Some or all of cost sharing amounts may be reduced or waived if you are an American Indian or an Alaska Native enrolled in any metal level plan purchased through the Marketplace. The Marketplace determines eligibility. There is no cost sharing for covered services that are Essential Health Benefits received from an Indian health organization or participating (innetwork) provider. Indian health organization providers include: Indian Health Service Indian tribe Tribal organization Urban Indian Health Organization Cost sharing applies for services that are not Essential Health Benefits, such as the adult dental services and adult enhanced vision benefit covered under this plan. Please see plan materials for more information on cost sharing obligations for non-essential Health Benefits. Please visit the Indian Health Service (IHS) website at www.ihs.gov to locate the IHS facility closest to you. Your local IHS facility can help answer questions and provide assistance. 1 of 10
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 www.phxchoice.com or by calling 1-855-463-7275 (TTY: 1-855-463-7279). Important Questions Answers Why this Matters: What is the overall See the chart starting on page 3 for your costs for services this plan $0 person/ $0 family deductible? covers. 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? Yes. $100. 50% coinsurance after $100 deductible cost share applies to adult Class II dental services. No. This plan has no out-of-pocket limit. No. Yes. Call 1-855-463-7275 (TTY: 1-855-463-7279) or visit www.phxchoice.com/providerdirectory for a list of participating providers. No. Yes. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. There s no limit on how much you could pay during a coverage period for your share of the cost of covered services. Not applicable because there s no out-of-pocket limit on your expenses. The chart starting on page 3 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. Plans use the term in-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. 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 7. See your policy or plan document for additional information about excluded services. 2 of 10
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 participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic Services You May Need Your Cost If You Use a Participating or Indian Health Organization Provider Your Cost If You Use a Non-Participating or Non-Indian Health Organization Provider Limitations & Exceptions Primary care visit to treat an injury or illness ---------------------None-------------------- Specialist visit ---------------------None-------------------- Coverage is limited to 60 visits/year for habilitation services; 60 visits/year for rehabilitation services; & 20 Other practitioner office visit (Habilitation services, visits/year for chiropractic care. Preauthorization required otherwise rehabilitation services & chiropractic care) Acupuncture not covered. Preventive care/ screening/immunization Subject to age and clinical recommendation limitations as provided under state and federal law. 3 of 10
Common Medical Event If you have a test Services You May Need Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Your Cost If You Use a Participating or Indian Health Organization Provider Your Cost If You Use a Non-Participating or Non-Indian Health Organization Provider Limitations & Exceptions Pre-authorization required for certain services otherwise services may not be covered. See plan materials for more information. Tier 1 Preferred generic If you need drugs to drugs Coverage includes 30, 60 or 90-day treat your illness or condition Tier 2 Generic drugs supply/fill through retail or mail order pharmacy, except where quantity limits Tier 3 Preferred brand drugs apply. If you select a brand name drug More information Tier 4 Non-preferred brand about prescription that has a generic equivalent, your cost drugs will be higher. Pre-authorization drug coverage is Tier 5 Preferred specialty available at required for some drugs otherwise they drugs may not be covered. See plan www.phxchoice.com/ Tier 6 Non-Preferred Formulary. specialty drugs Facility fee (e.g., ambulatory If you have surgery center) outpatient surgery Physician/surgeon fees Emergency room services ---------------------None-------------------- If you need Emergency medical immediate medical ---------------------None-------------------- transportation attention Urgent care ---------------------None-------------------- If you have a Facility fee (e.g., hospital hospital stay room) 4 of 10
Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need Your Cost If You Use a Participating or Indian Health Organization Provider Physician/surgeon fee Your Cost If You Use a Non-Participating or Non-Indian Health Organization Provider Limitations & Exceptions Mental/Behavioral health (office); outpatient services (other) Mental/Behavioral health Pre-authorization required for certain inpatient services services otherwise services may not be Substance use disorder (office); covered. See plan materials for more outpatient services (other) information. Substance use disorder inpatient services Prenatal and postnatal care Pre-authorization required for certain services otherwise services may not be Delivery and all inpatient covered. See plan materials for more services information. Coverage is limited to 42 visits/year. Home health care Coverage is limited to 60 visits/year. Rehabilitation services Coverage is limited to 60 visits/year. Habilitation services 5 of 10
Common Medical Event If your child needs dental or eye care Services You May Need Your Cost If You Use a Participating or Indian Health Organization Provider Skilled nursing care Durable medical equipment Hospice service Your Cost If You Use a Non-Participating or Non-Indian Health Organization Provider Limitations & Exceptions Coverage is limited to 90 days/year. Eye exam Coverage is limited to 1 exam/year. Glasses Coverage is limited to 1 pair of glasses/year (contact lenses, in lieu of glasses when medically necessary & appropriate in the treatment of certain conditions). Dental check-up Coverage is limited to 1 dental checkup every 6 months. Pre-authorization required otherwise services may not be covered. See plan materials for more information. 6 of 10
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.) Acupuncture Cosmetic surgery Elective abortion (Except as permitted under Arizona law as follows: when necessary to save the life of the woman, necessary to avert substantial & irreversible impairment of major bodily function or pregnancy is the result of rape or incest.) Infertility treatment (Plan does not cover fertility & infertility services to improve or achieve fertility (e.g., in-vitro or artificial insemination). Coverage is limited to medical history, physical exams, related diagnostic & lab tests, infertility evaluation & diagnosis & medical supervision with generally accepted medical practice.) Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing (Coverage is limited to only when medically necessary as part of inpatient hospital services.) 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.) Dental care (Adult) (Coverage is limited to Chiropractic care (20 visits per year) Routine foot care (Coverage is limited to care Class I (diagnostic/preventive) & Class II Hearing aids (1 hearing aid per ear per year) for diabetes, neurological involvement or (restorative/other basic) dental services. Plan Routine eye care (Adult) (Coverage is limited peripheral vascular disease of the foot/lower will cover up to $500 in covered services per to 1 exam per year as part of annual physical. leg.) year. Plan does not cover Class III Screening is done to determine need for (complex/major) or Class IV (orthodontia) vision correction. Please note that the dental services.) enhanced adult vision benefit coverage Bariatric surgery includes 1 eye exam per year with dilation, if professionally indicated, and $100 allowance for eyewear (e.g., glasses).) 7 of 10
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 us at 1-855-463-7275 (TTY: 1-855-463-7279). You may also contact your State insurance department at (602) 364-2499 or (800) 325-2548 (outside Phoenix) or by email at consumers@azinsurance.gov; the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/; or the U.S. Department of Health and Human Services at 1-877- 267-2323 x61565 or www.cms.gov/cciio/index.html. 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 us at 1-855-463-7275 (TTY: 1-855-463-7279). You also can contact the Arizona Department of Insurance, Consumer Affairs Division, by mail at 2910 N. 44th, Suite 210, Phoenix, AZ 85018 or by phone at (602) 364-2499 or 1-(800) 325-2548 (outside Phoenix). Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-855-463-7275 (TTY: 1-855-463-7279). Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-463-7275 (TTY: 1-855-463-7279). Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 1-855-463-7275 (TTY: 1-855-463-7279). Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-463-7275 (TTY: 1-855-463-7279). To see examples of how this plan might cover costs for a sample medical situation, see the next page. 8 of 10
Coverage Examples Phoenix Health Plans, Inc. Coverage for: Individuals & Families Plan Type: HMO 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 $7,540 Patient pays $0 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 $0 Copays $0 Coinsurance $0 Limits or exclusions $0 Total $0 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $5,400 Patient pays $0 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 $0 Copays $0 Coinsurance $0 Limits or exclusions $0 Total $0 9 of 10
Coverage Examples Phoenix Health Plans, Inc. Coverage for: Individuals & Families Plan Type: HMO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All 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. 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. 10 of 10