2016 awane silver hra sbc

7/24/2019 2016 AWANE SILVER HRA SBC

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AWANE: SILVER HRA Coverage Period: 01/01/2016-12/31/2016

Suar! of "e#efi$% a#d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&a# '!(e: HRA

')i% i% o#&! a %uar!* If you want more detail about your coverage and costs, you can get the completeterms in the policy or plan document at https://eoc.anthem.com/eocdps/f or by calling 1-844-404-6843.

Employer Contribution to the Health Account $1,!" individual and $!,#" %amily. &he contribution isincluded in the deductible and out'of'poc(et limits below.

I(or$a#$ +ue%$io#% A#%,er% W)! $)i% a$$er%:

What is the overalldeductible?

%or in'networ( providers

.20 individual /

.00 family

%or out'of'networ( providers

.00 individual /

.1100 family

)oesn*t apply to in'networ(

preventive care, routine eyee+ams.

ou must pay all the costs up to the deductible amountbefore this plan begins to pay for covered services you use.Chec( your policy or plan document to see when thedeductible starts over -usually, but not always, anuary1st/. 0ee the chart starting on page for how much you payfor covered services after you meet the deductible.

Are there otherdeductibles forspecic services?

2o. ou must pay all of the costs for these services up to thespeci3c deductible amount before this plan begins to payfor these services.

Is there an out–of–pocet li!it on !"

e#penses?

%or in'networ( porivders

.6600 individual / .13200 family

%or out'of'networ( providers

.13200 individual /

.2600 family

&he out-of-pocet li!it is the most you could pay during acoverage period -usually one year/ for your share of the costof covered services. &his limit helps you plan for health care

e+penses.

What is not includedin the out–of–pocetli!it?

4ut'of'2etwor( deductible,premiums, penalties fornon'compliance, balance'billed charges, and healthcare this plan doesn*t cover.

Even though you pay these e+penses, they don*t counttoward the out-of-pocet li!it.

$uestions% Call 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren*t clear about any of the underlined terms used in this form, see the 5lossary. ou can view the 5lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re6uest a copy.

https://eoc.anthem.com/eocdps/fi

https://eoc.anthem.com/eocdps/fi



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Is there an overallannual li!it on &hatthe plan pa"s?

2o.&he chart starting on page describes any limits on whatthe plan will pay for specifc covered services, such as o7ice

visits.

(oes this plan use anet&or ofproviders?

es. %or a list of preferredproviders, seewww.anthem.com or call

1'#''8#

If you use an in'networ( doctor or other health careprovider , this plan will pay some or all of the costs of

covered services. 9e aware, your in'networ( doctor orhospital may use an out'of'networ( provider for someservices. :lans use the term in'networ(, preferred, orparticipating for providers in their net&or . 0ee the chartstarting on page for how this plan pays di7erent (inds ofproviders.

(o I need a referralto see a specialist?

2o. ou can see the specialist you choose without permissionfrom this plan.

Are there services

this plan doesn)tcover? es.

0ome of the services this plan doesn*t cover are listed on

page 8. 0ee your policy or plan document for additionalinformation about e#cluded services.

• *opa"!ents are 3+ed dollar amounts -for e+ample, $1"/ you pay for covered health care, usually when you

receive the service.

• *oinsurance is your share of the costs of a covered service, calculated as a percent of the allo&ed

a!ount for the service. %or e+ample, if the plan*s allo&ed a!ount for an overnight hospital stay is$1,, your coinsurance payment of !; would be $!. &his may change if you haven*t met yourdeductible.

•

&he amount the plan pays for covered services is based on the allo&ed a!ount. If an out'of'networ( provider charges more than the allo&ed a!ount, you may have to pay the di7erence. %or e+ample, if anout'of'networ( hospital charges $1," for an overnight stay and the allo&ed a!ount is $1,, you mayhave to pay the $" di7erence. -&his is called balance billin+./

• &his plan may encourage you to use in'networ( providers by charging you lower deductibles,

copa"!ents and coinsurance amounts.




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Coo#edi4a& Eve#$

Servi4e% 5ou a! Need

5our Co%$ If 5ou %e a#I#-#e$,or7Provider

5our Co%$ If 5ou %e a#

8u$-of-#e$,or7Provider

Lii$a$io#% 9 E4e($io#%

If "ou visit ahealth careprovider)so,ice or clinic

:rimary care visit to treat anin<ury or illness

#";coinsurance

";coinsurance

============none============

0pecialist visit#";coinsurance

";coinsurance

============none============

4ther practitioner o7ice visit#";coinsurance

";coinsurance

Chiropractic care limited to1! visits per member percalendar year.

:reventivecare>screening>immuni?ation

2o Charge";coinsurance

============none============

If "ou have a

test

)iagnostic test -+'ray, bloodwor(/

#";coinsurance

";coinsurance

============none============

Imaging -C&>:E& scans, @Is/ #";coinsurance

";coinsurance

============none============

If "ou needdru+s to treat "our illness orcondition

@oreinformationaboutprescriptiondru+ covera+e is available atwww.medco.com

@aintenance @eds are re6uired to be3lled mail order after 3lls at retail-penalty applies/. If pre'auth re6uired Bnot obtained, drug may not be covered.Certain :reventive meds no copay. If ageneric e6uivalent is available B brand isprescribed>member will pay brand namecost di7erence. :lan uses preferred druglist to identify coverage.

&he mail order cost will be

based on the medication tier-generic, preferred, non'preferred/. 0pecialty meds cannot be 3lled at retailpharmacies.

If "ou haveoutpatientsur+er"

%acility fee -e.g., ambulatorysurgery center/

#";coinsurance

";coinsurance

============none============

:hysician>surgeon fees#";coinsurance

";coinsurance

============none============




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Coo#edi4a& Eve#$






If "ou needi!!ediate!edicalattention

Emergency room services#";

coinsurance

";

coinsurance

@embers may be balancebilled for out of networ(services.

Emergency medicaltransportation

#";coinsurance

";coinsurance

@embers may be balancebilled for out of networ(services

rgent care#";coinsurance

";coinsurance

@embers may be balancebilled for out of networ(services

If "ou have ahospital sta"

%acility fee -e.g., hospital room/

#";

coinsurance

";

coinsurance

:recerti3cation is re6uiredfor Inpatient hospital

admission. A $" penalty isapplied if an 4ut of 2etwor(admission is not precerti3ed.

:hysician>surgeon fee#";coinsurance

";coinsurance

============none============




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Coo#edi4a& Eve#$






If "ou needhelp recoverin+or have other

special healthneeds

Home health care#";coinsurance

";coinsurance

Dimited to 1 per calendar year.

ehabilitation services#";coinsurance

";coinsurance

Inpatient physical medicinerehabilitation is limited to1 days per member percalendar year. Dimited to 8

visits combined physicaltherapy, speech therapy andoccupational therapy. Alltherapy limits are combinedin and out of networ(.

Habilitation services#";coinsurance

";coinsurance

All rehabilitation andhabilitation visits counttoward your rehabilitation visitlimit.

0(illed nursing care#";coinsurance

";coinsurance

Dimited to 1 inpatient daysper member per calendar

year.

)urable medical e6uipment#";coinsurance

";coinsurance

============none============

Hospice service#";

coinsurance

";

coinsurance============none============

If "our childneeds dental or e"e care

Eye e+am 2o Charge";coinsurance

Dimited to one e+am per yearfor 1# and younger. Dimitedto one e+am every ! years for1 and older.

5lasses 2ot Covered 2ot Covered ============none============

)ental chec('up 2ot Covered 2ot Covered ============none============




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E4&uded Servi4e% 9 8$)er Covered Servi4e%:

Servi4e% 5our P&a# ;oe% N8' Cover ./his isn)t a co!plete list' *hec "our polic" or plan docu!ent for othere#cluded services'

F Acupuncture

F Cosmetic surgery

F )ental care -Adult/

F Dong'term care

F 2on'emergency care when traveling

outside the .0.

F outine foot care

F Geight loss programs

8$)er Covered Servi4e% ./his isn)t a co!plete list' *hec "our polic" or plan docu!ent for other coveredservices and "our costs for these services'

F 9ariatric surgery

F Chiropractic care -Dimits apply/

F Infertility treatment -Dimits apply/

F Coverage provided outside thenited 0tates.0ee www.9C90.com>bluecardworldwide

F Hearing aids -Dimitations apply/

F outine eye care -Adult 'Dimitations apply/

5our Rig)$% $o Co#$i#ue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, %ederal and 0tate laws may provide

protections that allow you to (eep health coverage. Any such rights may be limited in duration and will re6uire you

to pay a pre!iu!, which may be signi3cantly higher than the premium you pay while covered under the plan.

4ther limitations on your rights to continue coverage may also apply.

%or more information on your rights to continue coverage, contact the plan at 1'#'!"#'"1#. ou may also contact your state insurance department, the .0. )epartment of Dabor, Employee 9ene3ts 0ecurity Administration at 1'#88''!! or www.dol.gov>ebsa, or the .0. )epartment of Health and Human 0ervices at 1'#'!8'!! +81"8" orwww.cciio.cms.gov.


http://www.bcbs.com/bluecardworldwide


http://www.dol.gov/ebsa

http://www.cciio.cms.gov/



http://www.dol.gov/ebsa

http://www.cciio.cms.gov/



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5our <rieva#4e a#d A((ea&% Rig)$%:

If you have a complaint or are dissatis3ed with a denial of coverage for claims under your plan, you may be able to appeal or 3le a +rievance. %or 6uestions about your rights, this notice, or assistance, you can contact

Anthem 9lue Cross and 9lue 0hield:.4. 9o+ "1"Dos Angeles, CA "'1"

%or grievances and>or appeals regarding you prescription drug coverage, call the number listed on the bac( ofprescription member I) card or visit www.e+press'scripts.com.

%or EI0A information contact

)epartment of Dabor*s Employee 9ene3ts 0ecurity Administration1'#88''E90A -!!/

www.dol.gov>ebsa>healthreform

Additionally, a consumer assistance program can help you 3le your appeal. Contact

2ew Hampshire )epartment of Insurance!1 0outh %ruit 0treet, 0uite 1Concord, 2H 1-#/ #"!'18www.nh.gov>insuranceconsumerservicesJins.nh.gov


http://www.express-scripts.com/

http://www.dol.gov/ebsa/healthreform

http://www.nh.gov/insurance

mailto:[email protected]

http://www.express-scripts.com/

http://www.dol.gov/ebsa/healthreform

http://www.nh.gov/insurance

mailto:[email protected]



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;oe% $)i% Coverage Provide i#iu E%%e#$ia& Coverage>

&he A7ordable Care Act re6uires most people to have health care coverage that 6uali3es as Kminimum essential

coverage.L This plan or policy does provide minimum essential coverage.

;oe% $)i% Coverage ee$ $)e i#iu Va&ue S$a#dard>

&he A7ordable Care Act establishes a minimum value standard of bene3ts of a health plan. &he minimum value

standard is 8; -actuarial value/. This health coverage does meet the minimum value standard for the

benets it provides.

La#guage A44e%% Servi4e%:

======================To see examples o how this plan might cover costs or a sample medical situation, see the next

page.–––––––––––===========




Havi#g a ?a?!-normal delivery/

a#agi#g $!(e 2 dia?e$e%-routine maintenance of

a well'controlled condition/

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Coverage Ea(&e%

Coverage for: Individual/Family | P&a# '!(e: HRA

A?ou$ $)e%e CoverageEa(&e%:

&hese e+amples show how this planmight cover medical care in givensituations. se these e+amples tosee, in general, how much 3nancialprotection a sample patient mightget if they are covered underdi7erent plans.

Aou#$ o,ed $o (rovider%: $7,5!

P&a# (a!% $",#!

Pa$ie#$ (a!% $",#!

Sa(&e 4are 4o%$%:

Hospital charges -mother/$!,

outine obstetric care$!,1

Hospital charges -baby/ $ Anesthesia $

Daboratory tests $"

:rescriptions $!

adiology $!

Maccines, other preventive $

/otal24

0

Pa$ie#$ (a!%:)eductibles

$!,#"

Copays $

Coinsurance $88

Dimits or e+clusions $1

/otal368

0

Aou#$ o,ed $o (rovider%: $5,!!

P&a# (a!% $5!

Pa$ie#$ (a!% $5,"5!

Sa(&e 4are 4o%$%:

:rescriptions$!,

@edical E6uipment and

0upplies

$1,

47ice Misits and :rocedures $

Education $

Daboratory tests $1

Maccines, other preventive $1

/otal40

0

Pa$ie#$ (a!%:

)eductibles$!,!

Copays $

Coinsurance $

Dimits or e+clusions$!,

/otal3

0


')i% i%#o$ a 4o%$e%$ia$or*

)on*t use thesee+amples to estimate

your actual costs underthis plan. &he actualcare you receive will bedi7erent from thesee+amples, and the costof that care will also bedi7erent.

0ee the ne+t page forimportant information



+ue%$io#% a#d a#%,er% a?ou$ $)e Coverage Ea(&e%:

W)a$ are %oe of $)ea%%u($io#% ?e)i#d $)eCoverage Ea(&e%>

• Costs don*t include pre!iu!s.

• 0ample care costs are based onnational averages supplied bythe .0. )epartment of Healthand Human 0ervices, andaren*t speci3c to a particulargeographic area or health plan.

• &he patient*s condition was notan e+cluded or pree+isting

condition.• All services and treatments

started and ended in the samecoverage period.

• &here are no other medicale+penses for any membercovered under this plan.

• 4ut'of'poc(et e+penses arebased only on treating thecondition in the e+ample.

• &he patient received all carefrom in'networ( providers. Ifthe patient had received carefrom out'of'networ( providers,costs would have been higher.

W)a$ doe% a Coverage Ea(&e%)o,>

%or each treatment situation, the

Coverage E+ample helps you seehow deductibles, copa"!ents,and coinsurance can add up. Italso helps you see what e+pensesmight be left up to you to paybecause the service or treatmentisn*t covered or payment is limited.

;oe% $)e Coverage Ea(&e

(redi4$ ! o,# 4are #eed%> o' &reatments shown are <ust

e+amples. &he care you wouldreceive for this condition couldbe di7erent based on yourdoctor*s advice, your age, howserious your condition is, andmany other factors.

;oe% $)e Coverage Ea(&e(redi4$ ! fu$ure e(e#%e%>

o' Coverage E+amples are not

cost estimators. ou can*t usethe e+amples to estimate costsfor an actual condition. &hey arefor comparative purposes only.

our own costs will be di7erentdepending on the care youreceive, the prices yourproviders charge, and thereimbursement your health planallows.

Ca# I u%e Coverage Ea(&e%

$o 4o(are (&a#%>

5es' Ghen you loo( at the

0ummary of 9ene3ts andCoverage for other plans, you*ll3nd the same CoverageE+amples. Ghen you compareplans, chec( the K:atient :aysLbo+ in each e+ample. &hesmaller that number, the morecoverage the plan provides.

Are $)ere o$)er 4o%$% I %)ou&d4o#%ider ,)e# 4o(ari#g(&a#%>

5es' An important cost is the

pre!iu! you pay. 5enerally,

the lower yourpre!iu!

, themore you*ll pay in out'of'poc(et



costs, such as copa"!ents,deductibles, and coinsurance.

ou should also considercontributions to accounts suchas health savings accounts-H0As/, Ne+ible spendingarrangements -%0As/ or health

reimbursement accounts -HAs/that help you pay out'of'poc(ete+penses.

2016 awane silver hra sbc

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