new york quality healthcare corporation dba fidelis care new york · 2021. 1. 1. · mid-hudson...

New York Quality Healthcare Corporation dba

Fidelis Care New York

Rate Manual - Individual Market

Effective Date: January 1, 2021

Table of Contents

Rate Pages Page 2-8

Counties Within Each Rating Region Page 9

Regional and Plan Variation Factors Page 10

HIOS ID Mapping Page 11

Form Numbers and Benefits Page 12-25

Rating Instructions and Example Page 26

Expected Loss Ratios Page 27

Broker Program Page 28

Page 1 of 28




Base Rate

Albany

Metal Level Platinum Gold Silver Bronze Catastrophic

HIOS ID 25303NY0040001 25303NY0030001 25303NY0020001 25303NY0010001 25303NY0090001

Individual $825.76 $681.54 $565.59 $401.57 $188.47

Ind+Sp $1,651.52 $1,363.08 $1,131.18 $803.14 $376.94

Ind+Ch(ren) $1,403.80 $1,158.62 $961.50 $682.67 $320.40

Family $2,353.42 $1,942.39 $1,611.93 $1,144.47 $537.14

Buffalo



Individual $690.70 $570.06 $473.09 $335.89 $157.64

Ind+Sp $1,381.40 $1,140.13 $946.18 $671.78 $315.28

Ind+Ch(ren) $1,174.19 $969.11 $804.25 $571.01 $267.99

Family $1,968.50 $1,624.69 $1,348.30 $957.29 $449.28

Long Island



Individual $873.91 $721.27 $598.57 $424.98 $199.46

Ind+Sp $1,747.82 $1,442.55 $1,197.13 $849.96 $398.92

Ind+Ch(ren) $1,485.65 $1,226.16 $1,017.57 $722.46 $339.09

Family $2,490.64 $2,055.63 $1,705.92 $1,211.20 $568.46

Mid-Hudson



Individual $902.34 $744.74 $618.04 $438.81 $205.95

Ind+Sp $1,804.67 $1,489.47 $1,236.09 $877.62 $411.89

Ind+Ch(ren) $1,533.97 $1,266.05 $1,050.67 $745.98 $350.11

Family $2,571.66 $2,122.50 $1,761.42 $1,250.61 $586.95

Page 2 of 28




Base Rate

New York City



Individual $940.53 $776.26 $644.20 $457.38 $214.66

Ind+Sp $1,881.06 $1,552.52 $1,288.40 $914.76 $429.33

Ind+Ch(ren) $1,598.90 $1,319.64 $1,095.14 $777.55 $364.93

Family $2,680.51 $2,212.34 $1,835.98 $1,303.54 $611.79

Rochester



Individual $757.49 $625.19 $518.83 $368.37 $172.89

Ind+Sp $1,514.98 $1,250.39 $1,037.67 $736.74 $345.79

Ind+Ch(ren) $1,287.74 $1,062.83 $882.02 $626.23 $293.92

Family $2,158.85 $1,781.81 $1,478.68 $1,049.85 $492.74

Syracuse



Individual $817.81 $674.98 $560.15 $397.71 $186.66

Ind+Sp $1,635.63 $1,349.96 $1,120.30 $795.42 $373.31

Ind+Ch(ren) $1,390.28 $1,147.47 $952.26 $676.11 $317.32

Family $2,330.77 $1,923.69 $1,596.42 $1,133.47 $531.97



Individual $759.49 $626.84 $520.20 $369.34 $173.35

Ind+Sp $1,518.99 $1,253.67 $1,040.41 $738.69 $346.69

Ind+Ch(ren) $1,291.14 $1,065.62 $884.35 $627.89 $294.69

Family $2,164.56 $1,786.49 $1,482.58 $1,052.63 $494.04

Utica/Watertown

Page 3 of 28

Metal Level Platinum 29 Gold 29 Silver 29 Bronze 29 Gold ADV 29 Silver ADV 29 Bronze HSA 29

HIOS ID 25303NY0200001 25303NY0170001 25303NY0140001 25303NY0110001 25303NY0560001 25303NY0500001 25303NY0620001

Individual $867.05 $715.61 $593.87 $421.65 $731.46 $608.99 $433.31

Ind+Sp $1,734.10 $1,431.22 $1,187.74 $843.30 $1,462.92 $1,217.99 $866.62

Ind+Ch(ren) $1,473.98 $1,216.54 $1,009.58 $716.81 $1,243.49 $1,035.29 $736.63

Family $2,471.10 $2,039.49 $1,692.53 $1,201.71 $2,084.66 $1,735.63 $1,234.94



Individual $725.24 $598.57 $496.74 $352.68 $611.82 $509.39 $362.44

Ind+Sp $1,450.48 $1,197.13 $993.48 $705.36 $1,223.65 $1,018.78 $724.88

Ind+Ch(ren) $1,232.91 $1,017.57 $844.46 $599.56 $1,040.11 $865.96 $616.15

Family $2,066.94 $1,705.92 $1,415.70 $1,005.15 $1,743.70 $1,451.77 $1,032.96



Individual $917.60 $757.34 $628.50 $446.23 $774.10 $644.50 $458.57

Ind+Sp $1,835.21 $1,514.67 $1,256.99 $892.46 $1,548.21 $1,289.00 $917.14

Ind+Ch(ren) $1,559.92 $1,287.47 $1,068.45 $758.59 $1,315.97 $1,095.66 $779.57

Family $2,615.17 $2,158.41 $1,791.22 $1,271.75 $2,206.20 $1,836.83 $1,306.93



Individual $947.46 $781.97 $648.94 $460.75 $799.29 $665.47 $473.49

Ind+Sp $1,894.92 $1,563.94 $1,297.88 $921.51 $1,598.59 $1,330.93 $946.98

Ind+Ch(ren) $1,610.68 $1,329.35 $1,103.20 $783.28 $1,358.80 $1,131.29 $804.93

Family $2,700.26 $2,228.62 $1,849.48 $1,313.14 $2,277.99 $1,896.58 $1,349.44




Includes Through Age 29 Rider

Albany

Buffalo

Long Island

Mid-Hudson

Page 4 of 28




Includes Through Age 29 Rider

Metal Level Platinum 29 Gold 29 Silver 29 Bronze 29 Gold ADV 29 Silver ADV 29 Gold Wellness to 29Silver Wellness to 29 Bronze HSA 29

HIOS ID 25303NY0200001 25303NY0170001 25303NY0140001 25303NY0110001 25303NY0560001 25303NY0500001 25303NY0580001 25303NY0600001 25303NY0620001

Individual $987.56 $815.08 $676.41 $480.26 $833.13 $693.64 $845.51 $676.01 $493.53

Ind+Sp $1,975.12 $1,630.15 $1,352.82 $960.51 $1,666.25 $1,387.27 $1,691.02 $1,352.03 $987.06

Ind+Ch(ren) $1,678.85 $1,385.63 $1,149.90 $816.44 $1,416.31 $1,179.18 $1,437.37 $1,149.22 $839.00

Family $2,814.55 $2,322.97 $1,927.76 $1,368.73 $2,374.41 $1,976.86 $2,409.70 $1,926.64 $1,406.57



Individual $795.37 $656.45 $544.77 $386.79 $670.98 $558.64 $397.49

Ind+Sp $1,590.74 $1,312.90 $1,089.54 $773.57 $1,341.97 $1,117.29 $794.97

Ind+Ch(ren) $1,352.12 $1,115.96 $926.11 $657.54 $1,140.68 $949.70 $675.73

Family $2,266.80 $1,870.89 $1,552.59 $1,102.34 $1,912.31 $1,592.14 $1,132.84



Individual $858.71 $708.72 $588.16 $417.59 $724.42 $603.13 $429.14

Ind+Sp $1,717.42 $1,417.45 $1,176.31 $835.18 $1,448.84 $1,206.27 $858.27

Ind+Ch(ren) $1,459.81 $1,204.83 $999.87 $709.91 $1,231.52 $1,025.33 $729.54

Family $2,447.33 $2,019.86 $1,676.24 $1,190.13 $2,064.60 $1,718.93 $1,223.04



Individual $797.46 $658.18 $546.21 $387.81 $672.75 $560.12 $398.53

Ind+Sp $1,594.93 $1,316.36 $1,092.41 $775.63 $1,345.51 $1,120.23 $797.06

Ind+Ch(ren) $1,355.69 $1,118.91 $928.55 $659.28 $1,143.69 $952.20 $677.50

Family $2,272.77 $1,875.81 $1,556.69 $1,105.26 $1,917.35 $1,596.33 $1,135.82

Utica/Watertown

New York City

Rochester

Syracuse

Page 5 of 28

Metal Level Platinum Gold Silver Bronze

HIOS ID 25303NY0080001 25303NY0070001 25303NY0060001 25303NY0050001

Albany $340.22 $280.79 $233.02 $165.44

Buffalo $284.57 $234.87 $194.91 $138.39

Long Island $360.05 $297.17 $246.61 $175.09

Mid-Hudson $371.77 $306.83 $254.64 $180.79

New York City $387.50 $319.82 $265.41 $188.44

Rochester $312.08 $257.58 $213.76 $151.77

Syracuse $336.94 $278.09 $230.78 $163.85

Utica/Watertown $312.91 $258.26 $214.32 $152.17




Child Only Rate

Page 6 of 28

Metal Level Gold ADV Silver ADV Bronze HSA

HIOS ID 25303NY0550001 25303NY0460001 25303NY0610001

Individual $696.63 $580.00 $412.68

Ind+Sp $1,393.26 $1,159.99 $825.36

Ind+Ch(ren) $1,184.27 $985.99 $701.56

Family $1,985.39 $1,652.98 $1,176.13


HIOS ID 25303NY0550001 25303NY0460001 25303NY0610001

Individual $582.69 $485.13 $345.18

Ind+Sp $1,165.38 $970.26 $690.36

Ind+Ch(ren) $990.57 $824.73 $586.80

Family $1,660.67 $1,382.63 $983.76


HIOS ID 25303NY0550001 25303NY0460001 25303NY0610001

Individual $737.24 $613.81 $436.73

Ind+Sp $1,474.49 $1,227.62 $873.47

Ind+Ch(ren) $1,253.31 $1,043.48 $742.44

Family $2,101.14 $1,749.35 $1,244.69


HIOS ID 25303NY0550001 25303NY0460001 25303NY0610001

Individual $761.23 $633.77 $450.94

Ind+Sp $1,522.46 $1,267.55 $901.88

Ind+Ch(ren) $1,294.09 $1,077.42 $766.60

Family $2,169.50 $1,806.25 $1,285.18




Non-Standard Plan Rates

Albany

Buffalo

Long Island

Mid-Hudson

Page 7 of 28




Non-Standard Plan Rates

Metal Level Gold ADV Silver ADV Gold Wellness Silver Wellness Bronze HSA


Individual $793.45 $660.61 $805.25 $643.83 $470.03

Ind+Sp $1,586.90 $1,321.22 $1,610.50 $1,287.65 $940.07

Ind+Ch(ren) $1,348.87 $1,123.04 $1,368.92 $1,094.50 $799.05

Family $2,261.34 $1,882.74 $2,294.95 $1,834.90 $1,339.60


HIOS ID 25303NY0550001 25303NY0460001 25303NY0610001

Individual $639.04 $532.04 $378.56

Ind+Sp $1,278.07 $1,064.08 $757.11

Ind+Ch(ren) $1,086.36 $904.47 $643.55

Family $1,821.25 $1,516.32 $1,078.89


HIOS ID 25303NY0550001 25303NY0460001 25303NY0610001

Individual $689.92 $574.41 $408.70

Ind+Sp $1,379.85 $1,148.82 $817.40

Ind+Ch(ren) $1,172.87 $976.50 $694.79

Family $1,966.28 $1,637.06 $1,164.80


HIOS ID 25303NY0550001 25303NY0460001 25303NY0610001

Individual $640.72 $533.44 $379.56

Ind+Sp $1,281.44 $1,066.89 $759.12

Ind+Ch(ren) $1,089.22 $906.85 $645.25

Family $1,826.06 $1,520.32 $1,081.74

Utica/Watertown

New York City

Rochester

Syracuse

Page 8 of 28




Counties within each Rating Region

Albany Region Rochester Region

Albany Livingston

Columbia Monroe

Fulton Ontario

Greene Seneca

Montgomery Wayne

Rensselaer Yates

Saratoga

Schenectady Syracuse Region

Schoharie Broome

Warren Cayuga

Washington Chemung

Cortland

Buffalo Region Onondaga

Allegany Schuyler

Cattaraugus Steuben

Chautauqua Tioga

Erie Tompkins

Genesee

Niagara Utica/Watertown Region

Orleans Chenango

Wyoming Clinton

Essex

Long Island Region Franklin

Nassau Hamilton

Suffolk Herkimer

Jefferson

MidHudson Region Lewis

Delaware Madison

Dutchess Oneida

Orange Oswego

Putnam Otsego

Sullivan St. Lawrence

Ulster

New York City Region

Bronx

Kings

New York City

Queens

Richmond

Rockland

Westchester

Page 9 of 28




Regional Factors

Region 2021 Regional Factors

Albany 0.952

Buffalo 0.796

Long Island 1.008

Mid-Hudson 1.041

New York City 1.085

Rochester 0.874

Syracuse 0.943

Utica/Watertown 0.876

Plan Variation Factors

Plan Description 2021 Adjustment Factors

With coverage through Age 26 Only 1.000

With Domestic Partner Coverage 1.000

Without Pediatric Dental Coverage 1.000

With coverage through Age 29 Only 1.050

Without Domestic Partner Coverage 1.000

With Pediatric Dental Coverage 1.000

Page 10 of 28




HIOS ID Mapping

HIOS ID Plan Name

25303NY0010001 Fidelis Care Bronze, Bronze, ST, INN, Pediatric Dental, Dep25, Free Telehealth

25303NY0020001 Fidelis Care Silver, Silver, ST, INN, Pediatric Dental, Dep25, Free Telehealth

25303NY0030001 Fidelis Care Gold, Gold, ST, INN, Pediatric Dental, Dep25, Free Telehealth

25303NY0040001 Fidelis Care Platinum, Platinum, ST, INN, Pediatric Dental, Dep25, Free Telehealth

25303NY0050001 Fidelis Care Bronze for Children, Child Only, ST, INN, Pediatric Dental, Free Telehealth

25303NY0060001 Fidelis Care Silver for Children, Child Only, ST, INN, Pediatric Dental, Free Telehealth

25303NY0070001 Fidelis Care Gold for Children, Child Only, ST, INN, Pediatric Dental, Free Telehealth

25303NY0080001 Fidelis Care Platinum for Children, Child Only, ST, INN, Pediatric Dental, Free Telehealth

25303NY0090001 Fidelis Care Catastrophic, Catastrophic, ST, INN, Pediatric Dental, Free Telehealth

25303NY0110001 Fidelis Care Bronze, Bronze, ST, INN, Pediatric Dental, Dep29, Free Telehealth

25303NY0140001 Fidelis Care Silver, Silver, ST, INN, Pediatric Dental, Dep29, Free Telehealth

25303NY0170001 Fidelis Care Gold, Gold, ST, INN, Pediatric Dental, Dep29, Free Telehealth

25303NY0200001 Fidelis Care Platinum, Platinum, ST, INN, Pediatric Dental, Dep29, Free Telehealth

25303NY0460001 Fidelis Care Silver Enhanced, Silver, NS, INN, Family Dental, Dep25, Family Vision, Free Telehealth

25303NY0500001 Fidelis Care Silver Enhanced, Silver, NS, INN, Family Dental, Dep29, Family Vision, Free Telehealth

25303NY0550001 Fidelis Care Gold Enhanced, Gold, NS, INN, Family Dental, Dep25, Family Vision, Free Telehealth

25303NY0560001 Fidelis Care Gold Enhanced, Gold, NS, INN, Family Dental, Dep29, Family Vision, Free Telehealth

25303NY0570001 Fidelis Care Gold Wellness, Gold, NS, INN, Family Dental, Dep25, Family Vision, Free Telehealth

25303NY0580001 Fidelis Care Gold Wellness, Gold, NS, INN, Family Dental, Dep29, Family Vision, Free Telehealth

25303NY0590001 Fidelis Care Silver Wellness, Silver, NS, INN, Family Dental, Dep25, Family Vision, Free Telehealth

25303NY0600001 Fidelis Care Silver Wellness, Silver, NS, INN, Family Dental, Dep29, Family Vision, Free Telehealth

25303NY0610001 Fidelis Care Bronze HSA, Bronze, ST, INN, Pediatric Dental, Dep25, Free Telehealth

25303NY0620001 Fidelis Care Bronze HSA, Bronze, ST, INN, Pediatric Dental, Dep29, Free Telehealth

Page 11 of 28



2020

Rate Table Reference Marketing Name Subscriber Contract Schedule of Benefits

Platinum Fidelis Care Platinum Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Platinum_7152019

Gold Fidelis Care Gold Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Gold_7152019

Silver Fidelis Care Silver Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Silver_7152019

Silver 250 Fidelis Care Silver Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Silver 1_7152019



Bronze Fidelis Care Bronze Subscriber Contract_FC-HBX-001_852019 FC-HBX-001-Bronze_7152019

Catastrophic Fidelis Care Catastrophic Coverage Subscriber Contract_FC-HBX-003_852019 FC-HBX-003-Catastrophic_7152019

Platinum Child Only Fidelis Care Platinum for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Platinum_7152019

Gold Child Only Fidelis Care Gold for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Gold_7152019

Silver Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Silver_7152019

Silver 250 Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Silver 1_7152019



Bronze Child Only Fidelis Care Bronze for Children Subscriber Contract_FC-HBX-002_852019 FC-HBX-002-Bronze_7152019






Platinum Fidelis Care Platinum for Children Subscriber Contract_FC-HBX-007_852019 FC-HBX-007-Platinum_7152019

Gold Fidelis Care Gold for Children Subscriber Contract_FC-HBX-007_852019 FC-HBX-007-Gold_7152019

Silver Fidelis Care Silver for Children Subscriber Contract_FC-HBX-007_852019 FC-HBX-007-Silver_7152019

Bronze Fidelis Care Bronze for Children Subscriber Contract_FC-HBX-007_852019 FC-HBX-007-Bronze_7152019

Silver Enhanced Fidelis Care Silver Enhanced Subscriber Contract_FC-HBX-010_852019 FC-HBX-010_Silver Enhanced_7152019

Silver Enhanced_250 Fidelis Care Silver Enhanced Subscriber Contract_FC-HBX-010_852019 FC-HBX-010_Silver Enhanced_1_7152019



Gold Enhanced Fidelis Care Gold Enhanced Subscriber Contract_FC-HBX-010_852019 FC-HBX-010_Gold Enhanced_7152019



Age 29 Rider is available for Platinum, Gold, Silver, Silver 250 and the Bronze plans.

Subscriber Contract_FC-HBX-004_5202019

An American Indian who earns less than 300% of the federal poverty level can be on a Bronze, Silver, Silver Enhanced, Gold, Gold Enhanced or Platinum plan. There will be no cost-sharing.

Fidelis Care [Metal Tier] Schedule of Benefits_FC-HBX-005-Zero Cost-Sharing_7152019

Fidelis Care [Metal Tier] Schedule of Benefits_FC-HBX-013_Zero Cost-Sharing Enhanced_7152019

An American Indian who earns more than 300% of the federal poverty level can be on a Bronze, Silver, Silver Enhanced, Gold, Gold Enhanced or Platinum plan. There will be no cost-sharing at certain providers.

Page 12 of 28



2021

Rate Table Reference Marketing Name Subscriber Contract Schedule of Benefits









Platinum Child Only Fidelis Care Platinum for Children Subscriber Contract_FC-HBX-002_512020 FC-HBX-002-Platinum_512020

Gold Child Only Fidelis Care Gold for Children Subscriber Contract_FC-HBX-002_512020 FC-HBX-002-Gold_512020

Silver Child Only Fidelis Care Silver for Children Subscriber Contract_FC-HBX-002_512020 FC-HBX-002-Silver_512020




Bronze Child Only Fidelis Care Bronze for Children Subscriber Contract_FC-HBX-002_512020 FC-HBX-002-Bronze_512020






Platinum Fidelis Care Platinum for Children Subscriber Contract_FC-HBX-007_512020 FC-HBX-007-Platinum_512020

Gold Fidelis Care Gold for Children Subscriber Contract_FC-HBX-007_512020 FC-HBX-007-Gold_512020

Silver Fidelis Care Silver for Children Subscriber Contract_FC-HBX-007_512020 FC-HBX-007-Silver_512020

Bronze Fidelis Care Bronze for Children Subscriber Contract_FC-HBX-007_512020 FC-HBX-007-Bronze_512020








Silver Wellness Fidelis Care Silver Wellness Subscriber Contract_FC-HBX-011_512020 FC-HBX-011_Silver Wellness_512020

Silver Wellness_250 Fidelis Care Silver Wellness Subscriber Contract_FC-HBX-011_512020 FC-HBX-011_Silver Wellness_512020



Gold Wellness Fidelis Care Gold Wellness Subscriber Contract_FC-HBX-011_512020 FC-HBX-011_Gold Wellness_512020

Silver Wellness Fidelis Care Silver Wellness Subscriber Contract_FC-HBX-014_512020 FC-HBX-014_Silver Wellness_512020

Gold Wellness Fidelis Care Gold Wellness Subscriber Contract_FC-HBX-014_512020 FC-HBX-014_Gold Wellness_512020

Bronze HSA Fidelis Care Bronze HSA Subscriber Contract_FC-HBX-001_512020 FC-HBX-001-Bronze HSA_512020

Bronze HSA Fidelis Care Bronze HSA Subscriber Contract_FC-HBX-006_512020 FC-HBX-006-Bronze HSA_512020

Age 29 Rider is available for Platinum, Gold, Silver, Silver 250 and the Bronze plans.

Subscriber Contract_FC-HBX-004_512020

Fidelis Care [Metal Tier] Schedule of Benefits_FC-HBX-005-Zero Cost-Sharing_512020

Fidelis Care [Metal Tier] Schedule of Benefits_FC-HBX-013_Zero Cost-Sharing Enhanced_512020

Fidelis Care [Metal Tier] Schedule of Benefits_FC-HBX-015_Zero Cost-Sharing Wellness_512020

An American Indian who earns less than 300% of the federal poverty level can be on a Bronze, Bronze HSA-compliant, Silver, Silver Enhanced, Silver Wellness, Gold, Gold Enhanced, Gold Wellness or Platinum plan. There

will be no cost-sharing.

An American Indian who earns more than 300% of the federal poverty level can be on a Bronze, Bronze HSA-compliant, Silver, Silver Enhanced, Silver Wellness, Gold, Gold Enhanced, Gold Wellness or Platinum plan. There

will be no cost-sharing at certain providers.

Page 13 of 28

Type of Service Platinum Gold Silver Bronze Catastrophic Bronze HSA-compliant

Deductible $0 $600 $1,300 $4,700 $8,550 $6,100

Maximum Out-of-Pocket $2,000 $4,000 $8,500 $8,550 $8,550 $6,900

Includes the deductible

COST SHARING SUMMARY

Inpatient Facility/SNF/Hospice $500

per admission

$1,000

per admission

$1,500

per admission

50% cost sharing 0% cost sharing 50% cost sharing

Outpatient Facility-Surgery,

including freestanding surgicenters

$100 $100 $150 50% cost sharing 0% cost sharing 50% cost sharing

Surgeon - Inpatient facility, $100 $100 $150 50% cost sharing 0% cost sharing 50% cost sharing

outpatient facility, including

freestanding surgicenters.

PCP $15 $25 $30 $50 0% cost sharing 50% cost sharing

Specialist $35 $40 $50 $75 0% cost sharing 50% cost sharing

PT/OT/ST - rehabilitative &

habilitative therapies

$25 $30 $30 $50 0% cost sharing

50% cost sharing

ER $100 $150 $300 50% cost sharing 0% cost sharing 50% cost sharing

Ambulance $100 $150 $150 50% cost sharing 0% cost sharing 50% cost sharing

Urgent Care $55 $60 $70 50% cost sharing 0% cost sharing 50% cost sharing

DME/Medical supplies 10% cost sharing 20% cost sharing 30% cost sharing 50% cost sharing 0% cost sharing 50% cost sharing

Hearing aids 10% cost sharing 20% cost sharing 30% cost sharing 50% cost sharing 0% cost sharing 50% cost sharing

Eyewear 10% cost sharing 20% cost sharing 30% cost sharing 50% cost sharing 0% cost sharing 50% cost sharing

INPATIENT HOSPITAL SERVICES

Observation stay ER copay per case; copay is waived if direct transfer from outpatient surgery

setting to an observation care unit.


Hospital services - non-maternity Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing 50% cost sharing

Maternity care stay (covers mother

and well newborn combined)

Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing 50% cost sharing

Mental health/Behavorial health care Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing 50% cost sharing

Detoxification Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing 50% cost sharing

Substance abuse disorder services Inpatient Facility copay per admission # 50% cost sharing 0% cost sharing 50% cost sharing

Skilled nursing facility Inpatient Facility copay per admission #; Indicated copay per admission is

waived if direct transfer from hospital inpatient setting to skilled nursing

facility.


Hospice (inpatient) Inpatient Facility copay per admission #; Indicated copay per admission is

waived if direct transfer from hospital inpatient setting or skilled nursing

facility to hospice facility.





Benefit Descriptions - Standard Plans

One such copay per surgery and applies only to surgery performed in a

hospital inpatient or a hospital outpatient facility setting, including

freestanding surgicenters, not to office surgery. See also “Maternity delivery

and post-natal care - physician/midwife” under “physician services”.

Page 14 of 28






EMERGENCY MEDICAL SERVICES

Facility charge - Emergency Room ER copay per case; copay is waived if patient is admitted as an inpatient

(including as an observation stay or

to an observation care unit) directly from the emergency room.


Physician charge - Emergency Room

visit

$0 copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Facility charge - Freestanding urgent

care center

Urgent Care copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Physician charge - Free standing

urgent care center visit

$0 copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Prehospital emergency services/

transportation, includes air

ambulance

Ambulance copay per case 50% cost sharing 0% cost sharing 50% cost sharing

OUTPATIENT HOSPITAL/FACILITY SERVICES

Outpatient facility surgery - hospital

facility charge, including

freestanding surgicenters

Outpatient Facility-Surgery copay per case 50% cost sharing 0% cost sharing 50% cost sharing

Pre-admission/pre-operative testing $0 copay 50% cost sharing 0% cost sharing 50% cost sharing

Diagnostic and routine laboratory

and pathology

Specialist copay per visit $50 0% cost sharing 50% cost sharing

Diagnostic and routine imaging

services including Xray; excluding

CAT/PET scans, MRI

$75 50% cost sharing 0% cost sharing 50% cost sharing

Imaging: CAT/PET scans, MRI $75 50% cost sharing 0% cost sharing 50% cost sharing

Chemotherapy PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Radiation therapy PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Hemodialysis/Renal dialysis PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Mental health/Behavorial health care PCP copay per visit PCP copay per visit 0% cost sharing 50% cost sharing

Substance abuse disorder services PCP copay per visit PCP copay per visit 0% cost sharing 50% cost sharing

Covered therapies (PT, OT, ST) -

rehabilitative & habilitative

PT/OT/ST copay per visit PT/OT/ST copay per

visit

0% cost sharing 50% cost sharing

Home care PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Hospice PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Specialist copay per visit


Page 15 of 28






PREVENTIVE & PRIMARY CARE SERVICES

Bone density testing NOTE: For preventive care visits/services as defined in section 2713 of ACA no deductible or cost sharing applies.

Cervical cytology Otherwise the cost sharing indicated below applies to all services in this benefit service category.

Colonoscopy screening

Gynecological exams

Immunizations

Mammography

Prenatal maternity care

Prostate cancer screening

Routine exams

Women's preventive health services

PHYSICIAN/PROFESSIONAL SERVICES

Inpatient hospital surgery - surgeon Surgeon copay per case 50% cost sharing 0% cost sharing 50% cost sharing

Outpatient hospital and freestanding

surgicenter - surgeon

Surgeon copay per case 50% cost sharing 0% cost sharing 50% cost sharing

Office surgery PCP/Specialist copay per visit (based on type of physician performing the

service)


Anesthesia (any setting) Covered in full, no deductible and no cost sharing applies 50% cost sharing 0% cost sharing 50% cost sharing



PT/OT/ST copay per visit PT/OT/ST copay per

visit


Additional surgical opinion Specialist copay per visit Specialist copay per visit 0% cost sharing 50% cost sharing

Second medical opinion for cancer Specialist copay per visit Specialist copay per visit 0% cost sharing 50% cost sharing

Maternity delivery and post natal

care - physician or midwife

Surgeon copay per case for delivery and post natal care services combined

(only one such copay per pregnancy)


In-hospital physician visits $0 copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Diagnostic office visits PCP/Specialist copay per visit (based on type of physician performing the

service)

PCP/Specialist copay

per visit (based on type

of physician performing

the service)



and pathology

PCP/Specialist copay per visit $50 0% cost sharing 50% cost sharing



CAT/PET scans, MRI

$75 50% cost sharing 0% cost sharing 50% cost sharing

Imaging: CAT/PET scans, MRI $75 50% cost sharing 0% cost sharing 50% cost sharing

Allergy testing PCP/Specialist copay per visit PCP/Specialist copay

per visit


Allergy shots PCP/Specialist copay per visit PCP/Specialist copay

per visit


Office/outpatient consultations PCP/Specialist copay per visit (based on type of physician performing the

service)


per visit (based on type

of physician performing

the service)


Mental health/Behavorial health care PCP copay per visit PCP copay per visit 0% cost sharing 50% cost sharing

Substance abuse disorder services PCP copay per visit PCP copay per visit 0% cost sharing 50% cost sharing

Chemotherapy PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Radiation therapy PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Hemodialysis/Renal dialysis PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Chiropractic care Specialist copay per visit Specialist copay per visit 0% cost sharing 50% cost sharing

PCP/Specialist copay per visit


Page 16 of 28






ADDITIONAL BENEFITS/SERVICES

ABA treatment for Autism Specturm

Disorder

PCP copay per visit PCP copay per visit 0% cost sharing 50% cost sharing

Assistive Communiciation Devices

for Autism Spectrum Disorder

PCP copay per device PCP copay per device 0% cost sharing 50% cost sharing

Durable medical equipment and

medical supplies

DME/Medical supplies coinsurance cost sharing applies DME/Medical supplies

coinsurance cost sharing

applies


Hearing evaluations/testing Specialist copay per visit Specialist copay per visit 0% cost sharing 50% cost sharing

Hearing aids Hearing aid coinsurance cost sharing applies Hearing aid coinsurance

cost sharing applies


Diabetic drugs and supplies PCP copay per 30 days supply but no more than $100 (including deductible)

paid for a 30-day supply of insulin

PCP copay per 30 days

supply but no more than

$100 (including

deductible) paid for a 30-

day supply of insulin

0% cost sharing 50% cost sharing but no

more than $100 (including

deductible) paid for a 30-

day supply of insulin

Diabetic education and self-

management

PCP copay per visit PCP copay per visit 0% cost sharing 50% cost sharing

Home care PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Exercise facility reimbursements

PEDIATRIC DENTAL SERVICES

Dental office visit PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

PEDIATRIC VISION SERVICES

Eye exam visit PCP copay per visit 50% cost sharing 0% cost sharing 50% cost sharing

Prescribed lenses and frames Eyewear coinsurance cost sharing applies to combined cost of lenses and

frames


Contact lenses Eyewear coinsurance cost sharing applies 50% cost sharing 0% cost sharing 50% cost sharing

PRESCRIPTION DRUGS

Generic or Tier 1 $10 $10 $10 $10 0% cost sharing $10

Formulary Brand or Tier 2 $30 $35 $35 $35 0% cost sharing $35

Non-Formulary Brand or Tier 3 $60 $70 $70 $70 0% cost sharing $70

Above are retail copay amounts; mail order copays are 2.5 times retail (except for Catastrophic Plans) for a 90 day supply

Deductible does not apply. $200/$100 reimbursement every six months for member/spouse.

* Partial reimbursement for facility fees every six months if member attains at least 50 visits.

Page 17 of 28




Benefit Descriptions - Cost Sharing Reduction Variations

These plans are only available to individuals and families who meet certain income qualifications or who are an American Indian.

Silver - CSR Versions American Indians

Type of Service 200 - 250 % FPL 150 - 200 % FPL 100 - 150 % FPL Less than or equal to 300% FPL

Deductible $1,100 $250 $0 $0

Maximum Out-of-Pocket $6,500 $2,200 $1,000 $0



Inpatient Facility/SNF/Hospice $1,500 per

admission

$250 per admission $100 per admission 0% cost sharing

Outpatient Facility-Surgery, including


$150 $75 $25 0% cost sharing

Surgeon - Inpatient facility, $150 $75 $25 0% cost sharing

outpatient facility, including freestanding

surgicenters

PCP $30 $15 $10 0% cost sharing

Specialist $50 $35 $20 0% cost sharing

PT/OT/ST - rehabilitative & habilitative

therapies

$30 $25 $15 0% cost sharing

ER $275 $75 $50 0% cost sharing

Ambulance $150 $75 $50 0% cost sharing

Urgent Care $70 $50 $30 0% cost sharing

DME/Medical supplies 25% cost sharing 10% cost sharing 5% cost sharing 0% cost sharing

Hearing aids 25% cost sharing 10% cost sharing 5% cost sharing 0% cost sharing

Eyewear 25% cost sharing 10% cost sharing 5% cost sharing 0% cost sharing


Observation stay ER copay per case; copay is waived if direct transfer from

outpatient surgery setting to an observation care unit.

0% cost sharing

Hospital services - non-maternity Inpatient Facility copay per admission # 0% cost sharing

Maternity care stay (covers mother and well

newborn combined)

Inpatient Facility copay per admission # 0% cost sharing

Mental health/Behavorial health care Inpatient Facility copay per admission # 0% cost sharing

Detoxification Inpatient Facility copay per admission # 0% cost sharing

Substance abuse disorder services Inpatient Facility copay per admission # 0% cost sharing

Skilled nursing facility Inpatient Facility copay per admission #; Indicated copay per

admission is waived if direct transfer from hospital inpatient

setting to skilled nursing facility.

0% cost sharing

Hospice (inpatient) Inpatient facility copay per admission #; Indicated copay per


setting or skilled nursing facility to hospice facility.

0% cost sharing

One such copay per surgery and applies only to surgery

performed in a hospital inpatient or a hospital outpatient facility

setting, including freestanding surgicenters, not to office

surgery. See also “Maternity delivery and post-natal care -

physician/midwife” under “physician services”.

Page 18 of 28









Facility charge - Emergency Room ER copay per case; copay is waived if patient is admitted as an

inpatient (including as an observation stay or


0% cost sharing

Physician charge - Emergency Room visit $0 copay per visit 0% cost sharing

Facility charge - Freestanding urgent care

center

Urgent Care copay per visit 0% cost sharing

Physician charge - Free standing urgent care

center visit

$0 copay per visit 0% cost sharing


transportation, includes air ambulance

Ambulance copay per case 0% cost sharing


Outpatient facility surgery - hospital facility

charge, including freestanding surgicenters

Outpatient Facility-Surgery copay per case 0% cost sharing

Pre-admission/pre-operative testing $0 copay 0% cost sharing

Diagnostic and routine laboratory and

pathology

Specialist copay per visit 0% cost sharing

Diagnostic and routine imaging services

including Xray; excluding CAT/PET scans,

MRI

$75 Specialist copay

per visit

Specialist copay

per visit

0% cost sharing

Imaging: CAT/PET scans, MRI $75 Specialist copay

per visit

Specialist copay

per visit

0% cost sharing

Chemotherapy PCP copay per visit 0% cost sharing

Radiation therapy PCP copay per visit 0% cost sharing

Hemodialysis/Renal dialysis PCP copay per visit 0% cost sharing

Mental health/Behavorial health care PCP copay per visit 0% cost sharing

Substance abuse disorder services PCP copay per visit 0% cost sharing



PT/OT/ST copay per visit 0% cost sharing

Home care PCP copay per visit 0% cost sharing

Hospice PCP copay per visit 0% cost sharing

Page 19 of 28









Bone density testing NOTE: For preventive care visits/services as defined in section 2713 of ACA no deductible or cost sharing

applies.

Cervical cytology Otherwise the cost sharing indicated below applies to all services in this benefit service category.


Gynecological exams

Immunizations

Mammography



Routine exams



Inpatient hospital surgery - surgeon Surgeon copay per case 0% cost sharing



Surgeon copay per case 0% cost sharing

Office surgery PCP/Specialist copay per visit (based on type of physician

performing the service)

0% cost sharing

Anesthesia (any setting) Covered in full, no deductible and no cost sharing applies 0% cost sharing



PT/OT/ST copay per visit 0% cost sharing

Additional surgical opinion Specialist copay per visit 0% cost sharing

Second medical opinion for cancer Specialist copay per visit 0% cost sharing

Maternity delivery and post natal care -

physician or midwife

Surgeon copay per case for delivery and post natal care services

combined (only one such copay per pregnancy)

0% cost sharing

In-hospital physician visits $0 copay per visit 0% cost sharing

Diagnostic office visits PCP/Specialist copay per visit (based on type of physician


0% cost sharing

Diagnostic and routine laboratory and

pathology

PCP/Specialist copay per visit 0% cost sharing

Diagnostic and routine imaging services

including Xray; excluding CAT/PET scans,

MRI

$75 PCP/Specialist

copay per visit


per visit

0% cost sharing

Imaging: CAT/PET scans, MRI $75 Specialist copay per

visit

Specialist copay per

visit

0% cost sharing

Allergy testing PCP/Specialist copay per visit 0% cost sharing

Allergy shots PCP/Specialist copay per visit 0% cost sharing

Office/outpatient consultations PCP/Specialist copay per visit (based on type of physician


0% cost sharing

Mental health/Behavorial health care PCP copay per visit 0% cost sharing

Substance abuse disorder services PCP copay per visit 0% cost sharing

Chemotherapy PCP copay per visit 0% cost sharing

Radiation therapy PCP copay per visit 0% cost sharing

Hemodialysis/Renal dialysis PCP copay per visit 0% cost sharing

Chiropractic care Specialist copay per visit 0% cost sharing

Page 20 of 28










Disorder

PCP copay per visit 0% cost sharing

Assistive Communiciation Devices for

Autism Spectrum Disorder

PCP copay per device 0% cost sharing

Durable medical equipment and medical

supplies

DME/Medical supplies coinsurance cost sharing applies 0% cost sharing

Hearing evaluations/testing Specialist copay per visit 0% cost sharing

Hearing aids Hearing aid coinsurance cost sharing applies 0% cost sharing

Diabetic drugs and supplies PCP copay per 30 days supply 0% cost sharing

Diabetic education and self-management PCP copay per visit 0% cost sharing

Home care PCP copay per visit 0% cost sharing

Exercise facility reimbursements Deductible does not apply. $200/$100 reimbursement every six months for member/spouse.



Dental office visit PCP copay per visit 0% cost sharing


Eye exam visit PCP copay per visit 0% cost sharing

Prescribed lenses and frames Eyewear coinsurance cost sharing applies to combined cost of

lenses and frames

0% cost sharing

Contact lenses Eyewear coinsurance cost sharing applies 0% cost sharing

PRESCRIPTION DRUGS

Generic or Tier 1 $10 $9 $6 0% cost sharing

Formulary Brand or Tier 2 $35 $20 $15 0% cost sharing

Non-Formulary Brand or Tier 3 $70 $40 $30 0% cost sharing


Page 21 of 28

Type of Service Gold Enhanced Silver Enhanced Gold Wellness Silver Wellness Silver Wellness - CSR Versions

CSR variants'

benefits same as

respective standard

silver CSR variants 200 - 250 % FPL 150 - 200 % FPL 100 - 150 % FPL

Deductible $600 $1,300 $750 $3,500 $2,425 $250 $0

Maximum Out-of-Pocket $4,000 $8,500 $4,500 $7,000 $6,400 $2,500 $1,000



Inpatient Facility/SNF/Hospice $1,000 per admission $1,500 per $1,000 per admission $1,500 per admission $1,500 per admission $250 per admission $100 per admission

Outpatient Facility-Surgery, $100 $150 $100 $150 $150 $75 $25

Surgeon - Inpatient facility, $100 $150 $100 $150 $150 $75 $25

outpatient facility, including


PCP $25 $30 $25 $40 $35 $15 $10

Specialist $40 $50 $40 $60 $50 $35 $20

PT/OT/ST - rehabilitative & $30 $30 $30 $40 $30 $25 $15

ER $150 $300 $150 $250 $250 $75 $50

Ambulance $150 $150 $150 $150 $150 $75 $50

Urgent Care $60 $70 $60 $70 $70 $50 $30

DME/Medical supplies 20% cost sharing 30% cost sharing 20% cost sharing 30% cost sharing 25% cost sharing 10% cost sharing 5% cost sharing

Hearing aids 20% cost sharing 30% cost sharing 20% cost sharing 30% cost sharing 25% cost sharing 10% cost sharing 5% cost sharing

Eyewear 20% cost sharing 30% cost sharing 20% cost sharing 30% cost sharing 25% cost sharing 10% cost sharing 5% cost sharing


Observation stay ER copay per case; copay is waived if direct transfer from

outpatient surgery setting to an observation care unit.

Hospital services - non-maternity Inpatient Facility copay per admission #

Maternity care stay (covers mother

and well newborn combined)

Inpatient Facility copay per admission #

Mental health/Behavorial health care Inpatient Facility copay per admission #

Detoxification Inpatient Facility copay per admission #

Substance abuse disorder services Inpatient Facility copay per admission #

Skilled nursing facility Inpatient Facility copay per admission #; Indicated copay per


setting to skilled nursing facility.

Hospice (inpatient) Inpatient Facility copay per admission #; Indicated copay per


setting or skilled nursing facility to hospice facility.

One such copay per surgery and applies only to surgery performed in a hospital inpatient or a hospital outpatient facility setting, including freestanding surgicenters, not to office surgery. See also “Maternity delivery and post-natal care -

physician/midwife” under “physician services”.

ER copay per case; copay is waived if direct transfer from outpatient surgery setting to an

observation care unit.






Inpatient Facility copay per admission #; Indicated copay per admission is waived if direct

transfer from hospital inpatient setting to skilled nursing facility.

Inpatient facility copay per admission #; Indicated copay per admission is waived if direct

transfer from hospital inpatient setting or skilled nursing facility to hospice facility.




Benefit Descriptions - Non-Standard Plans

ER copay per case; copay is waived if direct transfer from outpatient surgery

setting to an observation care unit.






Inpatient Facility copay per admission #; Indicated copay per admission is

waived if direct transfer from hospital inpatient setting to skilled nursing

facility.

Inpatient Facility copay per admission #; Indicated copay per admission is

waived if direct transfer from hospital inpatient setting or skilled nursing

facility to hospice facility.

Page 22 of 28







Facility charge - Emergency Room ER copay per case; copay is waived if patient is admitted as an

inpatient (including as an observation stay or


Physician charge - Emergency Room

visit

$0 copay per visit

Facility charge - Freestanding urgent

care center

Urgent Care copay per visit

Physician charge - Free standing

urgent care center visit

$0 copay per visit


transportation, includes air

ambulance

Ambulance copay per case


Outpatient facility surgery - hospital

facility charge, including


Outpatient Facility-Surgery copay per case

Pre-admission/pre-operative testing $0 copay


and pathology




CAT/PET scans, MRI

Specialist copay per visit $75

Imaging: CAT/PET scans, MRI Specialist copay $75

Chemotherapy PCP copay per visit

Radiation therapy PCP copay per visit

Hemodialysis/Renal dialysis PCP copay per visit

Mental health/Behavorial health care PCP copay per visit

Substance abuse disorder services PCP copay per visit



PT/OT/ST copay per visit

Home care PCP copay per visit

Hospice PCP copay per visit


Bone density testing

Cervical cytology


Gynecological exams

Immunizations

Mammography



Routine exams



Specialist copay Specialist copay

PCP copay per visit

PCP copay per visit

PCP copay per visit

PCP copay per visit (Deductible waived)

NOTE: For preventive care visits/services as defined in section 2713 of ACA no deductible or cost sharing applies.

Otherwise the cost sharing indicated below applies to all services in this benefit service category.




PCP copay per visit

PCP copay per visit

PCP copay per visit

PCP copay per visit

PCP copay per visit



PCP copay per visit

PCP copay per visit



$0 copay

Specialist copay per visit (Deductible waived)


ER copay per case; copay is waived if patient is admitted as an inpatient (including as an

observation stay or


$0 copay per visit


$0 copay per visit


$0 copay

Specialist copay per visit (Deductible waived)

ER copay per case; copay is waived if patient is admitted as an inpatient

(including as an observation stay or


$0 copay per visit


$0 copay per visit


Page 23 of 28







Inpatient hospital surgery - surgeon Surgeon copay per case



Surgeon copay per case

Office surgery PCP/Specialist copay per visit (based on

type of physician performing the service)

Anesthesia (any setting) Covered in full, no deductible and no cost

sharing applies




Additional surgical opinion Specialist copay per visit

Second medical opinion for cancer Specialist copay per visit

Maternity delivery and post natal

care - physician or midwife

Surgeon copay per case for delivery and

post natal care services combined (only

one such copay per pregnancy)

In-hospital physician visits $0 copay per visit

Diagnostic office visits PCP/Specialist copay per visit (based on

type of physician performing the service)


and pathology




CAT/PET scans, MRI

PCP/Specialist copay per visit $75

Imaging: CAT/PET scans, MRI Specialist copay per visit $75

Allergy testing

Allergy shots

Office/outpatient consultations

Mental health/Behavorial health care

Substance abuse disorder services

Chemotherapy

Radiation therapy

Hemodialysis/Renal dialysis

Chiropractic care

Acupuncture





N/A



PCP/Specialist copay per visit (based on type of physician


PCP copay per visit

PCP copay per visit

PCP copay per visit

PCP copay per visit

PCP copay per visit


PCP copay per visit

PCP copay per visit

PCP copay per visit





PCP/Specialist copay per visit (based on type of physician performing the service no

Deductible for PCP visits only)

PCP copay per visit (no Deductible)



Surgeon copay per case for delivery and post natal care services combined (only one such

copay per pregnancy)

Surgeon copay per case for delivery and post natal care services combined

(only one such copay per pregnancy)


PCP copay per visit

PCP copay per visit

PCP copay per visit





PCP/Specialist copay per visit (based on type of physician performing the service

no Deductible for PCP visits only)



$0 copay per visit

PCP/Specialist copay per visit (based on type of physician performing the

service, Deductible waived for PCP visits only)

PCP/Specialist copay per visit (Deductible waived)

PCP/Specialist copay per visit (based on type of physician performing the

service)

Covered in full, no deductible and no cost sharing applies





$0 copay per visit

PCP/Specialist copay per visit (based on type of physician performing the service,

Deductible waived for PCP visits only)

PCP/Specialist copay per visit (Deductible waived)

PCP/Specialist copay per visit (based on type of physician performing the service)

Covered in full, no deductible and no cost sharing applies





Page 24 of 28








Disorder

Assistive Communiciation Devices

for Autism Spectrum Disorder

Durable medical equipment and

medical supplies

Hearing evaluations/testing

Hearing aids

Diabetic drugs and supplies

Diabetic education and self-

management

Home care

Exercise facility reimbursements


Dental office visit

ADULT DENTAL SERVICES

Dental office visit


Eye exam visit

Prescribed lenses and frames

Contact lenses

ADULT VISION SERVICES

Eye exam visit

Prescribed lenses and frames

Contact lenses

PRESCRIPTION DRUGS

Generic or Tier 1 $10 $10 $10 $10 $10 $9 $6

Formulary Brand or Tier 2 $35 $35 $35 $35 $35 $20 $15

Non-Formulary Brand or Tier 3 $70 $70 $70 $70 $70 $40 $30


PCP copay per visit

Eyewear coinsurance cost sharing applies to combined cost of lenses and frames

Eyewear coinsurance cost sharing applies

PCP copay per visit

PCP copay per device

DME/Medical supplies coinsurance cost sharing applies


Hearing aid coinsurance cost sharing applies

PCP copay per 30 days supply

PCP copay per visit

PCP copay per visit

PCP copay per visit

PCP copay per visit

Eyewear coinsurance cost sharing applies to combined cost of

lenses and frames


PCP copay per visit

PCP copay per visit

PCP copay per visit

PCP copay per visit

Eyewear coinsurance cost sharing applies to combined cost of lenses and frames


PCP copay per visit







PCP copay per visit

PCP copay per visit

Deductible does not apply. $200/$100 reimbursement every six months for member/spouse.



PCP copay per visit

PCP copay per visit

PCP copay per visit





PCP copay per visit

Eyewear coinsurance cost sharing applies to combined cost of lenses and

frames


PCP copay per visit

PCP copay per visit

PCP copay per visit

Eyewear coinsurance cost sharing applies to combined cost of lenses and

frames

PCP copay per visit


Eyewear coinsurance cost sharing applies to combined cost of

lenses and frames

Page 25 of 28




Rating Instructions and Example

Instructions

2) Determine the rating region where the applicant lives

3) Determine which plan the applicant wants.

5) Look up the rate in the rate table.

Example:

1) The desired tier is Individual + Child(ren)

2) The rating region is Buffalo

3) The applicant wants a Silver plan

5) The rate is $959.91 per month

The unsubsidized premium will be $959.91 monthly.

4) Determine if there is a child between the ages of 26 and up to 30 to be covered: If so,

use the appropriate rate table with the rider included.

4) Since there is a child over the age of 26 but younger than 30, the family is eligible for

the "Through Age 29" rider. Use the rate table labeled "Includes Through Age 29 Rider"

An applicant lives in Erie county. The applicant wished to cover themselves, a 22-year

old child and a 28 year-old child. The applicant desires a Silver plan.

1) Determine which tier is desired: Child Only, Individual, Individual+Spouse,

Individual+Child(ren), or Family

Page 26 of 28




Expected Loss Ratio

Plan Expected Loss Ratio

Platinum 86.50%

Gold 86.50%

Silver 86.50%

Bronze 86.50%

Catastrophic 86.50%

Platinum through Age 29 86.50%

Gold through Age 29 86.50%

Silver through Age 29 86.50%

Bronze through Age 29 86.50%

Silver Enhanced 86.50%

Gold Enhanced 86.50%

Silver Enhanced through Age 29 86.50%

Gold Enhanced through Age 29 86.50%

Silver Wellness 86.50%

Gold Wellness 86.50%

Silver Wellness through Age 29 86.50%

Gold Wellness through Age 29 86.50%

Page 27 of 28



Broker Program

Full Assistance Standard:

.

Fidelis Care will offer commissions to certain licensed insurance brokers.

In this program, the broker assists the individual with enrollment and renewal. A per contract payment

of $12 per month is paid to the broker for each of the first 24 months. This fee does not increase based

on volume and is recouped if the individual dis-enrolls in the first 90 days.

Page 28 of 28

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