INSURANCE BENEFITS GUIDE

Transcription

1 INSURANCE BENEFITS GUIDE Corporate Health Systems, Inc. [Benefit Communication Solutions] Technology Drive, Suite B Eden Prairie, MN Phone (952) Fax (952)

2 NOTICE This is a benefit summary only and may not outline all of your benefits. When you enroll, you will receive a summary plan description or certificate of coverage. This booklet does not replace, supplement or change any of the individual benefit product summary plan descriptions or certificates of coverage and should not be used in determining actual benefits available. Remember this is a summary only and the legal plan documents determine actual benefits. Please be aware that if there are differences between the statements in this booklet and actual legal plan documents or laws, the legal course will prevail. Contact the insurance carrier for more information and answers to specific questions, or see your Human Resource Office for a copy of the plan document before making a decision. This booklet provides an overview of the following insurance benefits: Health Insurance Benefits Health Reimbursement Arrangement (HRA) / VEBA Dental Insurance Benefits Group Life and AD&D Insurance Benefits Supplemental Life, Supplemental Dependent Life and Supplemental AD&D Insurance Benefits Long Term Disability Insurance Benefits Base Plan Long Term Disability Insurance Benefits Buy up and Accident Only Plan Flexible Spending Accounts (FSA) Each benefit insurance section begins with a colored title page and includes the following sections. Plan Outline Commonly Asked Questions Benefits Summary Corporate Health Systems is the Benefit Consultant and/or Administrator for the above insurance benefits. For questions concerning enrollment, eligibility or ID cards (if applicable) please contact Corporate Health Systems at the number listed below. Amy Holm (952) ext. 139 aholm@corphealthsys.com You may also contact your employer s benefits representative. Human Resources (763) x 1301 To verify coverage or for questions concerning how a specific claim will be paid, please consult the applicable insurance carrier or plan document of the coverage in question. Neither Corporate Health Systems nor your employer can quote benefits for reasons involving accuracy and confidentiality. When in doubt, contact Corporate Health Systems and you will be directed to the appropriate resource.

3 HEALTH INSURANCE BENEFITS

4 Plan Outline Carrier: HealthPartners Local Phone: (952) Toll Free Phone: (800) Website: Policy or Group Number: Policy Anniversary Date: October 01 Employee Eligibility: Please refer to your Summary Insert Dependent Eligibility: Dependent children to age 26 Waiting Period for Enrollment: date of hire (Time employee must wait before being eligible to enroll) Initial Enrollment Period: (Time frame after the waiting period during which employee must enroll) Coverage Termination Date upon loss of eligibility: Premium Costs: First of the month coincident with or following 30 days Last day of the month in which eligibility is lost Please refer to your Summary Insert

5 Commonly Asked Questions What happens if I do not enroll now? You can enroll during the next open enrollment period or if you have a family status change without being subject to a pre-existing condition clause. (see pre-tax premiums section) Which providers are covered under this plan? Carrier networks can be found by going to: Click on Search for providers in our plan network, then click on find a provider under the HealthPartners Plans option, Then click Group medical networks and under Open Access Network click on Find a Doctor/Dentist or Find a Clinic/Hospital, depending upon what you are looking for. Then enter your search criteria. How does my prescription coverage work? You must present your insurance card at the pharmacy. Your pharmacist will collect your co-pay (if applicable) and automatically submit information to your insurance carrier so the claim can be applied to your deductible (if applicable). Can I add to my health insurance plan a non-tax qualified dependent under age 26? You may be able to add a non-tax qualified dependent child or relative to your health insurance. Please contact Corporate Health Systems, Inc. or your Human Resource Representative for further information, rates and tax consequences. Does my health plan offer any Value Add Benefits? Value Add Benefits are a part of your health plan. To find out more about these benefits contact HealthPartners at (952) or (800) You can also access this information by creating your personal user ID and password at Value Add Benefits include: CareLine Service Nurse advice line Nurse Navigator Program BabyLine Phone Service Behavioral Health Personalized Assistance Line (PAL) Frequent Fitness Healthy Discounts PLEASE NOTE: Prior authorization, pre-certification and/or preadmission notification(s) may be required for certain services. Please be aware that where such stipulations exist, there may be time sensitive notification requirements. Please refer to the Summary Plan Description for details. This summary is only an outline of general information. It is not a contract for coverage. Please refer to your summary plan description or certificate for detailed information.

6 Health Insurance Portability and Accountability Act HIPAA Federal HIPAA law requires us to notify you about two very important Plan provisions prior to your enrollment. The first, is your right to enroll under a Special Enrollment Provision if you acquire a new dependent, or you or an eligible dependent declines coverage because of alternative coverage and later lose such coverage due to certain qualifying reasons. Second, the notice advises you of the Plan s Pre-Existing Condition exclusion rules that may temporarily exclude coverage for certain preexisting conditions that you or your family may have. Your health premiums are deducted on a pre-tax basis and are therefore subject to the rules and regulations of IRS Code Section 125. Once you have made your health plan elections during the Annual Benefits Enrollment or during your initial enrollment period, there are limited circumstances under which you can make changes known as family status or HIPAA Special Enrollment events: o If you have a family status change as defined by IRS Code Section 125 during the plan year, you are allowed to make coverage level changes to your coverage that are consistent with that event. o If you have a family status change that is also a HIPAA Special Enrollment event and your employer offers more than one health plan, you will also be able to move to another health plan offered by the employer. Example: You currently have single Plan 1 health coverage, but will have a new dependent as a result of marriage: this is a HIPAA Special Enrollment. You can add your new spouse to your health insurance coverage (change from single to single + 1 coverage) and you may also move to a different plan (Plan Option 2, Plan Option 3, etc). A family status change may also be a HIPAA Special enrollment. What makes a family status change ALSO a HIPAA Special Enrollment is when the event involves circumstances previously unknown which necessitate the addition of coverage for yourself or your dependent. Please refer to the Special Enrollment Provisions below for details. Special Enrollment Provisions Loss of Coverage If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, and that coverage terminates due to certain qualifying reasons (i.e., COBRA exhaustion or state law continuation rights; eligibility loss due to legal separation, divorce, death, employment termination, or reduction in hours; or because employer contributions for other coverage cease) you may in the future be able to enroll yourself or your dependents in the benefit plans, provided that you request enrollment within 30 days after your other coverage ends - and that you meet certain other important conditions described in the Summary Plan Description. You must inform us in writing at the time you decline coverage that you are declining coverage because of other health insurance coverage in order to be eligible for this special enrollment period. In general, coverage will become effective the day following the date on which your other coverage would normally end.

7 Effective April 01, 2009, two additional special enrollment provisions have been added: If you or a dependent lose eligibility for Medicaid or coverage under a state children s health insurance program (SCHIP) If you or a dependent become eligible for a state premium assistance subsidy under the plan through Medicaid or SCHIP. Special enrollment for these two new special enrollment provisions must be requested within 60-days after the termination of coverage or the determination of eligibility for a state premium assistance subsidy, as applicable. Marriage, Birth, or Adoption If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30- days after the marriage, birth, adoption, or placement for adoption - and that you meet certain other important conditions as described in your Summary Plan Description. In general, coverage will become effective the date of marriage, birth, adoption, or placement for adoption. All coverage request changes must be consistent with the family status change. Should you wish to receive a replacement copy of our HIPAA privacy notice please contact your Corporate Health Systems benefit administrator and they will mail one to you. This privacy notice is the one you received when you first become enrolled into our health benefit plan.

8 Important Notice from your Plan Sponsor About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with your Plan Sponsor and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Your Plan Sponsor has determined that the prescription drug coverage offered by the benefit plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

9 If you decide to join a Medicare drug plan, your current Plan Sponsor s benefit plan coverage may be affected. If you do decide to join a Medicare drug plan and drop your current Plan Sponsor s benefit plan coverage, be aware that you and your dependents may be affected and may not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with the Plan Sponsor and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage.. Contact the person listed below for further information; NOTE: You ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the Plan Sponsor changes. You also may request a copy of this notice at any time.

10 For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at or call them at (TTY ). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: October 01, 2013 Name of Entity/Sender: Brooklyn Center School District #286 Contact--Position/Office: Human Resources Address: 6500 Humboldt Ave North, Brooklyn Center, MN Phone Number: (763)

11 Premium Assistance Under Medicaid and the Children s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, you can contact the Department of Labor electronically at or by calling toll-free EBSA (3272). If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of July 31, You should contact your State for further information on eligibility ALABAMA Medicaid Website: Phone: ALASKA Medicaid Website: Phone (Outside of Anchorage): Phone (Anchorage): ARIZONA CHIP Website: Phone (Outside of Maricopa County): Phone (Maricopa County): COLORADO Medicaid Medicaid Website: Medicaid Phone (In state): Medicaid Phone (Out of state): FLORIDA Medicaid Website: Phone: GEORGIA Medicaid Website: Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone:

12 IDAHO Medicaid and CHIP Medicaid Website: Medicaid Phone: CHIP Website: CHIP Phone: INDIANA Medicaid Website: Phone: IOWA Medicaid Website: Phone: KANSAS Medicaid Website: Phone: KENTUCKY Medicaid Website: Phone: LOUISIANA Medicaid Website: Phone: MAINE Medicaid Website: Phone: TTY MASSACHUSETTS Medicaid and CHIP Website: Phone: MINNESOTA Medicaid Website: Click on Health Care, then Medical Assistance Phone: MISSOURI Medicaid Website: Phone: MONTANA Medicaid Website: clientindex.shtml Phone: NEBRASKA Medicaid Website: Phone: NEVADA Medicaid Medicaid Website: Medicaid Phone: NEW HAMPSHIRE Medicaid Website: Phone: NEW JERSEY Medicaid and CHIP Medicaid Website: dmahs/clients/medicaid/ Medicaid Phone: CHIP Website: CHIP Phone: NEW YORK Medicaid Website: Phone: NORTH CAROLINA Medicaid Website: Phone: NORTH DAKOTA Medicaid Website: Phone:

13 OKLAHOMA Medicaid and CHIP Website: Phone: OREGON Medicaid and CHIP Website: Phone: PENNSYLVANIA Medicaid Website: Phone: RHODE ISLAND Medicaid Website: Phone: SOUTH CAROLINA Medicaid Website: Phone: SOUTH DAKOTA - Medicaid Website: Phone: TEXAS Medicaid Website: Phone: UTAH Medicaid and CHIP Website: Phone: VERMONT Medicaid Website: Phone: VIRGINIA Medicaid and CHIP Medicaid Website: HIPP.htm Medicaid Phone: CHIP Website: CHIP Phone: WASHINGTON Medicaid Website: Phone: ext WEST VIRGINIA Medicaid Website: Phone: , HMS Third Party Liability WISCONSIN Medicaid Website: Phone: WYOMING Medicaid Website: Phone: To see if any more States have added a premium assistance program since July 31, 2013, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services EBSA (3272) , Menu Option 4, Ext OMB Control Number (expires 09/30/2013)

14 WHCRA Enrollment Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call your Plan Administrator at (952) or (800)

15 HealthPartners: HP Choice - $300 Ded Coverage Period: 10/01/ /30/2014 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: All Coverage Levels 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? In-network: $300 Individual, $600 Family Out-of-network: $750 Individual, $1,500 Family Services marked with * in Common Medical Events are not subject to deductible No. Yes. In-network: $1,200 Individual, $3,600 Family Out-of-network: $3,500 Individual, None Family Premium, balance-billed charges (unless balanced billing is prohibited), and health care this plan doesn't cover. No. Yes. For a list of in-network providers, see rks or call No. You don't need a referral to see a specialist. 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 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. 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 in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 6 at or call to request a copy

16 HealthPartners: HP Choice - $300 Ded Coverage Period: 10/01/ /30/2014 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: All Coverage Levels 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 coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at /public/pharmacy/f ormularies/formular y/preferredrx/index. html. Services You May Need Your cost if you use a In-Network Provider Out-Of-Network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $30 copay* 20% coinsurance none Specialist visit $30 copay* 20% coinsurance none Other practitioner office visit $30 copay* 20% coinsurance none Preventive care/screening/immunization No charge 20% coinsurance none Diagnostic test (x-ray, blood work) No charge 20% coinsurance none Imaging (CT/PET scans, MRIs) No charge 20% coinsurance none Generic drugs Preferred brand drugs Non-preferred brand drugs Preferred: $20 copay* at retail, $40 copay* at mail Non-preferred: $80 copay* at retail, $160 copay* at mail $40 copay* at retail, $80 copay* at mail $80 copay* at retail, $160 copay* at mail 40% coinsurance at retail, mail not covered 31 Day supply retail/93 day supply mail order 2 of

17 HealthPartners: HP Choice - $300 Ded Coverage Period: 10/01/ /30/2014 Summary of Coverage: What this Plan Covers & What it Costs Common Medical Event If you have outpatient surgery Services You May Need Specialty drugs Coverage for: All Coverage Levels Plan Type: PPO Your cost if you use a In-Network Out-Of-Network Limitations & Exceptions Provider Provider 40% coinsurance $40 copay* at retail, mail not none covered Facility fee (e.g., ambulatory surgery center) 0% coinsurance 20% coinsurance none Physician/surgeon fees 0% coinsurance 20% coinsurance none Emergency room services $75 copay* $75 copay* none Emergency medical transportation No charge No charge none If you need immediate medical attention Urgent care $30 copay* $30 copay* none If you have a Facility fee (e.g., hospital room) 0% coinsurance 20% coinsurance none hospital stay Physician/surgeon fee 0% coinsurance 20% coinsurance none If you have mental Mental/Behavioral health outpatient services $30 copay* 20% coinsurance none health, behavioral Mental/Behavioral health inpatient services 0% coinsurance 20% coinsurance none health, or substance Substance use disorder outpatient services $30 copay* 20% coinsurance none abuse needs Substance use disorder inpatient services 0% coinsurance 20% coinsurance none If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Prenatal and postnatal care No charge 20% coinsurance none Delivery and all inpatient services 0% coinsurance 20% coinsurance none Home health care 20% coinsurance 20% coinsurance 120 visit limit Rehabilitation services $30 copay* 20% coinsurance none Habilitation services $30 copay* 20% coinsurance none Skilled nursing care 20% coinsurance 20% coinsurance 120 Days per confinement Durable medical equipment 20% coinsurance 20% coinsurance $350 Maximum on Wigs for Alopecia Areata. Hospice service No charge 20% coinsurance none Eye exam No charge Not covered none Glasses Not covered Not covered none Dental check-up Not covered Not covered none 3 of

18 HealthPartners: HP Choice - $300 Ded Coverage Period: 10/01/ /30/2014 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: All Coverage Levels 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 Dental care (Adult) Hearing aids Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing 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 Infertility treatment Routine eye care (Adult) 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 x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. You can contact your issuer s member assistance resources at For questions about your rights, this notice, or assistance, you can contact your state insurance department at the following: MN Dept of Health at / or the MN Dept of Commerce at / Additionally, a consumer assistance program can help you file your appeal. Contact the following: MN Dept of Health at / or the MN Dept of Commerce at / Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 4 of

19 HealthPartners: HP Choice - $300 Ded Coverage Period: 10/01/ /30/2014 Coverage Examples Coverage for: All Coverage Levels 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. Cost sharing or Patient pays amounts are based on selfonly coverage. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $7,020 Patient pays $520 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 $300 Copays $20 Coinsurance $0 Limits or exclusions $200 Total $520 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,120 Patient pays $1,280 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 $300 Copays $820 Coinsurance $80 Limits or exclusions $80 Total $1,280 5 of

20 HealthPartners: HP Choice - $300 Ded Coverage Period: 10/01/ /30/2014 Coverage Examples Coverage for: All Coverage Levels 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 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. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 6 of 6 at or call to request a copy The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. 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.

21 HealthPartners: HP Choice Ded SI - "HP Choice - $500 Ded" Coverage Period: 10/01/ /30/2014 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: All Coverage Levels 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? In-network: $500 Individual, $1,000 Family Out-of-network: $1,000 Individual, $2,000 Family Services marked with * in Common Medical Events are not subject to deductible No. Yes. In-network: $1,500 Individual, $4,500 Family Out-of-network: $4,500 Individual, None Family Premium, balance-billed charges (unless balanced billing is prohibited), and health care this plan doesn't cover. No. Yes. For a list of in-network providers, see rks or call No. You don't need a referral to see a specialist. 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 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. 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 in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 6 at or call to request a copy

22 HealthPartners: HP Choice Ded SI - "HP Choice - $500 Ded" Coverage Period: 10/01/ /30/2014 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: All Coverage Levels 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 coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at /public/pharmacy/f ormularies/formular y/preferredrx/index. html. Services You May Need Your cost if you use a In-Network Provider Out-Of-Network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $30 copay* 40% coinsurance none Specialist visit $30 copay* 40% coinsurance none Other practitioner office visit $30 copay* 40% coinsurance none Preventive care/screening/immunization No charge 40% coinsurance none 20% coinsurance Diagnostic test (x-ray, blood work) for x-rays, No 40% coinsurance none charge for lab Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance none Generic drugs Preferred brand drugs Non-preferred brand drugs Preferred: $20 copay* at retail, $40 copay* at mail Non-preferred: $80 copay* at retail, $160 copay* at mail $40 copay* at retail, $80 copay* at mail $80 copay* at retail, $160 copay* at mail 40% coinsurance at retail, mail not covered 31 Day supply retail/93 day supply mail order 2 of

23 HealthPartners: HP Choice Ded SI - "HP Choice - $500 Ded" Coverage Period: 10/01/ /30/2014 Summary of Coverage: What this Plan Covers & What it Costs Common Medical Event If you have outpatient surgery Services You May Need Specialty drugs Coverage for: All Coverage Levels Plan Type: PPO Your cost if you use a In-Network Out-Of-Network Limitations & Exceptions Provider Provider 40% coinsurance $40 copay* at retail, mail not none covered Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance none Physician/surgeon fees 20% coinsurance 40% coinsurance none Emergency room services 20% coinsurance 20% coinsurance none Emergency medical transportation 20% coinsurance 20% coinsurance none If you need immediate medical attention Urgent care $30 copay* $30 copay* none If you have a Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance none hospital stay Physician/surgeon fee 20% coinsurance 40% coinsurance none If you have mental Mental/Behavioral health outpatient services $30 copay* 40% coinsurance none health, behavioral Mental/Behavioral health inpatient services 20% coinsurance 40% coinsurance none health, or substance Substance use disorder outpatient services $30 copay* 40% coinsurance none abuse needs Substance use disorder inpatient services 20% coinsurance 40% coinsurance none If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Prenatal and postnatal care No charge 40% coinsurance none Delivery and all inpatient services 20% coinsurance 40% coinsurance none Home health care 20% coinsurance 40% coinsurance 120 visit limit Rehabilitation services $30 copay* 40% coinsurance none Habilitation services $30 copay* 40% coinsurance none Skilled nursing care 20% coinsurance 40% coinsurance 120 Days per confinement Durable medical equipment 20% coinsurance 40% coinsurance $350 Maximum on Wigs for Alopecia Areata. Hospice service No charge 40% coinsurance none Eye exam No charge Not covered none Glasses Not covered Not covered none Dental check-up Not covered Not covered none 3 of

24 HealthPartners: HP Choice Ded SI - "HP Choice - $500 Ded" Coverage Period: 10/01/ /30/2014 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: All Coverage Levels 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 Dental care (Adult) Hearing aids Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing 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 Infertility treatment Routine eye care (Adult) 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 x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. You can contact your issuer s member assistance resources at For questions about your rights, this notice, or assistance, you can contact your state insurance department at the following: MN Dept of Health at / or the MN Dept of Commerce at / Additionally, a consumer assistance program can help you file your appeal. Contact the following: MN Dept of Health at / or the MN Dept of Commerce at / Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 4 of

25 HealthPartners: HP Choice Ded SI - "HP Choice - $500 Ded" Coverage Period: 10/01/ /30/2014 Coverage Examples Coverage for: All Coverage Levels 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. Cost sharing or Patient pays amounts are based on selfonly coverage. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $5,840 Patient pays $1,700 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 $500 Copays $0 Coinsurance $1,000 Limits or exclusions $200 Total $1,700 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,820 Patient pays $1,580 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 $500 Copays $960 Coinsurance $40 Limits or exclusions $80 Total $1,580 5 of

26 HealthPartners: HP Choice Ded SI - "HP Choice - $500 Ded" Coverage Period: 10/01/ /30/2014 Coverage Examples Coverage for: All Coverage Levels 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 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. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 6 of 6 at or call to request a copy The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. 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.