University of Kentucky: PPO Coverage for: Plan Type: …

[Pages:11]Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2017? 06/30/2018

University of Kentucky: PPO

Coverage for: Individual + Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, . For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at sbc-glossary/ or call (855) 634-3383 to request a copy.

Important Questions What is the overall deductible?

Are there services covered before you meet your deductible?

Answers

$250/individual or $500/family for UK Providers. $500/ individual or $1,000/family for In-Network Providers. $1,500/ individual or $3,000/family for Out-of-Network Providers.

Yes. Preventive care, Primary Care visit, Vision exam and Specialist visit for UK Providers and In-Network Providers.

Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at .

Are there other deductibles for specific services? What is the out-ofpocket limit for this plan?

What is not included in the out-of-pocket limit?

No.

You don't have to meet deductibles for specific services.

$2,750/ individual or $5,500/family for UK Providers. $3,000/ individual or $6,000/family for In-Network Providers. Unlimited individual or Unlimited family for Out-ofNetwork Providers.

Services deemed not medically necessary by Medical Management and/or Anthem, Penalties for non-compliance, Prescription Drugs, Premiums, Balance-Billing charges, and Health Care this plan doesn't

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

KY/L/A/University of Kentucky-PPO-NA/NA-NA/ZWUUP/NA/07-17

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Will you pay less if you use a network provider?

cover.

Yes, BlueCard PPO. See or call (855) 634-3383 for a list of network providers.

You pay the least if you use a provider in UK. You pay more if you use a provider in InNetwork. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral No. to see a specialist?

You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Event

Services You May Need

Primary care visit to treat an injury or illness

UK Provider (You will pay the

least)

$15/visit deductible does not

apply

In-Network Provider

(You will pay more)

$25/visit deductible does not

apply

Out-of-Network Provider

(You will pay the most)

50% coinsurance

Limitations, Exceptions, & Other Important Information

--------none--------

Specialist visit

If you visit a health care provider's office or clinic

Preventive care/screening/ immunization

$40/visit

$50/visit

deductible does not deductible does not

apply

apply

No charge

No charge

Diagnostic test (x-ray, blood If you have a test work)

10% coinsurance 20% coinsurance

Imaging (CT/PET scans, MRIs) 10% coinsurance 20% coinsurance

50% coinsurance 50% coinsurance

50% coinsurance 50% coinsurance

--------none--------

Vision exam (routine): Not covered for UK Provider, InNetwork and Out-of-Network Providers. Colon cancer screenings (routine): 0% coinsurance for Out-of-Network Providers. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

UK and Anthem Network: Diagnostic X-rays and Laboratory are covered 100% up to $250 then appropriate deductible/coinsurance amount applies.

--------none--------

* For more information about limitations and exceptions, see plan or policy document at .

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Common Medical Event

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at [insert]. If you have outpatient surgery

If you need immediate medical attention

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

If you are pregnant

Services You May Need

Tier 1 - Typically Generic Tier 2 - Typically Preferred / Brand Tier 3 - Typically Non-Preferred / Specialty Drugs

UK Provider (You will pay the

least)

20% Coinsurance

What You Will Pay

In-Network Provider

(You will pay more)

20% Coinsurance

Out-of-Network Provider

(You will pay the most)

20% Coinsurance

40% Coinsurance 40% Coinsurance 40% Coinsurance

50% Coinsurance 50% Coinsurance 50% Coinsurance

Tier 4 - Typically Specialty Drugs

$100 copay

$100 copay

$100 copay

Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees

Emergency room care

Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fees

Outpatient services

Inpatient services Office visits

10% coinsurance 20% coinsurance

10% coinsurance

$100/visit then 20% coinsurance deductible does not

apply

20% coinsurance

$100/visit then 20% coinsurance deductible does not

apply

20% coinsurance 20% coinsurance

$50/visit deductible does not

apply

10% coinsurance

10% coinsurance

Office Visit $15/visit

deductible does not apply

Other Outpatient 10% coinsurance

10% coinsurance

$15/visit deductible does not

apply

$50/visit deductible does not

apply

20% coinsurance

20% coinsurance

Office Visit $25/visit

deductible does not apply

Other Outpatient 20% coinsurance

20% coinsurance

$25/visit deductible does not

apply

50% coinsurance 50% coinsurance

Covered as InNetwork

Covered as InNetwork

50% coinsurance

50% coinsurance 50% coinsurance

Office Visit 50% coinsurance Other Outpatient 50% coinsurance

50% coinsurance

50% coinsurance

Limitations, Exceptions, & Other Important Information

Tier 1 - $8 minimum, $50 maximum per 30 days Tier 2 - $20 minimum, $60 maximum per 30 days Tier 3 - $40 minimum per 30 days

Tier 4 ? Limit to 30 day supply

--------none---------------none--------

Copay waived if admitted.

--------none-------UK Twilight Clinic: $15/visit for PCP visit with an additional copay of $5/visit. --------none---------------none--------

Office Visit --------none-------Other Outpatient --------none--------

--------none-------Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

* For more information about limitations and exceptions, see plan or policy document at .

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Common Medical Event

If you need help recovering or have other special health needs

If your child needs dental or eye care

Services You May Need

Childbirth/delivery professional services Childbirth/delivery facility services Home health care

Rehabilitation services

Habilitation services

Skilled nursing care Durable medical equipment Hospice services Children's eye exam Children's glasses Children's dental check-up

UK Provider (You will pay the

least)

What You Will Pay

In-Network Provider

(You will pay more)

Out-of-Network Provider

(You will pay the most)

10% coinsurance 20% coinsurance 50% coinsurance

10% coinsurance 20% coinsurance 50% coinsurance

20% coinsurance 20% coinsurance 50% coinsurance

$20/visit deductible does not

apply

$20/visit deductible does not

apply

$30/visit deductible does not

apply

$30/visit deductible does not

apply

50% coinsurance 50% coinsurance

20% coinsurance 20% coinsurance 50% coinsurance

20% coinsurance 10% coinsurance

$15/visit deductible does not

apply Not covered Not covered

20% coinsurance 20% coinsurance

$25/visit deductible does not

apply Not covered Not covered

50% coinsurance 50% coinsurance

50% coinsurance

Not covered Not covered

Limitations, Exceptions, & Other Important Information

100 visits/benefit period for InNetwork and Out-of-Network Providers.

*See Therapy Services section

100 days limit/benefit period for In-Network and Out-of-Network Providers. --------none---------------none--------

*See Vision Services section

*See Dental Services section

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded

services.)

Cosmetic surgery

Dental care (adult)

Infertility treatment

Long- term care

Private-duty nursing

Abortion covered only when it is medically

Routine foot care unless you have been

Non-emergency care when traveling outside

necessary to preserve the life of the mother

diagnosed with diabetes.

the U.S.

Weight loss programs

* For more information about limitations and exceptions, see plan or policy document at .

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Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

Chiropractic care 45 visits/benefit period combined with Physical, Occupational, Speech, Pool /Exercise hydro, Acupuncture, Pulmonary Rehab, Cardiac Rehab and Osteopathic Manipulations. Following procedure codes 98940/98941/98942/99201 and diagnostic are the only services covered.

Acupuncture 45 visits/benefit period combined with Physical, Occupational, Speech, Pool /Exercise hydro, Pulmonary Rehab, Cardiac Rehab and Chiropractic and Osteopathic Manipulations.

Hearing aids one/ear every 36 months and include coverage for the bone anchors on hearing aids for children under the age of 18

Bariatric surgery Routine eye care (adult)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or ciio. . Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:

ATTN: Grievances and Appeals, P.O. Box 105568, Atlanta GA 30348-5568

Does this plan provide Minimum Essential Coverage? Yes

If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

??????????????????????To see examples of how this plan might cover costs for a sample medical situation, see the next section.??????????????????????

* For more information about limitations and exceptions, see plan or policy document at .

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About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby (9 months of in-network pre-natal care and a

hospital delivery)

The plan's overall deductible

$250

Specialist copayment

$40

Hospital (facility) coinsurance

10%

Other coinsurance

0%

Managing Joe's type 2 Diabetes (a year of routine in-network care of a well-

controlled condition)

The plan's overall deductible

$250

Specialist copayment

$40

Hospital (facility) coinsurance

10%

Other coinsurance

0%

Mia's Simple Fracture (in-network emergency room visit and follow

up care)

The plan's overall deductible

$250

Specialist copayment

$40

Hospital (facility) coinsurance

10%

Other coinsurance

0%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost

$12,840

In this example, Peg would pay: Cost Sharing

Deductibles Copayments Coinsurance

What isn't covered Limits or exclusions

The total Peg would pay is

$250 $45 $1,135

$96 $1,526

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost

$7,460

In this example, Joe would pay: Cost Sharing

Deductibles Copayments Coinsurance

What isn't covered Limits or exclusions

The total Joe would pay is

$0 $200

$0

$6,041 $6,241

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost

In this example, Mia would pay: Cost Sharing

Deductibles Copayments Coinsurance

What isn't covered Limits or exclusions The total Mia would pay is

$2,010

$250 $200 $277

$0 $727

The plan would be responsible for the other costs of these EXAMPLE covered services.

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