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Summary of Benefits and Coverage (SBC) & Uniform Glossary of Terms

Under the Affordable Care Act, all Insurance companies and group health plans are required to provide you with an easy‐to‐understand summary about a health plan’s benefits and coverage. This regulation is designed to help you better understand and evaluate your health insurance choices.

This summary includes a short, plain language Summary of Benefits and Coverage, or SBC. The SBC includes details, called “coverage examples,” which are comparison tools that allow you to see what the plan would generally cover in three common medical situations. You will have the right to receive the SBC when shopping for, or enrolling in coverage or if you request a copy from your issuer or group health plan.

The following pages include the Summary of Benefits and Coverage (SBC) for the 2020 Standard Point of Service (POS) Health Plan and the Uniform Glossary of Terms, which defines commonly used terms in health insurance coverage, such as "deductible" and "co-payment."

the Benefits Information Guide located at www.vbgov.com/benefits.

POS STANDARD VA Beach Schools/City Coverage Period: January 1, 2020 – December 31, 2020

Summary of Benefits and Coverage: What this Plan Covers & What it Costs ⃒ Coverage for: Individual/Family ⃒ Plan Type: POS

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020-12/31/2020 POS Standard Coverage for: Individual/Family | Plan Type: POS VA Beach Schools/City

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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, visit optimahealth.com or call 1-866-509-7567. 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 healthcare.gov/sbc-glossary or call 1-866-509-7567 to request a copy. Important Questions Answers Why This Matters:

What is the overall deductible?

$1,400/Individual or $2,800/family in-network. $2,800/Individual or $5,600/family out-of-network

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 policy, the overall family deductible has to be met before the plan begins to pay.

Are there services covered before you meet your deductible?

Yes. Preventive care, Vision Care and Materials are covered before you meet your 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 https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

For in-network providers $3,500 individual / $7,000 family. For out-of-network providers, $5,500 individual / $11,000 family

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.

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

Premiums, balance-billed charges, healthcare this plan doesn’t cover, ancillary drug charges and pre-authorization penalties.

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

Will you pay less if you use a network provider?

Yes. See optimahealth.com or call 1-866-509-7567 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. 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 to see a specialist? No. You can see the specialist you choose without a referral.

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

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

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions & Other Important

Information In-Network Provider (You will pay the least) Out-of-Network

Provider (You will pay the most)

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

Primary care visit to treat an injury or illness

10% Coinsurance/SQCN 20% Coinsurance/all other 50% coinsurance --none--

Specialist visit 10% Coinsurance/SQCN 20% Coinsurance/all other 50% coinsurance --none--

Preventive care/screening/ immunization

No charge Deductible does not apply 50% coinsurance

You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 50% coinsurance --none--

Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance Pre-authorization required.

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.optimahealth.com

Selected Generic drugs (Tier 1) $10 copayment/preferred network/$25 copayment retail /$25 copayment mail order

$10 copayment/preferred network/$25 copayment retail / mail order not covered

Medical deductible applies. Coverage is limited to maximum $150 ancillary cap per prescription per month in addition to applicable Copayment/Coinsurance. Coverage is limited to FDA-approved prescription drugs. If brand drugs are used when a generic is available, you must pay the difference in cost plus the Copayment or Coinsurance amount. Covers up to a 31-day supply (retail); up to a 90-day supply for 3 copayments (Preferred Pharmacies only); 31- to 90-day supply (mail order). Not all drugs are available through a mail order program.

Selected brand and other generic drugs (Tier 2)

$25 copayment/preferred network/$45 copayment retail /$60 copayment mail order

$25 copayment/preferred network/$45 copayment retail / mail order not covered

Non-selected brand drugs (Tier 3)

25% Coinsurance: $50 max preferred network/$75 max retail/$125 max mail order

25% Coinsurance: $50 max preferred network/$75 max retail/ mail order not covered

Specialty drugs (Tier 4) 25% coinsurance retail $200 max/ mail order not covered

25% coinsurance retail $200 max/ mail order not covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 20% coinsurance 50% coinsurance Pre-authorization required.

Physician/surgeon fees 20% coinsurance 50% coinsurance --none-- Emergency room care 20% coinsurance 20% coinsurance --none--

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If you need immediate medical attention

Emergency medical transportation

No charge/VB Volunteer Rescue Squad, deductible does not apply 20% coinsurance/all other

20% coinsurance Pre-authorization required for use other than emergency services.

Urgent care 20% coinsurance 50% coinsurance --none--

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance Pre-authorization required. Physician/surgeon fees 20% coinsurance 50% coinsurance --none--

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

Outpatient services

10% Coinsurance office visits/SQCN 20% Coinsurance office visits/all other 20% Coinsurance other visits

50% coinsurance

Pre-authorization required for intensive outpatient program, partial hospitalization services, electroconvulsive therapy, and Transcranial Magnetic Stimulation. No coverage for residential treatment.

Inpatient services 20% coinsurance 50% coinsurance Pre-authorization required for all inpatient services.

If you are pregnant

Office visits 10% Coinsurance/SQCN 20% Coinsurance/all other 50% coinsurance Pre-authorization required for prenatal services. Cost sharing does not apply to certain preventive services. Maternity care may include tests and services described elsewhere in this SBC (i.e. ultrasound).

Childbirth/delivery professional services 20% coinsurance 50% coinsurance

Childbirth/delivery facility services 20% coinsurance 50% coinsurance

If you need help recovering or have other special health needs

Home health care 20% coinsurance 50% coinsurance Pre-authorization required. 100 combined visits/plan year.

Rehabilitation services 20% coinsurance 50% coinsurance

Pre-authorization required. 30 visits/plan year combined with habilitation services for PT, 30 visits/plan year combined with habilitation services for OT. 30 visits/plan year combined with habilitation services for ST. 30 combined visits/plan year for short term rehab services.

Habilitation services 20% coinsurance 50% coinsurance Pre-authorization required. 30 visits/plan year combined with rehabilitation services for PT,

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30 visits/plan year combined with rehabilitation services for OT. 30 visits/plan year combined with rehabilitation services for ST.

Skilled nursing care 20% coinsurance 50% coinsurance Pre-authorization required. 100 combined days/plan year.

Durable medical equipment 20% coinsurance 50% coinsurance Pre-authorization required for single items over $750, all rental items, and repair and replacement.

Hospice services 20% coinsurance 50% coinsurance Pre-authorization required.

If your child needs dental or eye care

Children’s eye exam $20 copayment/spectacles $40 copayment/contact lenses Deductible does not apply

$40 reimbursement Deductible does not apply

Coverage limited to one exam every 12 months from participating EyeMed providers.

Children’s glasses Allowances: $150/spectacles $150/contact lenses Deductible does not apply

Not covered Coverage limited to one pair every 12 months from participating EyeMed providers.

Children’s dental check-up Not covered Not covered --none-- 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.) • Acupuncture • Bariatric surgery • Cosmetic surgery • Dental care (Adult)

• Infertility treatment • Long-term care • Pediatric dental check-up

• Private-duty nursing • Routine foot care • Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care • Habilitation services • Hearing aids

• Non-emergency care when traveling outside the U.S. (under out-of-network benefit) • Routine eye care (Adult)

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Your Rights to Continue Coverage: For more information on your rights to continue coverage, contact the plan at 1-866-509-7567. There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, at 1-877-310-6560 or [email protected]; the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform; or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. 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 www.HealthCare.gov 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: Member Services at the number on the back of your member ID card. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or your state department of insurance at the Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, P.O. Box 1157, Richmond, VA, 23218, 1-877-310-6560 or [email protected]. Additionally, a consumer assistance program can help you file your appeal. Contact the Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, P.O. Box 1157, Richmond, VA, 23218, 1-877-310-6560, or [email protected]. 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.––––––––––––––––––––––

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

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

hospital delivery)

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

up care)

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

controlled condition)

The plan’s overall deductible $1400 Specialist coinsurance 10% Hospital (facility) coinsurance 20% Other coinsurance 20% 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 $12,800 In this example, Peg would pay:

Cost Sharing Deductibles $1,400 Copayments $40 Coinsurance $2,060

What isn’t covered Limits or exclusions $0 The total Peg would pay is $3,500

The plan’s overall deductible $1400 Specialist coinsurance 10% Hospital (facility) coinsurance 20% Other coinsurance 20% 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 $7,400 In this example, Joe would pay:

Cost Sharing Deductibles $1,400 Copayments $635 Coinsurance $135

What isn’t covered Limits or exclusions $55 The total Joe would pay is $2,225

The plan’s overall deductible $1400 Specialist coinsurance 10% Hospital (facility) coinsurance 20% Other coinsurance 20% 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 $1,900 In this example, Mia would pay:

Cost Sharing Deductibles $1,095 Copayments $0 Coinsurance $240

What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,335

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.

Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: 1-866-503-2730.

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Optima Health Alternative Language Options for Notices and other Written Information English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-687-6260.

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تنبیھ: . 1-855-687-6260فإنھ تتوفر خدمات المساعدة اللغویة لك مجانًا. اتصل بالرقم إذا كنت تتحدث باللغة العربیة،

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v. 0118

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توجھ: تماس بگیرید. 6260-687-855-1پشتیبانی زبان در دسترس شماست. با شماره کنید، خدمات رایگان اگر بھ زبان فارسی صحبت می

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Glo

ssar

y of

Hea

lth C

over

age

and

Med

ical

Ter

ms

Pag

e 1

of 4

Glo

ssar

y of

Hea

lth C

over

age

and

Med

ical

Ter

ms

•T

his g

loss

ary

has m

any

com

mon

ly u

sed

term

s, bu

t isn

’t a

full

list.

The

se g

loss

ary

term

s and

def

initi

ons a

re in

tend

edto

be

educ

atio

nal a

nd m

ay b

e di

ffer

ent f

rom

the

term

s and

def

initi

ons i

n yo

ur p

lan.

Som

e of

thes

e te

rms a

lsom

ight

not

hav

e ex

actly

the

sam

e m

eani

ng w

hen

used

in y

our p

olic

y or

pla

n, a

nd in

any

such

cas

e, th

e po

licy

or p

lan

gove

rns.

(See

you

r Sum

mar

y of

Ben

efits

and

Cov

erag

e fo

r inf

orm

atio

n on

how

to g

et a

cop

y of

you

r pol

icy

or p

lan

docu

men

t.)•

Bold

blu

e te

xt in

dica

tes a

term

def

ined

in th

is G

loss

ary.

•Se

e pa

ge 4

for a

n ex

ampl

e sh

owin

g ho

w d

educ

tible

s, co

-insu

ranc

e an

d ou

t-of

-poc

ket l

imits

wor

k to

geth

er in

a re

allif

e sit

uatio

n.

Allo

wed

Am

ount

M

axim

um a

mou

nt o

n w

hich

pay

men

t is b

ased

for

cove

red

heal

th c

are

serv

ices

. T

his m

ay b

e ca

lled

“elig

ible

ex

pens

e,” “

paym

ent a

llow

ance

" or

"ne

gotia

ted

rate

." I

f yo

ur p

rovi

der c

harg

es m

ore

than

the

allo

wed

am

ount

, you

m

ay h

ave

to p

ay th

e di

ffer

ence

. (Se

e Ba

lanc

e Bi

lling

.)

App

eal

A re

ques

t for

you

r hea

lth in

sure

r or p

lan

to re

view

a

deci

sion

or a

grie

vanc

e ag

ain.

Bala

nce

Billi

ng

Whe

n a

prov

ider

bill

s you

for t

he d

iffer

ence

bet

wee

n th

e pr

ovid

er’s

char

ge a

nd th

e al

low

ed a

mou

nt. F

or e

xam

ple,

if th

e pr

ovid

er’s

char

ge is

$10

0 an

d th

e al

low

ed a

mou

nt

is $7

0, th

e pr

ovid

er m

ay b

ill y

ou fo

r the

rem

aini

ng $

30.

A p

refe

rred

pro

vide

r may

not

bal

ance

bill

you

for c

over

ed

serv

ices

.

Co-

insu

ranc

e Y

our s

hare

of t

he c

osts

of

a c

over

ed h

ealth

car

e se

rvic

e, ca

lcul

ated

as a

pe

rcen

t (fo

r exa

mpl

e, 20

%) o

f the

allo

wed

am

ount

for t

he se

rvic

e. Y

ou p

ay c

o-in

sura

nce

plus

any

ded

uctib

les

you

owe.

For e

xam

ple,

if th

e he

alth

insu

ranc

e or

pla

n’s a

llow

ed a

mou

nt fo

r an

offic

e vi

sit is

$10

0 an

d y

ou’v

e m

et y

our d

educ

tible

, you

r co

-insu

ranc

e pa

ymen

t of 2

0% w

ould

be

$20.

The

hea

lth

insu

ranc

e or

pla

n pa

ys th

e re

st o

f the

allo

wed

am

ount

.

Com

plic

atio

ns o

f Pre

gnan

cy

Con

ditio

ns d

ue to

pre

gnan

cy, l

abor

and

del

iver

y th

at

requ

ire m

edic

al c

are

to p

reve

nt se

rious

har

m to

the

heal

th

of th

e m

othe

r or t

he fe

tus.

Mor

ning

sick

ness

and

a n

on-

emer

genc

y ca

esar

ean

sect

ion

aren

’t co

mpl

icat

ions

of

preg

nanc

y.

Co-

paym

ent

A fi

xed

amou

nt (f

or e

xam

ple,

$15)

you

pay

for a

cov

ered

he

alth

car

e se

rvic

e, us

ually

whe

n yo

u re

ceiv

e th

e se

rvic

e.

The

am

ount

can

var

y by

the

type

of c

over

ed h

ealth

car

e se

rvic

e.

Ded

uctib

le

The

am

ount

you

ow

e fo

r he

alth

car

e se

rvic

es y

our

heal

th in

sura

nce

or p

lan

cove

rs b

efor

e yo

ur h

ealth

in

sura

nce

or p

lan

begi

ns

to p

ay. F

or e

xam

ple,

if yo

ur d

educ

tible

is $

1000

, yo

ur p

lan

won

’t pa

y an

ythi

ng u

ntil

you’

ve m

et

your

$10

00 d

educ

tible

for c

over

ed h

ealth

car

e se

rvic

es

subj

ect t

o th

e de

duct

ible

. The

ded

uctib

le m

ay n

ot a

pply

to

all

serv

ices

.

Dur

able

Med

ical

Equ

ipm

ent (

DM

E)

Equi

pmen

t and

supp

lies o

rder

ed b

y a

heal

th c

are

prov

ider

fo

r eve

ryda

y or

ext

ende

d us

e. C

over

age

for D

ME

may

in

clud

e: ox

ygen

equ

ipm

ent,

whe

elch

airs

, cru

tche

s or

bloo

d te

stin

g st

rips f

or d

iabe

tics.

Emer

genc

y M

edic

al C

ondi

tion

An

illne

ss, i

njur

y, sy

mpt

om o

r con

ditio

n so

serio

us th

at a

re

ason

able

per

son

wou

ld se

ek c

are

right

aw

ay to

avo

id

seve

re h

arm

.

Emer

genc

y M

edic

al T

rans

port

atio

n A

mbu

lanc

e se

rvic

es fo

r an

emer

genc

y m

edic

al c

ondi

tion.

Emer

genc

y R

oom

Car

e Em

erge

ncy

serv

ices

you

get

in a

n em

erge

ncy

room

.

Emer

genc

y Se

rvic

es

Eval

uatio

n of

an

emer

genc

y m

edic

al c

ondi

tion

and

trea

tmen

t to

keep

the

cond

ition

from

get

ting

wor

se.

(See

pag

e 4

for a

det

aile

d ex

ampl

e.)

Jane

pay

s 10

0%

Her

pla

n pa

ys

0%

(See

pag

e 4

for a

det

aile

d ex

ampl

e.)

Jane

pay

s 20

%

Her

pla

n pa

ys

80%

OM

B C

ontro

l Num

bers

154

5-22

29, 1

210-

0147

, and

093

8-11

46

Glo

ssar

y of

Hea

lth C

over

age

and

Med

ical

Ter

ms

Pag

e 2

of 4

Excl

uded

Ser

vice

s H

ealth

car

e se

rvic

es th

at y

our h

ealth

insu

ranc

e or

pla

n do

esn’

t pay

for o

r cov

er.

Grie

vanc

e A

com

plai

nt th

at y

ou c

omm

unic

ate

to y

our h

ealth

insu

rer

or p

lan.

Hab

ilita

tion

Serv

ices

H

ealth

car

e se

rvic

es th

at h

elp

a pe

rson

kee

p, le

arn

or

impr

ove

skill

s and

func

tioni

ng fo

r dai

ly li

ving

. Exa

mpl

es

incl

ude

ther

apy

for a

chi

ld w

ho is

n’t w

alki

ng o

r tal

king

at

the

expe

cted

age

. The

se se

rvic

es m

ay in

clud

e ph

ysic

al a

nd

occu

patio

nal t

hera

py, s

peec

h-la

ngua

ge p

atho

logy

and

ot

her s

ervi

ces f

or p

eopl

e w

ith d

isabi

litie

s in

a va

riety

of

inpa

tient

and/o

r out

patie

nt se

tting

s.

Hea

lth In

sura

nce

A c

ontr

act t

hat r

equi

res y

our h

ealth

insu

rer t

o pa

y so

me

or a

ll of

you

r hea

lth c

are

cost

s in

exch

ange

for a

pr

emiu

m.

Hom

e H

ealth

Car

e H

ealth

car

e se

rvic

es a

per

son

rece

ives

at h

ome.

Hos

pice

Ser

vice

s Se

rvic

es to

pro

vide

com

fort

and

supp

ort f

or p

erso

ns in

th

e la

st st

ages

of a

term

inal

illn

ess a

nd th

eir f

amili

es.

Hos

pita

lizat

ion

Car

e in

a h

ospi

tal t

hat r

equi

res a

dmiss

ion

as a

n in

patie

nt

and

usua

lly re

quire

s an

over

nigh

t sta

y. A

n ov

erni

ght s

tay

for o

bser

vatio

n co

uld

be o

utpa

tient

car

e.

Hos

pita

l Out

patie

nt C

are

Car

e in

a h

ospi

tal t

hat u

sual

ly d

oesn

’t re

quire

an

over

nigh

t sta

y.

In-n

etw

ork

Co-

insu

ranc

e T

he p

erce

nt (f

or e

xam

ple,

20%

) you

pay

of t

he a

llow

ed

amou

nt fo

r cov

ered

hea

lth c

are

serv

ices

to p

rovi

ders

who

co

ntra

ct w

ith y

our h

ealth

insu

ranc

e or

pla

n. I

n-ne

twor

k co

-insu

ranc

e us

ually

cos

ts y

ou le

ss th

an o

ut-o

f-ne

twor

k co

-insu

ranc

e.

In-n

etw

ork

Co-

paym

ent

A fi

xed

amou

nt (f

or e

xam

ple,

$15)

you

pay

for c

over

ed

heal

th c

are

serv

ices

to p

rovi

ders

who

con

trac

t with

you

r he

alth

insu

ranc

e or

pla

n. In

-net

wor

k co

-pay

men

ts u

sual

ly

are

less

than

out

-of-

netw

ork

co-p

aym

ents

.

Med

ical

ly N

eces

sary

H

ealth

car

e se

rvic

es o

r sup

plie

s nee

ded

to p

reve

nt,

diag

nose

or t

reat

an

illne

ss, i

njur

y, c

ondi

tion,

dise

ase

or

its sy

mpt

oms a

nd th

at m

eet a

ccep

ted

stan

dard

s of

med

icin

e.

Net

wor

k T

he fa

cilit

ies,

prov

ider

s and

supp

liers

you

r hea

lth in

sure

r or

pla

n ha

s con

trac

ted

with

to p

rovi

de h

ealth

car

e se

rvic

es.

Non

-Pre

ferr

ed P

rovi

der

A p

rovi

der w

ho d

oesn

’t ha

ve a

con

trac

t with

you

r hea

lth

insu

rer o

r pla

n to

pro

vide

serv

ices

to y

ou. Y

ou’ll

pay

m

ore

to se

e a

non-

pref

erre

d pr

ovid

er. C

heck

you

r pol

icy

to se

e if

you

can

go to

all

prov

ider

s who

hav

e co

ntra

cted

w

ith y

our h

ealth

insu

ranc

e or

pla

n, o

r if y

our h

ealth

in

sura

nce

or p

lan

has a

“tie

red”

net

wor

k an

d yo

u m

ust

pay

extr

a to

see

som

e pr

ovid

ers.

Out

-of-

netw

ork

Co-

insu

ranc

e T

he p

erce

nt (f

or e

xam

ple,

40%

) you

pay

of t

he a

llow

ed

amou

nt fo

r cov

ered

hea

lth c

are

serv

ices

to p

rovi

ders

who

do

not

con

trac

t with

you

r hea

lth in

sura

nce

or p

lan.

Out

-of

-net

wor

k co

-insu

ranc

e us

ually

cos

ts y

ou m

ore

than

in-

netw

ork

co-in

sura

nce.

Out

-of-

netw

ork

Co-

paym

ent

A fi

xed

amou

nt (f

or e

xam

ple,

$30)

you

pay

for c

over

ed

heal

th c

are

serv

ices

from

pro

vide

rs w

ho d

o no

t con

trac

t w

ith y

our h

ealth

insu

ranc

e or

pla

n. O

ut-o

f-ne

twor

k co

-pa

ymen

ts u

sual

ly a

re m

ore

than

in-n

etw

ork

co-p

aym

ents

.

Out

-of-

Pock

et L

imit

The

mos

t you

pay

dur

ing

a po

licy

perio

d (u

sual

ly a

ye

ar) b

efor

e yo

ur h

ealth

in

sura

nce

or p

lan

begi

ns to

pa

y 10

0% o

f the

allo

wed

am

ount

. T

his l

imit

neve

r in

clud

es y

our p

rem

ium

, ba

lanc

e-bi

lled

char

ges o

r he

alth

car

e yo

ur h

ealth

in

sura

nce

or p

lan

does

n’t c

over

. So

me

heal

th in

sura

nce

or p

lans

don

’t co

unt a

ll of

you

r co-

paym

ents

, ded

uctib

les,

co-in

sura

nce

paym

ents

, out

-of-

netw

ork

paym

ents

or

othe

r exp

ense

s tow

ard

this

limit.

Phys

icia

n Se

rvic

es

Hea

lth c

are

serv

ices

a li

cens

ed m

edic

al p

hysic

ian

(M.D

. –

Med

ical

Doc

tor o

r D.O

. – D

octo

r of O

steo

path

ic

Med

icin

e) p

rovi

des o

r coo

rdin

ates

.

(See

pag

e 4

for a

det

aile

d ex

ampl

e.)

Jane

pay

s 0%

H

er p

lan

pays

10

0%

Glo

ssar

y of

Hea

lth C

over

age

and

Med

ical

Ter

ms

Pag

e 3

of 4

Plan

A

ben

efit

your

em

ploy

er, u

nion

or o

ther

gro

up sp

onso

r pr

ovid

es to

you

to p

ay fo

r you

r hea

lth c

are

serv

ices

.

Prea

utho

rizat

ion

A d

ecisi

on b

y yo

ur h

ealth

insu

rer o

r pla

n th

at a

hea

lth

care

serv

ice,

trea

tmen

t pla

n, p

resc

riptio

n dr

ug o

r dur

able

m

edic

al e

quip

men

t is m

edic

ally

nec

essa

ry. S

omet

imes

ca

lled

prio

r aut

horiz

atio

n, p

rior a

ppro

val o

r pr

ecer

tific

atio

n. Y

our h

ealth

insu

ranc

e or

pla

n m

ay

requ

ire p

reau

thor

izat

ion

for c

erta

in se

rvic

es b

efor

e yo

u re

ceiv

e th

em, e

xcep

t in

an e

mer

genc

y. P

reau

thor

izat

ion

isn’t

a pr

omise

you

r hea

lth in

sura

nce

or p

lan

will

cov

er

the

cost

.

Pref

erre

d Pr

ovid

er

A p

rovi

der w

ho h

as a

con

tract

with

you

r hea

lth in

sure

r or

plan

to p

rovi

de se

rvic

es to

you

at a

disc

ount

. Che

ck y

our

polic

y to

see

if yo

u ca

n se

e al

l pre

ferr

ed p

rovi

ders

or i

f yo

ur h

ealth

insu

ranc

e or

pla

n ha

s a “

tiere

d” n

etw

ork

and

you

mus

t pay

ext

ra to

see

som

e pr

ovid

ers.

You

r hea

lth

insu

ranc

e or

pla

n m

ay h

ave

pref

erre

d pr

ovid

ers w

ho a

re

also

“pa

rtic

ipat

ing”

pro

vide

rs.

Part

icip

atin

g pr

ovid

ers

also

con

trac

t with

you

r hea

lth in

sure

r or p

lan,

but

the

disc

ount

may

not

be

as g

reat

, and

you

may

hav

e to

pay

m

ore.

Prem

ium

T

he a

mou

nt th

at m

ust b

e pa

id fo

r you

r hea

lth in

sura

nce

or p

lan.

You

and/o

r yo

ur e

mpl

oyer

usu

ally

pay

it

mon

thly

, qua

rter

ly o

r yea

rly.

Pres

crip

tion

Dru

g C

over

age

Hea

lth in

sura

nce

or p

lan

that

hel

ps p

ay fo

r pre

scrip

tion

drug

s and

med

icat

ions

.

Pres

crip

tion

Dru

gs

Dru

gs a

nd m

edic

atio

ns th

at b

y la

w re

quire

a p

resc

riptio

n.

Prim

ary

Car

e Ph

ysic

ian

A p

hysic

ian

(M.D

. – M

edic

al D

octo

r or D

.O. –

Doc

tor

of O

steo

path

ic M

edic

ine)

who

dire

ctly

pro

vide

s or

coor

dina

tes a

rang

e of

hea

lth c

are

serv

ices

for a

pat

ient

.

Prim

ary

Car

e Pr

ovid

er

A p

hysic

ian

(M.D

. – M

edic

al D

octo

r or D

.O. –

Doc

tor

of O

steo

path

ic M

edic

ine)

, nur

se p

ract

ition

er, c

linic

al

nurs

e sp

ecia

list o

r phy

sicia

n as

sista

nt, a

s allo

wed

und

er

stat

e la

w, w

ho p

rovi

des,

coor

dina

tes o

r hel

ps a

pat

ient

ac

cess

a ra

nge

of h

ealth

car

e se

rvic

es.

Prov

ider

A

phy

sicia

n (M

.D. –

Med

ical

Doc

tor o

r D.O

. – D

octo

r of

Ost

eopa

thic

Med

icin

e), h

ealth

car

e pr

ofes

siona

l or

heal

th c

are

faci

lity

licen

sed,

cer

tifie

d or

acc

redi

ted

as

requ

ired

by st

ate

law

.

Rec

onst

ruct

ive

Surg

ery

Surg

ery

and

follo

w-u

p tr

eatm

ent n

eede

d to

cor

rect

or

impr

ove

a pa

rt o

f the

bod

y be

caus

e of

birt

h de

fect

s, ac

cide

nts,

inju

ries o

r med

ical

con

ditio

ns.

Reh

abili

tatio

n Se

rvic

es

Hea

lth c

are

serv

ices

that

hel

p a

pers

on k

eep,

get

bac

k or

im

prov

e sk

ills a

nd fu

nctio

ning

for d

aily

livi

ng th

at h

ave

been

lost

or i

mpa

ired

beca

use

a pe

rson

was

sick

, hur

t or

disa

bled

. The

se se

rvic

es m

ay in

clud

e ph

ysic

al a

nd

occu

patio

nal t

hera

py, s

peec

h-la

ngua

ge p

atho

logy

and

ps

ychi

atric

reha

bilit

atio

n se

rvic

es in

a v

arie

ty o

f inp

atie

nt

and/

or o

utpa

tient

setti

ngs.

Skill

ed N

ursin

g C

are

Serv

ices

from

lice

nsed

nur

ses i

n yo

ur o

wn

hom

e or

in a

nu

rsin

g ho

me.

Ski

lled

care

serv

ices

are

from

tech

nici

ans

and

ther

apist

s in

your

ow

n ho

me

or in

a n

ursin

g ho

me.

Spec

ialis

t A

phy

sicia

n sp

ecia

list f

ocus

es o

n a

spec

ific

area

of

med

icin

e or

a g

roup

of p

atie

nts t

o di

agno

se, m

anag

e, pr

even

t or t

reat

cer

tain

type

s of s

ympt

oms a

nd

cond

ition

s. A

non

-phy

sicia

n sp

ecia

list i

s a p

rovi

der w

ho

has m

ore

trai

ning

in a

spec

ific

area

of h

ealth

car

e.

UC

R (U

sual

, Cus

tom

ary

and

Rea

sona

ble)

T

he a

mou

nt p

aid

for a

med

ical

serv

ice

in a

geo

grap

hic

area

bas

ed o

n w

hat p

rovi

ders

in th

e ar

ea u

sual

ly c

harg

e fo

r the

sam

e or

sim

ilar m

edic

al se

rvic

e. T

he U

CR

am

ount

som

etim

es is

use

d to

det

erm

ine

the

allo

wed

am

ount

.

Urg

ent C

are

Car

e fo

r an

illne

ss, i

njur

y or

con

ditio

n se

rious

eno

ugh

that

a re

ason

able

per

son

wou

ld se

ek c

are

right

aw

ay, b

ut

not s

o se

vere

as t

o re

quire

em

erge

ncy

room

car

e.

Glossary of Health Coverage and Medical Terms Page 4 of 4

How You and Your Insurer Share Costs - Example Jane’s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000

Jane reaches her $1,500 deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit.

Office visit costs: $75 Jane pays: 20% of $75 = $15 Her plan pays: 80% of $75 = $60

Jane hasn’t reached her $1,500 deductible yet Her plan doesn’t pay any of the costs.

Office visit costs: $125 Jane pays: $125 Her plan pays: $0

January 1st Beginning of Coverage Period

December 31st End of Coverage Period

more costs

more costs

Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year.

Office visit costs: $200 Jane pays: $0 Her plan pays: $200

Jane pays 100%

Her plan pays 0%

Jane pays 20%

Her plan pays 80%

Jane pays 0%

Her plan pays 100%

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