You should have already received your 2013 SIHO insurance card. An updated summary of benefits and coverage (SBC) is packaged alongside this letter.

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1 Dear IU Health Bloomington Group Health Plan member, You are receiving this letter to help keep you up-to-date on important changes and remind you of important details about your 2013 Indiana University Health Bloomington Group Health Plan. Thank you for all of your recent feedback concerning the new health plan structure. Your feedback is essential in building a health plan that continues to best serve your healthcare needs. I hope you ll find the information in this letter useful. If you have other questions about your 2013 benefits, call the IU Health Bloomington Human Resources team at or click Benefits at iuhealth.org/bloomington/careers. Steven D. Deckard Vice President Administration Human Resources Indiana University Health Bloomington p l f Maximize your health plan by using the IU Health Tier. The IU Health Tier of your health plan offers the best level of preferred provider benefits and reduced co-pays. To help you build your medical home and make discounts readily available to all enrollees, this special benefits tier incentivizes the use of IU Health providers and facilities. To maximize your health plan dollar, remember to ask your providers to have ALL your services and tests delivered by an IU Health facility or provider. The three tiers of preferred provider coverage explained: Tier 1: The IU Health Tier this offers you the best value for your healthcare investment. Tier 2: The Partner Tier this allows you to seek services outside of the IU Health family at a co-pay, deductible and co-insurance level similar to the previous 2012 health plan. These providers are participating in the Quality Partner program (Partner/PHCS). Most, but not all SIHO network providers are in this program. Tier 3: Out-of-Network Tier this tier details coverage for most other providers not included in Tiers 1 and 2. Providers not in the Quality Partner program or not in the SIHO network are covered at the Tier 3 level. NOTE: Any deductible paid for Tier 1 services will apply toward the deductible of Tier 2 services and vice versa. The deductible for Tier 3 must be met separately. If you choose a High Deductible Health Plan, the same three tiers of coverage apply. Find provider and tier details at SIHO.org. You can access provider network details to help you determine which tier your provider is in, your deductible levels, and a listing of your health plan benefits at any time. Visit SIHO.org and click Members to log-in to your SIHO Member Portal. Register using your SIHO member number, which is on your insurance card. Or you can contact SIHO by phone at or You should have already received your 2013 SIHO insurance card. An updated summary of benefits and coverage (SBC) is packaged alongside this letter. See important information on allowed ancillary tests on reverse side.

2 Coverage of ancillary tests provided by a non-iu Health provider/facility. If you choose to have medical tests (ex: lab tests, etc.) or any imaging services (ex: CT or MRI scans, etc.) performed by non-iu Health providers or facilities within the IU Health service area, there are only six that will be reimbursed/covered. Any test NOT on this list received at a non-iu Health provider within the IU Health service area will not receive reimbursement/coverage and you will be responsible for the full cost of the non-iu Health related test. Allowable (covered) non-iu Health provider tests - only the ancillary tests listed here WILL BE COVERED at Tier 2 provider levels if received at a non-iu Health provider: EKG Strep screen complete blood count finger stick blood sugar urinalysis stool occult blood screening For more information, please refer to your Summary of Benefits and Coverage, pages 2 & 5: Limitations and Exceptions. Quick Tip: Remember to ask your provider to use IU Health tests each time you visit to maximize your savings. All tests, services and procedures received at IU Health facilities will receive the IU Health Tier of coverage. Medical procedures (freezing a skin lesion, receiving an asthma treatment, etc.) will be covered at the corresponding tier level of the provider /facility. For example, an asthma treatment procedure received at a provider in the Tier 2 of preferred providers will be covered at the Tier 2 level; a procedure received at an IU Health provider will be covered at the IU Health Tier level. Additional OB/GYNs added to IU Health Tier. Because of your feedback, these additional obstetricians and gynecologists on the IU Health Bloomington Hospital Medical Staff are being added to the IU Health Tier: J. Brewer, MD; R Brewer, MD; W. Corning, MD; J. Goodman, NP; B. Ludlow, MD; C. Brittain, MD; E. Birch, NP; J. Labban, MD; P. Crooke, MD. Maximizing your prescription benefits. In 2013, your prescription benefits are offered through IU Health Pharmacy Benefits Management. Prescriptions filled at any IU Health Outpatient Pharmacy offer the best savings. More than 300 of the most commonly used medications are available for only $4 and co-pays are $10 on nearly all generic medications. For more information about how to maximize the strength of your IU Health Pharmacy benefits, including the new mail order option, visit one of the resources below: IU Health Bloomington Human Resources online iuhealth.org/bloomington/careers/benefits IU Health Bloomington Pharmacy Intranet site available via any work computer. SIHO.org click Members to log-in to your SIHO Member Portal. Register using your SIHO member number, which is on your insurance card. If you have further questions about IU Health Pharmacy Benefits Management, call or Find your IU Health provider. Whether you re searching for a primary or a specialized care provider, IU Health Southern Indiana Physicians is here to support your health. They offer a variety of services from over 140 skilled providers in nearly a dozen specialties. More than 20 family and internal medicine providers as well as many specialists are currently accepting patients. IU Health Southern Indiana Physicians accepts most major insurance, including SIHO and Anthem. Call 353.DOCS or visit SIPhysicians.org to learn more and choose the IU Health provider that s right for you.

3 Bloomington Hospital: Plan 1 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: PPO 2013 Indiana University Health Bloomington Group Health Plan 1 Single/Family PPO (Traditional Preferred Provider Organization Health Plan) SBC Rev. 04/04/2013 at and or call to request a copy.

4 Bloomington Hospital: Plan 1 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/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 Why this Matters: 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? 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 services this plan doesn t cover? IU Health $200/$400*; Partner/PHCS $400/$800*; Out-of-Network $1,000 /$2,000* (*individual/family). Deductibles cross-apply only between IU Health & Partner/PHCS. No. Yes. IU Health $1,500/$3,000*; Partner/PHCS $3,000/$6,000*; Out-of- Network Unlimited /Unlimited* (*individual /family). Pre-certification Penalties, Copayments, Prescription Drug charges. No. Yes. For a list of in-network providers call or see No. Yes. 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 1 st ). 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 outof-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, 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 services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. 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 6. See your policy or plan document for additional information about excluded services. 1 of 8

5 Bloomington Hospital: Plan 1 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: PPO 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 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, co-payments and amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/screening / immunization Diagnostic test (EKG, blood work) Imaging (CT/PET scans, MRIs, x-ray) Your Cost If You Use an In-Network Provider IU Health $0; Partner/PHCS $25 copay IU Health $25; Partner/PHCS $40 copay after deductible No charge Your Cost If You Use an Out-of- Network Provider 50% 50% 50% Not covered 50% 50% Limitations & Exceptions Services rendered during an office visit are subject to deductible and amounts. Services rendered during an office visit are subject to deductible and amounts. Follows SIHO Comprehensive Preventive Guidelines. Only 6 specific tests* (See pg. 5) are covered and no imaging covered if received at a Partner or Out-of- Network Provider in the IU Health service area. All tests are covered if at an IU Health facility. Any tests outside the service area are covered at the appropriate coverage level. 2 of 8

6 Bloomington Hospital: Plan 1 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: PPO Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider 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 If you need immediate medical attention Tier 1 Tier 2 Tier 3 Tier 4 Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care IU Health $10 copay (30- day); $25 copay (90-day and mail order); Kroger $15 copay (30-day) IU Health $30 copay (30- day); $75 copay (90-day and mail order); Kroger $35 copay (30-day) IU Health 30 % $50/$75(30-day); 30% $150/$300(90- day and mail order); Kroger 33% $60/$120(30-day) IU Health 25 % max $170(30-day); Kroger 30% max $210(30-day) IU Health $100; Partner/PHCS $100 copay IU Health $15; Partner/PHCS $50 copay $25 (30-day) copay Federally mandated preventive medications: no cost. Expanded list of generics are available: $4 (30 day) or $10 (90 day) copay. $50 (30-day) copay 50% (30 day) Not Covered. 50% 50% $100 copay 20% 50% Coverage limited to IU Health retail pharmacies for 90 day supplies and mail order. (When a minimum and maximum is required it will be listed with a / between two different dollar amounts) Prior Authorization required. If pre-cert is not received benefits will be reduced by $250. Prior Authorization required on select procedures. If pre-cert is not received benefits will be reduced by $250. Non-Emergent: $150 copay (IU & Partner)/$250 copay (Out of Network) Services rendered during an office visit are subject to deductible and amounts. 3 of 8

7 Bloomington Hospital: Plan 1 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: PPO Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider Limitations & Exceptions If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services IU Health $0; Partner/PHCS $25 copay IU Health $0; Partner/PHCS $25 copay 50% 50% 50% Prior Authorization required. If pre-cert is not received benefits will be reduced by $250. Services rendered during an office vistit are subject to deductible and amounts. 50% Prior Authorization required. 50% Services rendered during an office vistit are subject to deductible and amounts. 50% Prior Authorization required. 50% 50% Dependent daughters are covered. 4 of 8

8 Bloomington Hospital: Plan 1 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: PPO Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider Limitations & Exceptions Home health care 50% Prior Authorization required. If pre-cert is not received benefits will be reduced by $250 Rehabilitation services 50% If you need help recovering or have other special health needs Habilitation services Skilled nursing care Not covered 50% Speech Therapy requires prior authorization. If pre-cert is not received benefits will be reduced by $250 Durable medical equipment Hospice service 50% 50% Prior Authorization required on purchases over $200 & all rentals. If pre-cert is not received benefits will be reduced by $250 Prior Authorization required. If pre-cert is not received benefits will be reduced by $250. Eye exam Not covered Not covered ---None--- If your child needs Glasses Not covered Not covered ---None--- dental or eye care Dental check-up Not covered Not covered ---None--- *The 6 tests that are referred to on page 2 are as follows: EKG, complete blood count, urinalysis, strep screen, finger stick blood sugar, and stool occult blood screening 5 of 8

9 Bloomington Hospital: Plan 1 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: PPO 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.) Cosmetic surgery Hearing aids Infertility treatment Long term care Non-emergency care when traveling outside the U.S. Private duty Nursing (rendered in a hospital or skilled nursing facility) Routine eye care (Adult) Routine foot care Weight loss programs 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.) Acupuncture Bariatric Surgery Chiropractic Care Dental Care (Due to Accidental Injury) Dependent Daughter Maternity 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 the plan at 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 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: Appeals Coordinator in writing at PO Box 1787, Columbus, Indiana or call or contact the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

10 Bloomington Hospital: Plan 1 Coverage Period: 01/01/ /31/2013 Coverage Examples Coverage for: Single/Family Plan Type: PPO 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 $6,460 Patient pays $1,080 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 $200 Co-pays $20 Coinsurance $710 Limits or exclusions $150 Total $1,080 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,600 Patient pays $800 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 $200 Co-pays $400 Coinsurance $120 Limits or exclusions $80 Total $800 7 of 8

11 Bloomington Hospital: Plan 1 Coverage Period: 01/01/ /31/2013 Coverage Examples Coverage for: Single/Family Plan Type: PPO 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 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 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. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8

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13 Bloomington Hospital: Plan 2 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: HDHP 2013 Indiana University Health Bloomington Group Health Plan 2 Single/Family HDHP (High Deductible Health Plan) SBC Rev. 04/04/2013 at and or call to request a copy.

14 Bloomington Hospital: Plan 2 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: HDHP 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: 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? 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 services this plan doesn t cover? IU Health $1,250/$2,500*; Partner/PHCS $1,750/$3,500*; Out-of-Network $3,500 /$7,000* (*individual/family). Deductibles cross-apply only between IU Health & Partner/PHCS. No. Yes. IU Health $3,100/$6,250*; Partner/PHCS $4,250/$8,500 Out-of- Network Unlimited /Unlimited* (*individual /family). Pre-certification Penalties. No. Yes. For a list of in-network providers call or see No. Yes. 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 1 st ). 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 outof-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, 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 services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. 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 6. See your policy or plan document for additional information about excluded services. Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. 1 of 8

15 Bloomington Hospital: Plan 2 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: HDHP 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 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, co-payments and amounts. Common Medical Event Services You May Need Primary care visit to treat an injury or illness Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider 40% Limitations & Exceptions Deductible has to be met before applies. If you visit a health care provider s office or clinic If you have a test Specialist visit Other practitioner office visit Preventive care/screening / immunization Diagnostic test (EKG, blood work) Imaging (CT/PET scans, MRIs, x-ray) No charge 40% 40% Not covered 40% 40% Deductible has to be met before applies. Deductible has to be met before applies. Follows SIHO Comprehensive Preventive Guidelines. Only 6 specific tests* (See pg. 5) are covered and no imaging covered if received at a Partner or Out-of- Network Provider in the IU Health service area. All tests are covered if at an IU Health facility. Any tests outside the service area are covered at the appropriate coverage level. 2 of 8

16 Bloomington Hospital: Plan 2 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: HDHP Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider 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 If you need immediate medical attention Tier 1 Tier 2 Tier 3 Tier 4 Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care IU Health 10% (30-day, 90-day and mail order); Kroger 20% IU Health 10% (30-day, 90-day and mail order); Kroger 20% IU Health 10% (30-day, 90-day and mail order); Kroger 20% IU Health 10% (30-day); Kroger 20% IU Health 10% ; IU Health 10% ; 50% Federally mandated preventive medications: no cost. Expanded list of 50% generics are available: $4 (30 day) or $10 (90 day) copay. 50% Not Covered. 40% 40% 20% 20% 40% Coverage limited to IU Health retail pharmacies for 90 day supplies and mail order. Prior Authorization required. If pre-cert is not received benefits will be reduced by $250. Prior Authorization required on select procedures. If pre-cert is not received benefits will be reduced by $250. Non-Emergent Services: IU Health 10% after deductible; Partner/PHCS 20% after deductible; 40% after deductible out of network. Services rendered during an office visit are subject to deductible and amounts. 3 of 8

17 Bloomington Hospital: Plan 2 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: HDHP Common Medical Event Services You May Need Your Cost If You Use an In Network Provider Your Cost If You Use an Out of Network Provider Limitations & Exceptions If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services IU Health 10% ; IU Health 10% ; IU Health 10% ; IU Health: 10% ; IU Health 10% ; IU Health 10% ; IU Health 10% ; IU Health 10% ; 40% 40% 40% Prior Authorization required. If pre-cert is not received benefits will be reduced by $ % Prior Authorization required. 40% 40% Prior Authorization required. 40% 40% Dependent daughters are covered. 4 of 8

18 Bloomington Hospital: Plan 2 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: HDHP Common Medical Event Services You May Need Your Cost If You Use an In Network Provider Your Cost If You Use an Out of Network Provider Limitations & Exceptions Home health care IU Health 10% ; 40% Prior Authorization required. If pre-cert is not received benefits will be reduced by $250 Rehabilitation services IU Health 10% ; 40% If you need help recovering or have other special health needs Habilitation services Skilled nursing care IU Health 10% ; IU Health 10% ; 40% 40% Speech Therapy requires prior authorization. If pre-cert is not received benefits will be reduced by $250 Durable medical equipment Hospice service IU Health 10% ; IU Health 10% ; 40% 40% Prior Authorization required on purchases over $200 & all rentals. If pre-cert is not received benefits will be reduced by $250 Prior Authorization required. If pre-cert is not received benefits will be reduced by $250. Eye exam Not covered Not covered ---None--- If your child needs Glasses Not covered Not covered ---None--- dental or eye care Dental check-up Not covered Not covered ---None--- *The 6 tests that are referred to on page 2 are as follows: EKG, complete blood count, urinalysis, strep screen, finger stick blood sugar, and stool occult blood screening 5 of 8

19 Bloomington Hospital: Plan 2 Coverage Period: 01/01/ /31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family Plan Type: HDHP 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.) Cosmetic surgery Hearing aids Infertility treatment Long term care Non-emergency care when traveling outside the U.S. Private duty Nursing (rendered in a hospital or skilled nursing facility) Routine eye care (Adult) Routine foot care Weight loss programs 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.) Acupuncture Bariatric Surgery Chiropractic care Dental Care (Due to Accidental Injury) Dependent Daughter Maternity 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 the plan at 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 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: Appeals Coordinator in writing at P.O. Box 1787, Columbus, Indiana or call or contact the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

20 Bloomington Hospital: Plan 2 Coverage Period: 01/01/ /31/2013 Coverage Examples Coverage for: Single/Family Plan Type: HDHP 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 $5,540 Patient pays $2,000 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 $1,250 Co-pays $0 Coinsurance $600 Limits or exclusions $150 Total $2,000 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,670 Patient pays $1,730 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 $1,250 Co-pays $0 Coinsurance $400 Limits or exclusions $80 Total $1,730 7 of 8

21 Bloomington Hospital: Plan 2 Coverage Period: 01/01/ /31/2013 Coverage Examples Coverage for: Single/Family Plan Type: HDHP 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 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 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. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8

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