HUMANA HEALTH PLAN OF TX, INC/HUMANA INSURANCE CO: TX SG NPOS 11 Beginning on or after: 09/01/2013

Transcription

1 SBC0032M HUMANA HEALTH PLAN OF TX, INC/HUMANA INSURANCE CO: TX SG NPOS 11 Beginning on or after: 09/01/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage For: Individual + Family Plan Type: NPOS 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 Network: You must pay all the costs up to the deductible amount before this plan deductible? $3,000 Individual / $6,000 begins to pay for covered services you use. Check your policy or plan Family document to see when the deductible starts over (usually, but not always, Non-Network: January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. $9,000 Individual / $18,000 Family Doesn't apply to prescription drugs and preventive services. Co-insurance and co-payments don't count toward the deductible Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses No. You don't have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Yes. For Network providers The out-of-pocket limit is the most you could pay during a coverage period $0 Individual / $0 Family (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. For Non-Network providers $9,000 Individual / $18,000 Family Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 1 of 10

2 What is not included in Premiums, Balance-billed Even though you pay these expenses, they don't count toward the the out-of-pocket charges, Health care this plan out-of-pocket limit. limit? doesn't cover, Penalties, Non-network transplant, Co-Payments, Deductibles, prescription drugs, specialty drugs Is there an overall No. The chart starting on page 3 describes any limits on what the plan will pay annual limit on what for specific covered services, such as office visits. the plan pays? Does this plan use a Yes. See If you use a network doctor or other health care provider, this plan will pay network of providers? or call some or all of the costs of covered services. Be aware, your network doctor or for a list of hospital may use a non-network provider for some services. Plans use the Network providers. term network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? No. You can see the specialist you choose without permission from this plan. Are there services this Yes. Some of the services this plan doesn't cover are listed on page 7. See your plan doesn't cover? policy or plan document for additional information about services. excluded 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 a non-network provider charges more than the allowed amount, you may have to pay the difference. For example, if a non-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 network providers by charging you lower deductibles, copayments and coinsurance amounts. 2 of 10

3 Your Cost If Your Cost if Common You Use a You Use a Services You May Need Medical Event Network Non-Network Provider Provider If you visit a health care provider's office or clinic Limitations & Exceptions Primary care visit to treat an $30 copay/visit 30% coinsurance none injury or illness Specialist visit $55 copay/visit 30% coinsurance none Other practitioner office visit Chiropractor: Chiropractor: Chiropractor: $55 copay/visit 30% coinsurance 30 PT,OT,ST,CT, AT visit limit per year includes manips & adjustments For non-network, 10 PT,OT,CT,ST,AT visits per year includes manips & adjustments Preventive care / screening / No Charge 30% coinsurance limited coverage for preventive care immunization If you have a test Diagnostic test (x-ray, blood No Charge 30% coinsurance none work) Imaging (CT/PET scans, No Charge 30% coinsurance Preauthorization required, penalty may apply MRIs) 3 of 10

4 Your Cost If Your Cost if Common You Use a You Use a Services You May Need Medical Event Network Non-Network Provider Provider 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 If you have a hospital stay Limitations & Exceptions Level 1 - Lowest cost generic $10 copay 30% coinsurance Preauthorization required, penalties may apply. and brand-name drugs (Retail) after Network 30 day supply (Retail) $25 copay (Mail copay (Retail) 90 day supply (Mail Order) Order) Level 2 - Higher cost generic $40 copay See Level 1 for See Level 1 for Limitations and Exceptions and brand-name drugs (Retail) Non-Network $100 copay benefit (Mail Order) Level 3 - Generic and $70 copay See Level 1 for See Level 1 for Limitations and Exceptions brand-name drugs with (Retail) Non-Network higher cost than Level 2 $175 copay benefit (Mail Order) Level 4 - Highest cost drugs 25% coinsurance See Level 1 for See Level 1 for Limitations and Exceptions (Retail) Non-Network 25% coinsurance benefit (Mail Order) Facility fee (e.g., ambulatory No Charge 30% coinsurance Preauthorization required, penalty may apply surgery center) Physician/surgeon fees No Charge 30% coinsurance none Emergency room services $250 copay/visit $250 copay/visit Copayment waived if admitted Emergency medical No Charge No Charge none transportation Urgent care $55 copay/visit 30% coinsurance none Facility fee (e.g., hospital No Charge 30% coinsurance Preauthorization required, penalty may apply room) Physician/surgeon fee No Charge 30% coinsurance none 4 of 10

5 Your Cost If Your Cost if Common You Use a You Use a Services You May Need Medical Event Network Non-Network Provider Provider Limitations & Exceptions Mental/Behavioral health $55 copay/visit 30% coinsurance 20 visits per calendar year outpatient services If you have mental Mental/Behavioral health No Charge 30% coinsurance Preauthorization required, penalty may apply health, behavioral inpatient services 10 days per calendar year health, or substance Substance use disorder $55 copay/visit 30% coinsurance 20 visits per calendar year abuse needs outpatient services Substance use disorder No Charge 30% coinsurance Preauthorization required, penalty may apply inpatient services Prenatal and postnatal care No Charge 30% coinsurance none If you are pregnant Delivery and all inpatient No Charge 30% coinsurance none services 5 of 10

6 Your Cost If Your Cost if Common You Use a You Use a Services You May Need Medical Event Network Non-Network Provider Provider If you need help recovering or have other special health needs If your child needs dental or eye care Limitations & Exceptions Home health care No Charge 30% coinsurance Preauthorization required, penalty may apply Rehabilitation services $55 copay/visit 30% coinsurance Preauthorization required, penalty may apply 30 PT,OT,ST,CT, AT visit limit per year includes manips & adjustments For non-network, 10 PT,OT,CT,ST,AT visits per year includes manips & adjustments Any limits for Habilitation services and Rehabilitation services are combined. Habilitation services $55 copay/visit 30% coinsurance Preauthorization required, penalty may apply 30 PT,OT,ST,CT, AT visit limit per year includes manips & adjustments For non-network, 10 PT,OT,CT,ST,AT visits per year includes manips & adjustments Any limits for Habilitation services and Rehabilitation services are combined. Skilled nursing care No Charge 30% coinsurance Preauthorization required, penalty may apply 60 days per calendar year Durable medical equipment No Charge 30% coinsurance Preauthorization required, penalty may apply Hospice service No Charge 30% coinsurance Preauthorization required, penalty may apply Eye exam No Charge 30% coinsurance none Glasses Not Covered Not Covered none Dental check-up Not Covered Not Covered none 6 of 10

7 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.) Bariatric surgery Dental care (Adult) Routine foot care Child dental check-up Long-term care Weight loss programs Child glasses Cosmetic surgery, unless to correct a functional impairment caused by injury, infection, disease Non-emergency care when traveling outside the U.S. for more than 6 consecutive months in a year Private-duty nursing Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Chiropractic care - spinal manipulations Routine eye care (Adult) when in are covered treatment for diabetes 7 of 10

8 Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at You may also contact your state insurance department at Department of Insurance, PO Box , Austin, TXÂ , Phone: 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: Department of Insurance, PO Box , Austin, TXÂ , Phone: or Consumer Health Assistance Program, Department of Insurance, Mail Code 111-1A, PO Box , Austin, TX 78714, Website: chap@tdi.state.tx.us, Phone: Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page. 8 of 10

9 About these Coverage Having a baby Managing type 2 diabetes Examples: (normal delivery) (routine maintenance of a well-controlled condition) These examples show how this plan might cover n Amount owed to providers: $7,540 n Amount owed to providers: $5,400 medical care in given situations. Use these n Plan pays * n Plan pays * examples to see, in general, how much financial n Patient pays * n Patient pays * protection a sample patient might get if they are covered under different plans. Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and $1,300 Hospital charges (baby) $900 Supplies This is Anesthesia $900 Office Visits and Procedures $700 not a cost Laboratory tests $500 Education $300 estimator. Prescriptions $200 Laboratory tests $100 Radiology $200 Vaccines, other preventive $100 Don't use these examples to estimate your actual costs Vaccines, other preventive $40 Total $5,400 under this plan. The actual Total $7,540 Patient pays: care you receive will be Patient pays: Deductibles * different from these examples, and the cost of Deductibles * Copays * that care will also be Copays * Coinsurance * different. Coinsurance * Limits or exclusions * Limits or exclusions * Total * See the next page for Total important information about * these examples. * Coverage Examples are not complete at this time. Example amounts for the "Patient pays" and "Plan pays" fields will be available at a later date. 9 of 10

10 Questions and answers about the Coverage Examples: What are some of the What does a Coverage Can I use Coverage Examples to assumptions behind the Example show? compare plans? Coverage Examples? For each treatment situation, the üyes. When you look at the Summary Costs don't include premiums. Coverage Example helps you see how of Benefits and Coverage for other Sample care costs are based on national deductibles, copayments, and plans, you'll find the same Coverage averages supplied by the U.S. coinsurance can add up. It also helps you Examples. When you compare plans, Department of Health and Human see what expenses might be left up to you check the "Patient Pays" box in each Services, and aren't specific to a to pay because the service or treatment example. The smaller that number, the particular geographic area or isn't covered or payment is limited. more coverage the plan provides. health plan. The patient's condition was not an Does the Coverage Example Are there other costs I should excluded or preexisting condition. predict my own care needs? All services and treatments started and consider when comparing plans? ended in the same coverage period. ûno. Treatments shown are just There are no other medical expenses for üyes. An important cost is the any member covered under this plan. examples. The care you would receive premium you pay. Generally, the Out-of-pocket expenses are based for this condition could be different lower your premium, the more you'll only on treating the condition in based on your doctor's advice, your age, pay in out-of-pocket costs, such as the example. how serious your condition is, and copayments, deductibles, and many other factors. The patient received all care from coinsurance. You should also consider network providers. If the patient had contributions to accounts such as received care from non-network health savings accounts (HSAs), flexible Does the Coverage Example providers, costs would have spending arrangements (FSAs) or predict my future expenses? been higher. health reimbursement accounts (HRAs) that help you pay ûno. Coverage Examples are not cost out-of-pocket expenses. 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 at or call to request a copy. 10 of 10