. Simple Steps helps participants turn knowledge about their health into action, through: A secure online health assessment Tailored health reports Personalized online wellness programs Reaching health goals one step at a time Our online wellness programs** target health and wellness goals such as: Stress management Nutrition and diet Quitting smoking Weight management/physical activity Managing depression Sleeping better These self-paced programs also include interactive tools so employees can feel confident they are making healthy choices that fit into their busy schedules. Women s Preventive Health Benefits New changes effective August 1, 2012 As you may know, the Affordable Care Act (ACA, or Health Care Reform law) includes changes that are being phased in over a number of years. The latest set of changes includes additional benefits for certain women s preventive health services. When plans renew or are effective after August 1, 2012, all of the following women s health services will be considered preventive (some were already covered). These services generally will be covered at no cost share, when provided in network: Well-woman visits (annually and now including prenatal visits) Screening for gestational diabetes Human papillomavirus (HPV) DNA testing Counseling for sexually transmitted infections Counseling and screening for human immunodeficiency virus (HIV) Screening and counseling for interpersonal and domestic violence Breastfeeding support, supplies and counseling Generic formulary contraceptives, certain brand formulary contraceptives are covered without member cost share (for example, no copayment); certain religious organizations or religious employers may be exempt from offering contraceptive services *This program is available at no additional cost to you and your Aetna medical employees. ** Online wellness programs are brought to you by HealthMedia, Inc. 9

10 What is Consumer Flex Choice? Consumer Flex Choice makes it possible to tailor your benefits to better meet the needs of your employees. Offer your employees as many medical plan designs as you'd like (using the current portfolio). This means you are not limited to offering only one or two plan options, but a variety of plan designs to meet your employees specific health care needs. What are the advantages of Consumer Flex Choice? You can manage costs. Your contribution is based on the least expensive plan in the portfolio, regardless of the plans selected or how many plans are offered. Employees can manage choice. Employees can select the benefit plan that meets their individual needs. Different employees want different things from their medical plans. For instance some employees fit the Basic Buyer profile, and may want a medical plan where they share in more of the cost. But, employees who are value seekers may want a plan with more investment options such as an HSA compatible plan. Still other employees may prefer a more traditional plan with fixed costs. With Consumer Flex Choice, you can manage their costs and provide a choice for your employees. Easy administration. Employer contribution: 50% of the Employee Only Cost of the lowest cost plan in the portfolio (even if you do not select that plan). (If the Point of Service is not available, contributions will be based upon the Open Access Managed Choice Employee Only cost). Standard participation underwriting guidelines apply: For non-contributory plans, 100% participation is required, excluding valid waivers. For contributory plans, 75% of eligible employees is required, excluding valid waivers. At least one employee must be enrolled in each plan offered. What is ValuePick? ValuePick* is our suite of plans designed specifically for small businesses. ValuePick offers reduced minimum participation and employer contribution requirements. ValuePick offers the following advantages: Lower participation and contribution requirements Value plans have lower participation and contribution requirements, except when offered with a non-value plan.** Greater employee choice You can offer up to three of the Value plans. Flexibility and affordability By choosing a Value plan, you are now able to offer benefits to help meet the needs of your employees. Total freedom We are committed to providing solutions to help meet the needs of small businesses. You can now offer quality coverage at affordable prices. Easy administration Setting up this program is simple: 1. You choose up to three of the Value plans to offer on the Employer Application. 2. You choose how much to contribute. 3. Each employee chooses the plan that s right for him or her. ValuePick Target audience Plan choices*** Minimum participation Employer contribution Employee participation 50% eligible employees Up to 3 ValuePick plans 4 or more enrolled employees 25% of the employee premium or $50 per employee *Available with four or more enrolled employees. ** If an employer chooses a ValuePick plan to offer with a non-value plan, the standard participation and contribution requirements on the non-value plan will apply to both plans offered. ***Contact your local Aetna representative for specific ValuePick plan information. 10

11 Administrative Fees Fee description HSA Initial set-up $0 Monthly fees $0 POP Fee Initial set-up* $175 Renewal $100 HRA and FSA** fees Initial set-up 2 25 Employees $ Employees $ Employees $550 Renewal fee 1 25 Employees $ Employees $ Employees $325 Monthly fees*** $5.25 per participant Additional set-up fee for stacked plans $150 (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants $10.25 per participant Minimum fees 1 25 Employees $25 per month minimum Employees $50 per month minimum COBRA Annual fee Employees $ Employees $175 Per employee per month Employees $ Employees $1.02 Initial notice fee $1.50 per notice (includes notices at time of implementation and during ongoing administration) Monthly fee TRA Annual fee $350 Transit monthly fees $0.88 per employee $4.25 per participant Health Savings Account (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with an HSAcompatible high-deductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, you and your employees can make account contributions. The HSA can be used to pay for qualified expenses tax free. Aetna High-Deductible Plans (HSA-compatible) The Aetna insurance options that are compatible with a Health Savings Account (HSA) provide you and your qualified employees with an affordable tax-advantaged solution that allows them to better manage their qualified medical and dental expenses. Employees can build a savings fund to assist in covering their future medical and dental expenses. You can fund HSA accounts. But, employees own the account and can take them with them if they leave the plan. Fund contributions may be tax-deductible (limits apply). When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. Member s HSA Plan HSA Account Members own the HSA Members can contribute tax free Members choose how and when to use their dollars The balance rolls over each year The account earns interest, tax free Today Members can use the funds for qualified expenses with tax-free dollars Future Members can plan for future and retiree health-related costs High-deductible health plan Eligible in-network preventive care services will not be subject to the deductible Members pay 100% until deductible is met, then they only pay a share of the cost Once the member meets the out-of-pocket maximum, the plan pays 100% Parking monthly fees $3.15 per participant * Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Nondiscrimination testing only available for FSA and POP products. ** Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. *** For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. For FSA, the debit card is available for an additional $1 per participant per month. Mailing reimbursement checks direct to employee homes is an additional $1 per participant per month. Aetna HRAs are subject to employer-defined use and forfeiture rules. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 11

12 Health Reimbursement Arrangement (HRA) The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and you have control over HRA plan designs. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher out-of-pocket health care expenses. Our consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families while helping lower your costs. COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can help you manage the complex billing and notification processes that are required for COBRA compliance, while also helping to save you time and money. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and you can pay less in payroll taxes. There are three ways to save: Premium Only Plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. Flexible Savings Account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health Care Spending Accounts allow employees to set aside pretax dollars to pay for out-of-pocket expenses as defined by the IRS. Dependent Care Spending Accounts allow participants to use pretax dollars to pay child or elder care expenses. Transit Reimbursement Account (TRA) TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work. 12

13 Notes 13

14 National POS - Compass Plans In-Network Care Tier 1: Preventive and Primary Care Services Tier 2: Acute Care Services (hospital based) Tier 3: Other Medical Care Deductible Applies Applies 2000-Compass None $2,000 Individual/$6,000 Family 3000-Compass None $3,000 Individual/$9,000 Family Copays $25 for Primary Care Visits, e-visits and walk in clinics $0 Copay for Wellness on Us preventive care services and vision exams $500 per inpatient admission $50, then Aetna pays 100% for specialist office visits (no additional coinsurance applies) $75, then Aetna pays 100% for urgent care visits (no additional coinsurance applies) $250 for outpatient surgery Coinsurance None Member Pays 20% after copay Member pays 40% for all other medical care Services Primary care physician visits Walk in clinics e-visits (specialist/pcp) Adult/Child wellness exams Immunizations Vision examinations Mammograms Annual well-woman visit Pre-natal care Colorectal cancer screening Inpatient hospital admission Outpatient surgery Skilled nursing facility Hospice (inpatient/outpatient) Transplants Mental health inpatient admissions Substance abuse admissions Ambulance (Emergency) Specialist physician visits Home health care Rehabilitative therapy Emergency care Urgent care Outpatient diagnostics (X-ray, lab, complex imaging) Durable medical equipment Out of Pocket Maximum 2000-Compass 3000-Compass Deductible, coinsurance and copays apply to the OOP Maximum $5,000 Individual/$15,000 Family $6,000 Individual/$18,000 Family Prescription Drugs $15/$35/$60/20% (maximum copay of $180 for 4th tier specialty drugs) Out of Network Refer to page 63 of the plan guide for out of network benefits and limitations Smarter is healthy. And with rising health care costs, smarter is necessary. The Aetna Compass Plan is a consumer-directed health benefits plan with a traditional concept. It allows you to offer flexibility, control and choice for employees and their families. And it allows a way for you to maximize the value of your health care budgets with affordable copays for preventive care, primary care and prescription drugs. Online tools help members evaluate health care costs and manage their health care. The Aetna Navigator secure member website is a valuable online resource for personalized benefits and health information. The Aetna InteliHealth website provides members with online health and wellness topics. Through the website ( members can access resources and services designed to help them better manage their health and stay on track. In this new day of increased costs, managing health care expenses can be intimidating for employers and employees. That s why we continue to look for ways to help you make informed decisions. See page 27 for endnotes. 14

15 National POS - Compass Plans Georgia (2-100 Eligible Employees) NP Compass NP Compass In Network Services Coinsurance (Member pays) 20/40% 20/40% Deductible (Individual/Family) $2,000/$6,000 $3,000/$9,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $5,000/$15,000 $6,000/$18,000 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services $25, deductible waived $25, deductible waived Specialist Office Visits $50, after deductible $50, after deductible Chiropractic/Subluxation services $50, after deductible $50, after deductible Hospital Based Services Inpatient Hospital $500+20%, after deductible $500+20%, after deductible Inpatient Mental Health $500+20%, after deductible $500+20%, after deductible Outpatient Surgery $250+20%, after deductible $250+20%, after deductible Other Medical Outpatient Lab 40%, after deductible 40%, after deductible Outpatient X-ray 40%, after deductible 40%, after deductible Outpatient Complex Imaging 40%, after deductible 40%, after deductible Emergency Care 40%, after deductible 40%, after deductible Urgent Care $75, after deductible $75, after deductible Rehabilitative Therapy (PT, OT, ST) 30 visits per year 40%, after deductible 40%, after deductible Pharmacy Prescription drugs (Mail order available at 2.5X copay) $15/$35/$60/20% $15/$35/$60/20% Rx Deductible None None Specialty Drug (4th tier) Copay maximum $180 $180 Out-of-Network Services Coinsurance (Member pays) 40% 40% Deductible (Individual/Family) $4,000/$12,000 $6,000/$18,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $15,000/$45,000 $18,000/$54,000 Emergency Room and Transportation Paid as in network Paid as in network All Other Services 40%, after deductible 40%, after deductible Plans Available MC MC See page 27 for endnotes. 15

16 National POS - Traditional Deductible and Coinsurance Plans Georgia (2-100 Eligible Employees) NP NP NP In Network Services Coinsurance (Member pays) 20% 20% 20% Deductible (Individual/Family) $1,000/$3,000 $1,500/$4,500 $2,000/$6,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $3,500/$10,500 $4,000/$12,000 $4,500/$13,500 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services $25, deductible waived $25, deductible waived $25, deductible waived Specialist Office Visits $50, deductible waived $50, deductible waived $50, deductible waived Chiropractic/Subluxation services $50, deductible waived $50, deductible waived $50, deductible waived Hospital Based Services Inpatient Hospital 20%, after deductible 20%, after deductible 20%, after deductible Inpatient Mental Health 20%, after deductible 20%, after deductible 20%, after deductible Outpatient Surgery 20%, after deductible 20%, after deductible 20%, after deductible Other Medical Outpatient Lab $25, deductible waived $25, deductible waived $25, deductible waived Outpatient X-ray $75, deductible waived $75, deductible waived $75, deductible waived Outpatient Complex Imaging 20%, after deductible 20%, after deductible 20%, after deductible Emergency Care $250, deductible waived $250, deductible waived $250, deductible waived Urgent Care $75, deductible waived $75, deductible waived $75, deductible waived Rehabilitative Therapy (PT, OT, ST) 30 visits per year 20%, after deductible 20%, after deductible 20%, after deductible Pharmacy Prescription drugs (Mail order available at 2.5X copay) $10/$40/$60/20% $10/$40/$60/20% $10/$40/$60/20% Rx Deductible None None None Specialty Drug (4th tier) Copay maximum $180 $180 $180 Out-of-Network Services Coinsurance (Member pays) 40% 40% 40% Deductible (Individual/Family) $2,000/$6,000 $3,000/$9,000 $4,000/$12,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $10,000/$30,000 $12,000/$36,000 $12,000/$36,000 Emergency Room and Transportation Paid as in network Paid as in network Paid as in network All Other Services 40%, after deductible 40%, after deductible 40%, after deductible Plans Available MC MC/PPO MC See page 27 for endnotes. 16

17 National POS - Traditional Deductible and Coinsurance Plans Georgia (2-100 Eligible Employees) NP NP In Network Services Coinsurance (Member pays) 20% 20% Deductible (Individual/Family) $2,500/$7,500 $3,000/$9,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $5,000/$15,000 $6,000/$18,000 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services $25, deductible waived $25, deductible waived Specialist Office Visits $50, deductible waived $50, deductible waived Chiropractic/Subluxation services $50, deductible waived $50, deductible waived Hospital Based Services Inpatient Hospital 20%, after deductible 20%, after deductible Inpatient Mental Health 20%, after deductible 20%, after deductible Outpatient Surgery 20%, after deductible 20%, after deductible Other Medical Outpatient Lab $25, deductible waived $25, deductible waived Outpatient X-ray $75, deductible waived $75, deductible waived Outpatient Complex Imaging 20%, after deductible 20%, after deductible Emergency Care $300, deductible waived $300, deductible waived Urgent Care $75, deductible waived $75, deductible waived Rehabilitative Therapy (PT, OT, ST) 30 visits per year 20%, after deductible 20%, after deductible Pharmacy Prescription drugs (Mail order available at 2.5X copay) $10/$40/$60/20% $10/$40/$60/20% Rx Deductible None None Specialty Drug (4th tier) Copay maximum $180 $180 Out-of-Network Services Coinsurance (Member pays) 40% 40% Deductible (Individual/Family) $5,000/$15,000 $6,000/$18,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $15,000/$45,000 $18,000/$54,000 Emergency Room and Transportation Paid as in network Paid as in network All Other Services 40%, after deductible 40%, after deductible Plans Available MC/PPO MC See page 27 for endnotes. 17

18 National POS - 100% Plans Georgia (2-100 Eligible Employees) NP NP NP13-10K-100S In Network Services Coinsurance (Member pays) 0% 0% 0% Deductible (Individual/Family) $1,500/$4,500 $3,000/$9,000 $10,000/$10,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $1,500/$4,500 $3,000/$9.000 $10,000/$10,000 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services $25, deductible waived $30, deductible waived $35, deductible waived Specialist Office Visits $50, deductible waived $60, deductible waived $70, deductible waived Chiropractic/Subluxation services $50, deductible waived $60, deductible waived $70, deductible waived Hospital Based Services Inpatient Hospital 0%, after deductible 0%, after deductible 0%, after deductible Inpatient Mental Health 0%, after deductible 0%, after deductible 0%, after deductible Outpatient Surgery 0%, after deductible 0%, after deductible 0%, after deductible Other Medical Outpatient Lab $25, deductible waived $30, deductible waived 0%, after deductible Outpatient X-ray $75, deductible waived $100, deductible waived 0%, after deductible Outpatient Complex Imaging 0%, after deductible 0%, after deductible 0%, after deductible Emergency Care $250, deductible waived $300, deductible waived 0%, after deductible Urgent Care $75, deductible waived $75, deductible waived 0%, after deductible Rehabilitative Therapy (PT, OT, ST) 30 visits per year $50, deductible waived $60, deductible waived 0%, after deductible Pharmacy Prescription drugs (Mail order available at 2.5X copay) $15/$45/$65/20% $20/$50/$75/20% $20/$50/$75/20% Rx Deductible None None None Specialty Drug (4th tier) Copay maximum $195 $225 $225 Out-of-Network Services Coinsurance (Member pays) 30% 30% 30% Deductible (Individual/Family) $3,000/$9,000 $6,000/$18,000 $10,000/$10,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $6,000/$18,000 $10,000/$30,000 $20,000/$60,000 Emergency Room and Transportation Paid as in network Paid as in network Paid as in network All Other Services 30%, after deductible 30%, after deductible 30%, after deductible Plans Available MC MC MC See page 27 for endnotes. 18

19 National POS HSA & Indemnity Plans Georgia (2-100 Eligible Employees) NP HSA Ind In Network Services Coinsurance (Member pays) 0% 20% Deductible (Individual/Family) $3,000/$6,000 $1,000/$3,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $6,000/$12,000 $8,000/$24,000 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services $25, after deductible 20%, after deductible Specialist Office Visits $50, after deductible 20%, after deductible Chiropractic/Subluxation services $50, after deductible 20%, after deductible Hospital Based Services Inpatient Hospital 0%, after deductible 20%, after deductible Inpatient Mental Health 0%, after deductible 20%, after deductible Outpatient Surgery 0%, after deductible 20%, after deductible Other Medical Outpatient Lab 0%, after deductible 20%, after deductible Outpatient X-ray 0%, after deductible 20%, after deductible Outpatient Complex Imaging $250, after deductible 20%, after deductible Emergency Care $250, after deductible 20%, after deductible Urgent Care $75, after deductible 20%, after deductible Rehabilitative Therapy (PT, OT, ST) 30 visits per year $25, after deductible 20%, after deductible Pharmacy Prescription drugs (Mail order available at 2.5X copay) $15/$45/$65/20% $15/$45/$65/20% Rx Deductible Medical Deductible applies None Specialty Drug (4th tier) Copay maximum $195 $195 Out-of-Network Services Coinsurance (Member pays) 30% Deductible (Individual/Family) $6,000/$12,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $18,000/$36,000 Same as in-network services Emergency Room and Transportation Paid as in network All Other Services 30%, after deductible Plans Available MC Indemnity See page 27 for endnotes. 19

20 Health Network Plans - Traditional Deductible & Coinsurance Plans Georgia (2-100 Eligible Employees) In Network Services Coinsurance (Member pays) 20% 20% 20% Deductible (Individual/Family) $1,000/$3,000 $1,500/$4,500 $2,000/$6,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $4,000/$12,000 $5,000/$15,000 $5,500/$16,500 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services $30, deductible waived $40, deductible waived $40, deductible waived Specialist Office Visits $50, deductible waived $60, deductible waived $60, deductible waived Chiropractic/Subluxation services $50, deductible waived $60, deductible waived $60, deductible waived Hospital Based Services Inpatient Hospital 20%, after deductible 20%, after deductible 20%, after deductible Inpatient Mental Health 20%, after deductible 20%, after deductible 20%, after deductible Outpatient Surgery 20%, after deductible 20%, after deductible 20%, after deductible Other Medical Outpatient Lab $30, deductible waived $40, deductible waived $40, deductible waived Outpatient X-ray $75, deductible waived $100, deductible waived $100, deductible waived Outpatient Complex Imaging 20%, after deductible 20%, after deductible 20%, after deductible Emergency Care $200, deductible waived $300, deductible waived $300, deductible waived Urgent Care $75, deductible waived $75, deductible waived $75, deductible waived Rehabilitative Therapy (PT, OT, ST) 30 visits per year 20%, after deductible 20%, after deductible 20%, after deductible Pharmacy Prescription drugs (Mail order available at 2.5X copay) $15/$45/$65/20% $15/$45/$65/20% $15/$45/$65/20% Rx Deductible None None None Specialty Drug (4th tier) Copay maximum $195 $195 $195 Out-of-Network Services Coinsurance (Member pays) 40% 50% 50% Deductible (Individual/Family) $2,000/$6,000 $3,000/$9,000 $4,000/$12,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $10,000/$30,000 $15,000/$45,000 $16,500/$49,500 Emergency Room and Transportation Paid as in network Paid as in network Paid as in network All Other Services 40%, after deductible 50%, after deductible 50%, after deductible Plans Available HNOption HNOption/HNOnly HNOption See page 27 for endnotes. 20

21 Health Network Plans - Traditional Deductible & Coinsurance Plans Georgia (2-100 Eligible Employees) In Network Services Coinsurance (Member pays) 30% 30% Deductible (Individual/Family) $2,500/$7,500 $5,000/$15,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $7,000/$21,000 $10,000/$30,000 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services $40, deductible waived $40, deductible waived Specialist Office Visits $60, deductible waived $60, deductible waived Chiropractic/Subluxation services $60, deductible waived $60, deductible waived Hospital Based Services Inpatient Hospital 30%, after deductible 30%, after deductible Inpatient Mental Health 30%, after deductible 30%, after deductible Outpatient Surgery 30%, after deductible 30%, after deductible Other Medical Outpatient Lab $40, deductible waived $40, deductible waived Outpatient X-ray $100, deductible waived $100, deductible waived Outpatient Complex Imaging 30%, after deductible 30%, after deductible Emergency Care $300, deductible waived $300, deductible waived Urgent Care $75, deductible waived $75, deductible waived Rehabilitative Therapy (PT, OT, ST) 30 visits per year 30%, after deductible 30%, after deductible Pharmacy Prescription drugs (Mail order available at 2.5X copay) $15/$45/$65/20% $20/$50/$75/20% Rx Deductible None None Specialty Drug (4th tier) Copay maximum $195 $225 Out-of-Network Services Coinsurance (Member pays) 50% 50% Deductible (Individual/Family) $5,000/$15,000 $10,000/$30,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $20,000/$60,000 $20,000/$60,000 Emergency Room and Transportation Paid as in network Paid as in network All Other Services 50%, after deductible 50%, after deductible Plans Available HNOption HNOption See page 27 for endnotes. 21

22 Health Network Plans - 100% Plans Georgia (2-100 Eligible Employees) Rx In Network Services Coinsurance (Member pays) 0% 0% 0% Deductible (Individual/Family) $1,000/$3,000 $1,500/$4,500 $1,500/$4,500 Out-of-Pocket Maximum (Individual/Family) includes deductible $1,000/$3,000 $1,500/$4,500 $1,500/$4,500 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services $25, deductible waived $30, deductible waived $30, deductible waived Specialist Office Visits $50, deductible waived $50, deductible waived $50, deductible waived Chiropractic/Subluxation services $50, deductible waived $50, deductible waived $50, deductible waived Hospital Based Services Inpatient Hospital 0%, after deductible 0%, after deductible 0%, after deductible Inpatient Mental Health 0%, after deductible 0%, after deductible 0%, after deductible Outpatient Surgery 0%, after deductible 0%, after deductible 0%, after deductible Other Medical Outpatient Lab $25, deductible waived $30, deductible waived $30, deductible waived Outpatient X-ray $60, deductible waived $75, deductible waived $75, deductible waived Outpatient Complex Imaging 0%, after deductible 0%, after deductible 0%, after deductible Emergency Care $200, deductible waived $250, deductible waived $250, deductible waived Urgent Care $75, deductible waived $75, deductible waived $75, deductible waived Rehabilitative Therapy (PT, OT, ST) 30 visits per year $50, deductible waived $50, deductible waived $50, deductible waived Pharmacy Prescription drugs (Mail order available at 2.5X copay) $15/$35/$60/20% $15/$45/$65/20% $15/$45/$80/20% Rx Deductible None None $200/$400 (Ind./Family) applies to tier 2/3 Rx only Specialty Drug (4th tier) Copay maximum $180 $195 $240 Out-of-Network Services Coinsurance (Member pays) 30% 30% 30% Deductible (Individual/Family) $2,000/$6,000 $3,000/$9,000 $3,000/$9,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $4,000/$12,000 $6,000/$18,000 $6,000/$18,000 Emergency Room and Transportation Paid as in network Paid as in network Paid as in network All Other Services 30%, after deductible 30%, after deductible 30%, after deductible Plans Available HNOption HNOption/HNOnly HNOption See page 27 for endnotes. 22

23 Health Network Plans - 100% Plans Georgia (2-100 Eligible Employees) Rx K-100 In Network Services Coinsurance (Member pays) 0% 0% 0% 0% Deductible (Individual/Family) $2,500/$7,500 $2,500/$7,500 $4,000/$12,000 $10,000/$10,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $2,500/$7,500 $2,500/$7,500 $4,000/$12,000 $10,000/$10,000 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services $40, deductible waived $40, deductible waived $25, deductible waived $35, deductible waived Specialist Office Visits $60, deductible waived $60, deductible waived $50, after deductible 0%, after deductible Chiropractic/Subluxation services $60, deductible waived $60, deductible waived $50, after deductible 0%, after deductible Hospital Based Services Inpatient Hospital 0%, after deductible 0%, after deductible 0%, after deductible 0%, after deductible Inpatient Mental Health 0%, after deductible 0%, after deductible 0%, after deductible 0%, after deductible Outpatient Surgery 0%, after deductible 0%, after deductible 0%, after deductible 0%, after deductible Other Medical Outpatient Lab $40, deductible waived $40, deductible waived $25, deductible waived 0%, after deductible Outpatient X-ray $100, deductible waived $100, deductible waived 0%, after deductible 0%, after deductible Outpatient Complex Imaging 0%, after deductible 0%, after deductible $200, after deductible 0%, after deductible Emergency Care $250, deductible waived $250, deductible waived $250, after deductible 0%, after deductible Urgent Care $75, deductible waived $75, deductible waived $75, deductible waived 0%, after deductible Rehabilitative Therapy (PT, OT, ST) 30 visits per year $60, deductible waived $60, deductible waived $50, after deductible 0%, after deductible Pharmacy Prescription drugs (Mail order available at 2.5X copay) $15/$45/$65/20% $15/$45/$80/20% $20/$50/$75/20% $20/$50/$75/20% Rx Deductible None $200/$400 (Ind./Family) applies to tier 2/3 Rx only $200/$400 (Ind./Family) applies to tier 2/3 Rx only Specialty Drug (4th tier) Copay maximum $195 $240 $225 $225 Out-of-Network Services Coinsurance (Member pays) 30% 30% 30% 30% Deductible (Individual/Family) $5,000/$15,000 $5,000/$15,000 $8,000/$24,000 $10,000/$10,000 Out-of-Pocket Maximum (Individual/Family) includes deductible None $10,000/$30,000 $10,000/$30,000 $12,000/$36,000 $20,000/$60,000 Emergency Room and Transportation Paid as in network Paid as in network Paid as in network Paid as in network All Other Services 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible Plans Available HNOption HNOption HNOption HNOption See page 27 for endnotes. 23

24 Health Network Plans - Simply Savings Georgia (2-100 Eligible Employees) T T T T In Network Services Coinsurance (Member pays) 30% 30% 30% 30% Deductible (Individual/Family) $1,500/$4,500 $2,500/$7,500 $3,000/$9,000 $3,500/$10,500 Out-of-Pocket Maximum (Individual/Family) includes deductible $4,500/$13,500 $5,500/$16,500 $6,000/$18,000 $8,000/$24,000 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services $30, deductible waived $40, deductible waived $40, deductible waived $40, deductible waived Specialist Office Visits $50, deductible waived $60, deductible waived $60, deductible waived $60, deductible waived Chiropractic/Subluxation services $50, deductible waived $60, deductible waived $60, deductible waived $60, deductible waived Hospital Based Services Inpatient Hospital $ %, after deductible $ %, after deductible $ %, after deductible $ %, after deductible Inpatient Mental Health Outpatient Surgery $ %, after deductible $500+30%, after deductible $ %, after deductible $500+30%, after deductible $ %, after deductible $500+30%, after deductible $ %, after deductible $500+30%, after deductible Other Medical Outpatient Lab $30, deductible waived $40, deductible waived $40, deductible waived $40, deductible waived Outpatient X-ray $100, deductible waived $100, deductible waived $100, deductible waived $100, deductible waived Outpatient Complex Imaging 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible Emergency Care $250, deductible waived $250, deductible waived $250, deductible waived 30%, after deductible Urgent Care $75, deductible waived $75, deductible waived $75, deductible waived $75, deductible waived Rehabilitative Therapy (PT, OT, ST) 30 visits per year 30%, after deductible 30%, after deductible 30%, after deductible 30%, after deductible Pharmacy Prescription drugs (Mail order available at 2.5X copay) $15/$45/$65/20% $15/$45/$65/20% $20/$50/$75/20% $20/$50/$75/20% Rx Deductible None None None None Specialty Drug (4th tier) Copay maximum $195 $195 $225 $225 Out-of-Network Services Coinsurance (Member pays) 40% 40% 40% 50% Deductible (Individual/Family) $3,000/$9,000 $5,000/$15,000 $6,000/$18,000 $7,000/$21,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $12,000/$36,000 $15,000/$45,000 $18,000/$54,000 $20,000/$60,000 Emergency Room and Transportation Paid as in network Paid as in network Paid as in network Paid as in network All Other Services 40%, after deductible 40%, after deductible 40%, after deductible 50%, after deductible Plans Available HNOption HNOption HNOption HNOption See page 27 for endnotes. 24

25 Health Network Plan - HSA Plan Georgia (2-100 Eligible Employees) HSA In Network Services Coinsurance (Member pays) 20% Deductible (Individual/Family) $2,500/$5,000 Out-of-Pocket Maximum (Individual/Family) includes deductible $5,000/$10,000 Wellness on Us Preventive Care, including well baby/child exams, annual adult exams and cancer screening services. Women s Health including pap smears, mammograms, pre-natal care and contraceptives. $0, deductible waived $0, deductible waived Physician Services Primary Care Physician and Walk in Clinic Services Specialist Office Visits Chiropractic/Subluxation services Hospital Based Services Inpatient Hospital Inpatient Mental Health Outpatient Surgery Other Medical Outpatient Lab Outpatient X-ray Outpatient Complex Imaging Emergency Care Urgent Care Rehabilitative Therapy (PT, OT, ST) 30 visits per year Pharmacy Prescription drugs (Mail order available at 2.5X copay) Rx Deductible Specialty Drug (4th tier) Copay maximum $195 Out-of-Network Services Coinsurance (Member pays) 40% 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible 20%, after deductible $15/$45/$65/20% Medical deductible applies Deductible (Individual/Family) $5,000/$10,000 Out-of-Pocket Maximum (Individual/Family) includes deductible Emergency Room and Transportation All Other Services Plans Available $15,000/$30,000 Paid as in network 40%, after deductible HNOption See page 27 for endnotes. 25