CITIGROUP : Aexcel Plus Aetna Choice POS II - Choice Plan ... · or clinic Age and frequency...
16
Important Questions Answers Why this Matters: This is only a summary. at www.HealthReformPlanSBC.com or by calling 1-888-982-3862. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document Aexcel Designated: Individual $500 / Family $1,000. Out–of–Network: Individual $1,500 / Family $3,000. Does not apply to emergency care, and preventive care. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. What is the overall deductible? No. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Are there other deductibles for specific services? Yes. Aexcel Designated: Individual $3,000 / Family $6,000. Out–of–Network: Individual $6,000 / Family $12,000. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Is there an out-of-pocket limit on my expenses? Premiums, balance-billed charges, penalties for failure to obtain pre-authorization for service and health care this plan does not cover. Even though you pay these expenses, they don't count toward the out-of pocket limit. What is not included in the out-of-pocket limit? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Is there an overall annual limit on what the plan pays? If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Does this plan use a network of providers? Yes. See www.aetna.com or call 1-888-982-3862 for a list of Aexcel designated providers. No. You can see the specialist you choose without permission from this plan. Do I need a referral to see a specialist? Yes. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. Are there services this plan doesn't cover? Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS Coverage Period: 01/01/2016 - 12/31/2016 Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy. 071800-090020-021550 1 of 8 CITIGROUP : Aexcel ® Plus Aetna Choice ® POS II - Choice Plan 500 with Aexcel :
Transcript of CITIGROUP : Aexcel Plus Aetna Choice POS II - Choice Plan ... · or clinic Age and frequency...
Important Questions Answers Why this Matters:
This is only a summary.at www.HealthReformPlanSBC.com or by calling 1-888-982-3862.
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document
Aexcel Designated: Individual $500 / Family$1,000. Out–of–Network: Individual $1,500 /Family $3,000. Does not apply to emergencycare, and preventive care.
You must pay all the costs up to the deductible amount before this plan beginsto pay for covered services you use. Check your policy or plan document to seewhen the deductible starts over (usually, but not always, January 1st). See thechart starting on page 2 for how much you pay for covered services after youmeet the deductible.
What is the overalldeductible?
No. You don't have to meet deductibles for specific services, but see the chartstarting on page 2 for other costs for services this plan covers.
Are there other deductiblesfor specific services?
Yes. Aexcel Designated: Individual $3,000 /Family $6,000. Out–of–Network: Individual$6,000 / Family $12,000.
The out-of-pocket limit is the most you could pay during a coverage period(usually one year) for your share of the cost of covered services. This limithelps you plan for health care expenses.
Is there anout-of-pocket limiton my expenses?
Premiums, balance-billed charges, penaltiesfor failure to obtain pre-authorization forservice and health care this plan does notcover.
Even though you pay these expenses, they don't count toward the out-ofpocket limit.
What is not included inthe out-of-pocket limit?
No.The chart starting on page 2 describes any limits on what the plan will pay forspecific covered services, such as office visits.
Is there an overallannual limit on whatthe plan pays?
If you use an in-network doctor or other health care provider, this plan will paysome or all of the costs of covered services. Be aware, your in-network doctor orhospital may use an out-of-network provider for some services. Plans use theterm in-network, preferred, or participating for providers in their network. Seethe chart starting on page 2 for how this plan pays different kinds of providers.
Does this plan use anetwork of providers?
Yes. See www.aetna.com or call1-888-982-3862 for a list of Aexcel designatedproviders.
No. You can see the specialist you choose without permission from this plan.Do I need a referral tosee a specialist?
Yes.Some of the services this plan doesn't cover are listed on page 5. See yourpolicy or plan document for additional information about excluded services.
Are there services thisplan doesn't cover?
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aexcel® Plus Aetna Choice® POS II - Choice Plan500 with Aexcel:
AH25232
Text Box
H000157243
Limitations & Exceptions
Your Cost If You Use an
AexcelNon-Designated
Provider
CommonMedical Event Services You May Need
Your Cost If You Use an In-Network
Provider
Your Cost If You Use an
AexcelDesignated
Provider
Your Cost If You Use an
Out–of–NetworkProvider
10% coinsurance10% coinsurancePrimary care visit to treat aninjury or illness
Includes Internist, GeneralPhysician, FamilyPractitioner or Pediatrician.
40% coinsurance20% coinsurance
10% coinsurance10% coinsuranceSpecialist visit –––––––none–––––––40% coinsurance20% coinsurance
Not applicableNot applicableOther practitioner officevisit
Coverage is limited to 20visits per calendar year forChiropractic care.
40% coinsurance20% coinsurance
No chargeNo chargePreventive care/ screening/immunization
If you visit ahealth careprovider's officeor clinic
Age and frequencyschedules may apply.
No charge up to$250; 40%coinsurance,deductible waived,thereafter
No charge
Not applicableNot applicableDiagnostic test (x-ray, bloodwork) –––––––none–––––––40% coinsurance20% coinsurance
Not applicableNot applicableImaging (CT/PET scans,MRIs)
If you have a test–––––––none–––––––40% coinsurance20% coinsurance
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowedamount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowedamount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if theplan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if youhaven't met your deductible.
This plan may encourage you to use Aexcel designated providers by charging you lower deductibles, copayments, and coinsurance amounts.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aexcel® Plus Aetna Choice® POS II - Choice Plan500 with Aexcel:
Limitations & Exceptions
Your Cost If You Use an
AexcelNon-Designated
Provider
CommonMedical Event Services You May Need
Your Cost If You Use an In-Network
Provider
Your Cost If You Use an
AexcelDesignated
Provider
Your Cost If You Use an
Out–of–NetworkProvider
Not applicableNot applicableGeneric drugs Not coveredCopay/prescription(RX): $5 (retail),$12.50 (mail order)
Not applicableNot applicablePreferred brand drugs Not coveredCopay/RX: $30(retail), $75 (mailorder-MOD)
Not applicableNot applicableNon-preferred brand drugs
Covers 34 day supply(retail), 34-90 day supply(mail order), 30 day supply(specialty drugs). Includescontraceptive drugs &devices obtainable from apharmacy, oral fertilitydrugs. No charge forformulary genericFDA-approved women'scontraceptives in-network.
Not covered
50% coins: to $50minimum (min) &$150 maximum(max) (retail),$125min & $375 max(MOD)
Not applicableNot applicableSpecialty drugs
If you need drugsto treat yourillness orconditionPrescription drugcoverage isadministered byExpress Scripts
More informationabout prescriptiondrug coverage isavailable atwww.aetna.com/pharmacy-insurance/individuals-families
–––––––none–––––––Not covered
25% coins: to $50min & $150 max(formulary), 50%coins: to $100 min& $250 max(non-formulary)(retail & MOD)
Not applicableNot applicableFacility fee (e.g., ambulatorysurgery center) –––––––none–––––––40% coinsurance20% coinsurance
10% coinsurance10% coinsurancePhysician/surgeon fees
If you haveoutpatient surgery
–––––––none–––––––40% coinsurance20% coinsurance
Not applicableNot applicableEmergency room services No coverage fornon-emergency use.$100 copay/visit$100 copay/visit
Not applicableNot applicableEmergency medicaltransportation –––––––none–––––––No chargeNo charge
Not applicableNot applicableUrgent care
If you needimmediatemedical attention
–––––––none–––––––20% coinsurance20% coinsurance
Not applicableNot applicableFacility fee (e.g., hospitalroom)
Pre-authorization requiredfor out-of-network care.40% coinsurance20% coinsurance
10% coinsurance10% coinsurancePhysician/surgeon fee
If you have ahospital stay
–––––––none–––––––40% coinsurance20% coinsurance
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aexcel® Plus Aetna Choice® POS II - Choice Plan500 with Aexcel:
Limitations & Exceptions
Your Cost If You Use an
AexcelNon-Designated
Provider
CommonMedical Event Services You May Need
Your Cost If You Use an In-Network
Provider
Your Cost If You Use an
AexcelDesignated
Provider
Your Cost If You Use an
Out–of–NetworkProvider
Not applicableNot applicableMental/Behavioral healthoutpatient services –––––––none–––––––40% coinsurance20% coinsurance
Not applicableNot applicableMental/Behavioral healthinpatient services
Pre-authorization requiredfor out-of-network care.40% coinsurance20% coinsurance
Not applicableNot applicableSubstance use disorderoutpatient services –––––––none–––––––40% coinsurance20% coinsurance
Not applicableNot applicableSubstance use disorderinpatient services
If you have mentalhealth, behavioralhealth, orsubstance abuseneeds
Pre-authorization requiredfor out-of-network care.40% coinsurance20% coinsurance
No chargeNo chargePrenatal and postnatal care –––––––none–––––––40% coinsuranceNo charge
Not applicableNot applicableDelivery and all inpatientservices
If you arepregnant
Pre- authorization may berequired out-of- networkcare. Includes outpatientpostnatal care.
40% coinsurance20% coinsurance
Not applicableNot applicableHome health care
Coverage limited to 200visits per calendar yearcombined with private-duty nursing. Pre-authorization requiredout-of-network care.
40% coinsurance20% coinsurance
Not applicableNot applicableRehabilitation services
Coverage limited to 60visits Physical (PT) & (OT)Occupational Therapycombined, 90 visits SpeechTherapy (ST) per calendaryear.
40% coins: 1st 60visits PT & OT; 1st90 visits ST, 50%coins there after
20% coins: 1st 60visits PT & OT; 1st90 visits ST, 30%coins there after
Not applicableNot applicableHabilitation services
If you need helprecovering or haveother specialhealth needs
Coverage limited to 60visits Autism PT & OTcombined, 90 visits ST percalendar year, combinedrehabilitation services &developmental delays.
40% coinsurance1st 60 visits, 50%coinsurancethereafter
20% coinsurance1st 60 visits, 30%coinsurancethereafter
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aexcel® Plus Aetna Choice® POS II - Choice Plan500 with Aexcel:
Limitations & Exceptions
Your Cost If You Use an
AexcelNon-Designated
Provider
CommonMedical Event Services You May Need
Your Cost If You Use an In-Network
Provider
Your Cost If You Use an
AexcelDesignated
Provider
Your Cost If You Use an
Out–of–NetworkProvider
Not applicableNot applicableSkilled nursing care
Coverage is limited to 120days per calendar year.Pre-authorization requiredfor out-of-network care.
40% coinsurance20% coinsurance
Not applicableNot applicableDurable medical equipment –––––––none–––––––40% coinsurance20% coinsurance
Not applicableNot applicableHospice service Pre-authorization requiredfor out-of-network care.40% coinsurance20% coinsurance
Not applicableNot applicableEye examCoverage is limited to 1routine eye exam per 12months.
40% coinsurance,deductible waivedNo charge
Not applicableNot applicableGlasses Not covered.Not coveredNot coveredNot applicableNot applicableDental check-up
If your child needsdental or eye care
Not covered.Not coveredNot covered
(This isn't a complete list. Check your policy or plan document for other excluded services.)Excluded Services & Other Covered Services:Services Your Plan Does NOT Cover
Cosmetic surgeryDental care (Adult & Child)Glasses (Child)
Long-term careNon-emergency care when traveling outside theU.S.
Prescription drugsRoutine foot careWeight loss programs
(This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)Other Covered Services
AcupunctureBariatric surgeryChiropractic care - Coverage is limited to 20 visitsper calendar year.
Hearing aids - Coverage is limited to 1 hearing aidper ear per 24 months for child, every 36 monthsfor adult.Infertility treatment - Benefit limitations may apply.
Private-duty nursing - Coverage is limited to 200 - 8hour shifts per calendar year combined with homehealth care.Routine eye care (Adult) - Coverage is limited to 1routine eye exam per 12 months.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aexcel® Plus Aetna Choice® POS II - Choice Plan500 with Aexcel:
Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay whilecovered under the plan. Other limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at 1-888-982-3862. You may also contact your state insurance department, the U.S.Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and HumanServices at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questionsabout your rights, this notice, or assistance, you can contact us by calling the toll free number on your Medical ID Card. If your group health plan is subject toERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform.Additionally, a consumer assistance program can help you file your appeal. Contact information is athttp://www.aetna.com/individuals-families-health-insurance/rights-resources/complaints-grievances-appeals/index.html
The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provideminimum essential coverage.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This healthcoverage does meet the minimum value standard for the benefits it provides.
Does this Coverage Meet Minimum Value Standard?
Language Access Services:
Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-982-3862.Para obtener asistencia en Español, llame al 1-888-982-3862. 1-888-982-3862.
-------------------To see examples of how this plan might cover costs for a sample medical situation, see the next page.-------------------Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-982-3862.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aexcel® Plus Aetna Choice® POS II - Choice Plan500 with Aexcel:
About these CoverageExamples:
Amount owed to providers: $7,540Plan pays: $5,940Patient pays: $1,600
Sample care costs:
Amount owed to providers: $5,400Plan pays: $1,700Patient pays: $3,700
Sample care costs:Hospital charges (mother)Routine obstetric careHospital charges (baby)AnesthesiaLaboratory testsPrescriptionsRadiologyVaccines, other preventiveTotal
$200
$500
$2,100$2,700
$900$900
$40$7,540
Patient pays:
Patient pays:
DeductiblesCopaysCoinsuranceLimits or exclusions
$500$0
$900
$1,600$200
$3,700
PrescriptionsMedical Equipment and SuppliesOffice Visits and Procedures
DeductiblesCopaysCoinsuranceLimits or exclusions
$500$0
$300$2,900
$700$300
$1,300$2,900
$5,400
These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.
EducationLaboratory testsVaccines, other preventive$200
$100$100
Having a baby(normal delivery)
Managing type 2 diabetes(routine maintenance of
a well-controlled condition)
Total
Total
Total
This is nota costestimator.
Don't use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care also will bedifferent.
See the next page forimportant information aboutthese examples.
Coverage Examples Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
071800-090020-0215507 of 8
CITIGROUP : Aexcel® Plus Aetna Choice® POS II - Choice Plan500 with Aexcel:
Questions and answers about the Coverage Examples:What are some of the assumptionsbehind the Coverage Examples?
What does a CoverageExample show?
Can I use Coverage Examples tocompare plans?
Does the Coverage Examplepredict my own care needs? Are there other costs I should
consider when comparing plans?
Does the Coverage Examplepredict my future expenses?
Costs don't include premiums.
For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn't covered or payment is limited.
The care you would receive for thiscondition could be different, based on yourdoctor's advice, your age, how serious yourcondition is, and many other factors.
Treatments shown are just examples.
Coverage Examples are not costestimators. You can't use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Yourown costs will be different depending onthe care you receive, the prices yourproviders charge, and the reimbursementyour health plan allows.
you pay. Generally, the lower yourpremium, the more you'll pay inout-of-pocket costs, such as copayments,deductibles, and coinsurance. You shouldalso consider contributions to accounts suchas health savings accounts (HSAs), flexiblespending arrangements (FSAs) or healthreimbursement accounts (HRAs) that helpyou pay out-of-pocket expenses.
Benefits and Coverage for other plans,you'll find the same Coverage Examples.When you compare plans, check the "PatientPays" box in each example. The smaller thatnumber, the more coverage the planprovides.
When you look at the Summary of
An important cost is the premium
No.
No.
Yes.
Yes.
Sample care costs are based on nationalaverages supplied by the U.S. Departmentof Health and Human Services, and aren'tspecific to a particular geographic area orhealth plan.The patient's condition was not anexcluded or preexisting condition.All services and treatments started andended in the same coverage period.There are no other medical expenses forany member covered under this plan.Out-of-pocket expenses are based only ontreating the condition in the example.The patient received all care fromin-network providers. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.
Coverage Examples Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aexcel® Plus Aetna Choice® POS II - Choice Plan500 with Aexcel:
Important Questions Answers Why this Matters:
This is only a summary.at www.HealthReformPlanSBC.com or by calling 1-888-982-3862.
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document
Network: Individual $500 / Family $1,000.Out–of–Network: Individual $1,500 / Family$3,000. Does not apply to emergency care andpreventive care in-network.
You must pay all the costs up to the deductible amount before this plan beginsto pay for covered services you use. Check your policy or plan document to seewhen the deductible starts over (usually, but not always, January 1st). See thechart starting on page 2 for how much you pay for covered services after youmeet the deductible.
What is the overalldeductible?
Yes. For prescription drug expenses -Individual $100 / Family $200. There are noother specific deductibles.
You must pay all of the costs for these services up to the specific deductibleamount before this plan begins to pay for these services.
Are there other deductiblesfor specific services?
Yes. Network: Individual $3,000 / Family$6,000. Out–of–Network: Individual $6,000 /Family $12,000. Prescription drugs: Individual$1,500 / Family $3,000.
The out-of-pocket limit is the most you could pay during a coverage period(usually one year) for your share of the cost of covered services. This limithelps you plan for health care expenses.
Is there anout-of-pocket limiton my expenses?
Premiums, balance-billed charges, health carethis plan does not cover, and penalties forfailure to obtain pre-authorization for service.
Even though you pay these expenses, they don't count toward the out-ofpocket limit.
What is not included inthe out-of-pocket limit?
No.The chart starting on page 2 describes any limits on what the plan will pay forspecific covered services, such as office visits.
Is there an overallannual limit on whatthe plan pays?
If you use an in-network doctor or other health care provider, this plan will paysome or all of the costs of covered services. Be aware, your in-network doctor orhospital may use an out-of-network provider for some services. Plans use theterm in-network, preferred, or participating for providers in their network. Seethe chart starting on page 2 for how this plan pays different kinds of providers.
Does this plan use anetwork of providers?
Yes. See www.aetna.com or call1-888-982-3862 for a list of networkproviders.
No. You can see the specialist you choose without permission from this plan.Do I need a referral tosee a specialist?
Yes.Some of the services this plan doesn't cover are listed on page 5. See yourpolicy or plan document for additional information about excluded services.
Are there services thisplan doesn't cover?
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aetna Choice® POS II - Choice Plan 500:
Limitations & Exceptions
Your Cost If You Use an
Out–of–NetworkProvider
Services You May Need
Your Cost If You Use a
Network ProviderCommonMedical Event
40% coinsurance20% coinsurancePrimary care visit to treat an injury orillness
Includes Internist, General Physician,Family Practitioner or Pediatrician.
40% coinsurance20% coinsuranceSpecialist visit –––––––––––none–––––––––––
40% coinsurance20% coinsuranceOther practitioner office visit Coverage is limited to 20 visits per calendaryear for Chiropractic care.
No charge up to $250;40% coinsurance,deductible waived,thereafter
No chargePreventive care /screening/immunization
If you visit a healthcare provider's officeor clinic
Age and frequency schedules may apply.
40% coinsurance20% coinsuranceDiagnostic test (x-ray, blood work) –––––––––––none–––––––––––40% coinsurance20% coinsuranceImaging (CT/PET scans, MRIs)
If you have a test–––––––––––none–––––––––––
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowedamount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowedamount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if theplan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if youhaven't met your deductible.
This plan may encourage you to use network providers by charging you lower deductibles, copayments, and coinsurance amounts.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aetna Choice® POS II - Choice Plan 500:
Limitations & Exceptions
Your Cost If You Use an
Out–of–NetworkProvider
Services You May Need
Your Cost If You Use a
Network ProviderCommonMedical Event
Copay/prescription:50% coinsurance(retail)
Copay/prescription: $5(retail), $12.50 (mailorder)
Generic drugs
Copay/prescription:50% coinsurance(retail)
Copay/prescription:$30 (retail), $75 (mailorder)
Preferred brand drugs
Copay/prescription:50% coinsurance(retail)
Copay/prescription:50% coinsurance witha $50 minimum (min)and a $150 maximum(max)/ prescription(retail), 50%coinsurance with a$125 min and a $375max/ prescription(mail order)
Non-preferred brand drugs
Covers 34 day supply (retail), 34-90 daysupply (mail order), 30 day supply (specialtydrugs). Includes contraceptive drugs &devices obtainable from a pharmacy, oralfertility drugs. No charge for formularygeneric FDA-approved women'scontraceptives in-network.
Not covered
25% coinsurance witha $50 min and a $150max/ prescription(formulary), 50%coinsurance with a$100 min and a $250max/ prescription(non-formulary) (retail& mail order)
Specialty drugs
If you need drugs totreat your illness orcondition. Prescription drugcoverage isadministered byExpress Scripts
More informationabout prescriptiondrug coverage isavailable atwww.aetna.com/pharmacy-insurance/individuals-families –––––––––––none–––––––––––
40% coinsurance20% coinsuranceFacility fee (e.g., ambulatory surgerycenter) –––––––––––none–––––––––––
40% coinsurance20% coinsurancePhysician/surgeon fees
If you haveoutpatient surgery
–––––––––––none–––––––––––$100 copay/visit$100 copay/visitEmergency room services No coverage for non-emergency use.No chargeNo chargeEmergency medical transportation –––––––––––none–––––––––––20% coinsurance20% coinsuranceUrgent care
If you needimmediate medicalattention –––––––––––none–––––––––––
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aetna Choice® POS II - Choice Plan 500:
Limitations & Exceptions
Your Cost If You Use an
Out–of–NetworkProvider
Services You May Need
Your Cost If You Use a
Network ProviderCommonMedical Event
40% coinsurance20% coinsuranceFacility fee (e.g., hospital room) Pre-authorization required forout-of-network care.
40% coinsurance20% coinsurancePhysician/surgeon fee
If you have a hospitalstay
–––––––––––none–––––––––––
40% coinsurance20% coinsuranceMental/Behavioral health outpatientservices –––––––––––none–––––––––––
40% coinsurance20% coinsuranceMental/Behavioral health inpatientservices
Pre-authorization required forout-of-network care.
40% coinsurance20% coinsuranceSubstance use disorder outpatientservices –––––––––––none–––––––––––
40% coinsurance20% coinsuranceSubstance use disorder inpatientservices
If you have mentalhealth, behavioralhealth, or substanceabuse needs
Pre-authorization required forout-of-network care.
40% coinsuranceNo chargePrenatal and postnatal care –––––––––––none–––––––––––
40% coinsurance20% coinsuranceDelivery and all inpatient servicesIf you are pregnant Includes outpatient postnatal care.
Pre-authorization may be required forout-of-network care.
40% coinsurance20% coinsuranceHome health care
Coverage is limited to 200 visits percalendar year combined with private-dutynursing. Pre-authorization required forout-of-network care.
40% coinsurance 1st60 visits; 50%coinsurance for PT &OT thereafter; 40%coinsurance 1st 90visits; 50% coinsurancefor ST thereafter
20% coinsurance 1st60 visits; 30%coinsurance for PT &OT thereafter; 20%coinsurance 1st 90visits; 30% coinsurancefor ST thereafter
Rehabilitation services
Coverage is limited to 60 visits per calendaryear for Physical (PT) & Occupational (OT)Therapy combined, 90 visits per calendaryear for Speech Therapy (ST).
40% coinsurance 1st60 visits; 50%coinsurance thereafter
20% coinsurance 1st60 visits; 30%coinsurance thereafter
Habilitation services
If you need helprecovering or haveother special healthneeds
Coverage is limited to 60 visits per calendaryear for Autism PT & OT combined, 90visits per calendar year for Autism ST,combined with rehabilitation services anddevelopmental delays.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aetna Choice® POS II - Choice Plan 500:
Limitations & Exceptions
Your Cost If You Use an
Out–of–NetworkProvider
Services You May Need
Your Cost If You Use a
Network ProviderCommonMedical Event
40% coinsurance20% coinsuranceSkilled nursing careCoverage is limited to 120 days per calendaryear. Pre-authorization required forout-of-network care.
40% coinsurance20% coinsuranceDurable medical equipment –––––––––––none–––––––––––
40% coinsurance20% coinsuranceHospice service Pre-authorization required forout-of-network care.
No charge up to $250;40% coinsurancethereafter
No chargeEye exam Coverage is limited to 1 routine eye examper 12 months.
Not coveredNot coveredGlasses Not covered.Not coveredNot coveredDental check-up
If your child needsdental or eye care
Not covered.
(This isn't a complete list. Check your policy or plan document for other excluded services.)Excluded Services & Other Covered Services:Services Your Plan Does NOT Cover
Cosmetic surgeryDental care (Adult & Child)
Glasses (Child)Long-term care
Prescription drugsWeight loss programs
(This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)Other Covered Services
AcupunctureBariatric surgeryChiropractic care - Coverage is limited to 20 visitsper calendar year.
Hearing aids - Coverage is limited to 1 hearing aidper ear per 24 months for children up to age 19; 36months after age 19.Infertility treatment - Benefit limitations may apply.Non-emergency care when traveling outside theU.S.
Private-duty nursing - Coverage is limited to 200 - 8hour shifts per calendar year combined with homehealth care.Routine eye care (Adult) - Coverage is limited to 1routine eye exam per 12 months.Routine foot care
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aetna Choice® POS II - Choice Plan 500:
Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay whilecovered under the plan. Other limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at 1-888-982-3862. You may also contact your state insurance department, the U.S.Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and HumanServices at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questionsabout your rights, this notice, or assistance, you can contact us by calling the toll free number on your Medical ID Card. If your group health plan is subject toERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform.Additionally, a consumer assistance program can help you file your appeal. Contact information is athttp://www.aetna.com/individuals-families-health-insurance/rights-resources/complaints-grievances-appeals/index.html
The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provideminimum essential coverage.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This healthcoverage does meet the minimum value standard for the benefits it provides.
Does this Coverage Meet Minimum Value Standard?
Language Access Services:
Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-982-3862.Para obtener asistencia en Español, llame al 1-888-982-3862. 1-888-982-3862.
-------------------To see examples of how this plan might cover costs for a sample medical situation, see the next page.-------------------Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-982-3862.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aetna Choice® POS II - Choice Plan 500:
About these CoverageExamples:
Amount owed to providers: $7,540Plan pays: $5,940Patient pays: $1,600
Sample care costs:
Amount owed to providers: $5,400Plan pays: $1,600Patient pays: $3,800
Sample care costs:Hospital charges (mother)Routine obstetric careHospital charges (baby)AnesthesiaLaboratory testsPrescriptionsRadiologyVaccines, other preventiveTotal
$200
$500
$2,100$2,700
$900$900
$40$7,540
Patient pays:
Patient pays:
DeductiblesCopaysCoinsuranceLimits or exclusions
$500$0
$900
$1,600$200
$3,800
PrescriptionsMedical Equipment and SuppliesOffice Visits and Procedures
DeductiblesCopaysCoinsuranceLimits or exclusions
$500$0
$400$2,900
$700$300
$1,300$2,900
$5,400
These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.
EducationLaboratory testsVaccines, other preventive$200
$100$100
Having a baby(normal delivery)
Managing type 2 diabetes(routine maintenance of
a well-controlled condition)
Total
Total
Total
This is nota costestimator.
Don't use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care also will bedifferent.
See the next page forimportant information aboutthese examples.
Coverage Examples Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aetna Choice® POS II - Choice Plan 500:
Questions and answers about the Coverage Examples:What are some of the assumptionsbehind the Coverage Examples?
What does a CoverageExample show?
Can I use Coverage Examples tocompare plans?
Does the Coverage Examplepredict my own care needs? Are there other costs I should
consider when comparing plans?
Does the Coverage Examplepredict my future expenses?
Costs don't include premiums.
For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn't covered or payment is limited.
The care you would receive for thiscondition could be different, based on yourdoctor's advice, your age, how serious yourcondition is, and many other factors.
Treatments shown are just examples.
Coverage Examples are not costestimators. You can't use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Yourown costs will be different depending onthe care you receive, the prices yourproviders charge, and the reimbursementyour health plan allows.
you pay. Generally, the lower yourpremium, the more you'll pay inout-of-pocket costs, such as copayments,deductibles, and coinsurance. You shouldalso consider contributions to accounts suchas health savings accounts (HSAs), flexiblespending arrangements (FSAs) or healthreimbursement accounts (HRAs) that helpyou pay out-of-pocket expenses.
Benefits and Coverage for other plans,you'll find the same Coverage Examples.When you compare plans, check the "PatientPays" box in each example. The smaller thatnumber, the more coverage the planprovides.
When you look at the Summary of
An important cost is the premium
No.
No.
Yes.
Yes.
Sample care costs are based on nationalaverages supplied by the U.S. Departmentof Health and Human Services, and aren'tspecific to a particular geographic area orhealth plan.The patient's condition was not anexcluded or preexisting condition.All services and treatments started andended in the same coverage period.There are no other medical expenses forany member covered under this plan.Out-of-pocket expenses are based only ontreating the condition in the example.The patient received all care fromin-network providers. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.
Coverage Examples Coverage for: Individual + Family | Plan Type: POS
Coverage Period: 01/01/2016 - 12/31/2016
Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.
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CITIGROUP : Aetna Choice® POS II - Choice Plan 500:
