ALBM Summary of Benefits and Coverage - Capitol Group


Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. Coverage ... www.healthcare.gov/coverage/preventive-care-benefits/. Are there .... transportation .... UnitedHealthcare Civil Rights Grievance.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Choice Plus ALBM /YM

Coverage Period: Based on group plan year Coverage for: Employee/Family | Plan Type: POS

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 www.welcometouhc.com or by calling 1-866-673-6293. 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 www.cciio.cms.gov or www.dol.gov/ebsa/healthreform or call 1-866-487-2365 to request a copy.

Important Questions What is the overall deductible? Are there services covered before you meet your deductible?

Answers

Why This Matters:

Network: $2,500 Individual / $5,000 Family Non-Network: $3,000 Individual / $6,000 Family Per calendar year. Yes. Preventive care is covered before you meet your deductible.

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 must be met before the plan begins to pay. 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 www.healthcare.gov/coverage/preventive-care-benefits/. You don’t have to meet deductibles for specific services.

Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider?

No.

Do you need a referral to see a specialist?

No.

ALBM

Network: $6,000 Individual / $12,000 Family Non-Network: $10,000 Individual / $20,000 Family Premiums, balance-billing charges, health care this plan doesn’t cover and penalties for failure to obtain preauthorization for services. Yes. See www.welcometouhc.com or call 1-866-673-6293 for a list of network providers.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. 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. You can see the specialist you choose without a referral.

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

Common Medical Event

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

What You Will Pay Services You May Need

Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/immunization

If you have a test

Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)

Network Provider (You will pay the least) $25 copay per visit

Non-Network Provider (You will pay the most) 30% coinsurance

$45 copay per visit No Charge

30% coinsurance

10% coinsurance

30% coinsurance

10% coinsurance

30% coinsurance

30% coinsurance

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Limitations, Exceptions, & Other Important Information Virtual visits (Telehealth) - $25 copay per visit by a Designated Virtual Network Provider. If you receive services in addition to office visit, additional copays, deductibles, or coinsurance may apply e.g. surgery. If you receive services in addition to office visit, additional copays, deductibles, or coinsurance may apply e.g. surgery. Includes preventive health services specified in the health care reform law. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Preauthorization required for Non-Network for certain services or benefit reduces to 50% of allowed. Preauthorization required for Non-Network or benefit reduces to 50% of allowed.

Common Medical Event

What You Will Pay Services You May Need

Network Provider (You will pay the least) If you need drugs Tier 1 - Your Lowest-Cost Retail: $10 copay to treat your Option Mail-Order: $25 illness or copay condition Specialty Drugs: $10 copay More information about prescription Tier 2 - Your Midrange-Cost Retail: $40 copay Option Mail-Order: $100 drug coverage is copay available at www. Specialty Drugs: welcometouhc.com. $100 copay Tier 3 - Your Midrange-Cost Retail: $75 copay Option Mail-Order: $187.50 copay Specialty Drugs: $300 copay Tier 4 - Additional Not Applicable High-Cost Options

Non-Network Provider (You will pay the most) Retail: $10 copay Specialty Drugs: $10 copay

If you have Facility fee (e.g., ambulatory outpatient surgery surgery center) Physician/surgeon fees If you need Emergency room care immediate medical attention Emergency medical transportation Urgent care If you have a Facility fee (e.g., hospital hospital stay room)

10% coinsurance

30% coinsurance

10% coinsurance 10% coinsurance

30% coinsurance 10% coinsurance

Provider means pharmacy for purposes of this section. Retail: Up to a 31 day supply. Mail-Order: Up to a 90 day supply. If you use a non-Network pharmacy (including a mail order pharmacy), you may be responsible for any amount over the allowed amount. Copay is per prescription order up to the day supply limit listed above. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us. Certain drugs may have a preauthorization requirement or may result in a higher cost. You may be required to use a lower-cost drug(s) prior to benefits under your policy being available for certain prescribed drugs. See the website listed for information on drugs covered by your plan. Not all drugs are covered. If a dispensed drug has a chemically equivalent drug, the cost difference between drugs in addition to any applicable copay and/or coinsurance may be applied. Certain preventive medications and Tier 1 contraceptives are covered at No Charge. Preauthorization required for certain services for Non-Network or benefit reduces to 50% of allowed. None None

10% coinsurance

10% coinsurance

None

10% coinsurance 10% coinsurance

30% coinsurance 30% coinsurance

None Preauthorization required for Non-Network or benefit reduces to 50% of allowed.

Retail: $40 copay Specialty Drugs: $100 copay

Retail: $75 copay Specialty Drugs: $300 copay

Not Applicable

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Limitations, Exceptions, & Other Important Information

Common Medical Event

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

If you are pregnant

If you need help recovering or have other special health needs

What You Will Pay Services You May Need Network Provider (You will pay the least) 10% coinsurance $45 copay per visit

Non-Network Provider (You will pay the most) 30% coinsurance 30% coinsurance

Inpatient services

10% coinsurance

30% coinsurance

Office visits

No Charge

30% coinsurance

Childbirth/delivery professional services Childbirth/delivery facility services

10% coinsurance

30% coinsurance

10% coinsurance

30% coinsurance

Home health care

10% coinsurance

30% coinsurance

Rehabilitation services

$25 copay per outpatient visit

30% coinsurance

Habilitation services

$25 copay per outpatient visit

30% coinsurance

Skilled nursing care

10% coinsurance

30% coinsurance

Durable medical equipment

10% coinsurance

30% coinsurance

Physician/surgeon fees Outpatient services

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Limitations, Exceptions, & Other Important Information None Network Partial hospitalization/intensive outpatient treatment: 10% coinsurance Preauthorization required for certain services for Non-Network or benefit reduces to 50% of allowed. Preauthorization required for Non-Network or benefit reduces to 50% of allowed. Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, deductibles, or coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Inpatient preauthorization apply for Non-Network if stay exceeds 48 hours (C-Section: 96 hours) or benefit reduces to 50% of allowed. Limited to 100 visits per calendar year. Preauthorization required for Non-Network or benefit reduces to 50% of allowed. Limits per calendar year Physical and Occupational 30 visits combined; Speech 30 visits; Pulmonary and Cardiac: Unlimited. Preauthorization required for certain services for Non-Network or benefit reduces to 50% of allowed. Limits per calendar year: Physical and Occupational 30 visits combined; Speech 30 visits. Preauthorization required for certain services for Non-Network or benefit reduces to 50% of allowed. Skilled Nursing is limited to 100 days per calendar year (combined with Inpatient Rehabilitation) . Preauthorization required for Non-Network or benefit reduces to 50% of allowed. Preauthorization required for Non-Network DME over $1,000 or no coverage.

Common Medical Event

What You Will Pay Services You May Need

Hospice services If your child needs Children’s eye exam dental or eye care Children’s glasses Children’s dental check-up

Network Provider (You will pay the least) 10% coinsurance

Non-Network Provider (You will pay the most) 30% coinsurance

$25 copay per visit, deductible does not apply 50% coinsurance 0% coinsurance

50% coinsurance 50% coinsurance 0% coinsurance

Limitations, Exceptions, & Other Important Information Preauthorization required for Non-Network before admission for an Inpatient Stay in a hospice facility or benefit reduces to 50% of allowed. One exam every 12 months. One pair every 12 months. Cleanings covered 2 times per 12 months. Additional limitations may apply.

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)

Long-Term Care

Non-emergency care when traveling outside the U.S.

Routine Foot Care

Weight Loss Programs

Infertility Treatment

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care-30 visits per calendar year

Hearing Aids-$2,500/ calendar year

Private-Duty Nursing - 2 visits/calendar year

Routine eye care (Adult)-1 exam/12 months

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: 1-866-444-3272 or www.dol.gov/ebsa/healthreform for the U.S. Department of Labor, Employee Benefits Security Administration, or 1-877-267-2323 x61565 or www.cciio.cms.gov for the U.S. Department of Health and Human Services. You may also contact us at 1-866-673-6293 . 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,

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this notice, or assistance, contact: 1-866-673-6293 ; or the Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform or the Virginia Bureau of Insurance at 1-877-310-6560 or www.scc.virginia.gov/boi. 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 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. Language Access Services: Spanish (Espa ol): Para obtener asistencia en Espa ol, llame al 1-866-673-6293 . Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-673-6293 . Chinese 1-866-673-6293 . Navajo (Dine): Dinek ehgo shika at ohwol ninisingo, kwiijigo holne 1-866-673-6293 . To see examples of how this plan might cover costs for a sample medical situation, see the next section.

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

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan’s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-controlled condition) $ 2,500 $45 10% 10%

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 In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is

The plan’s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance

$ 2,500 $45 10% 10%

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)

$12,800

$2,500 $30 $800 $60 $3,390

Total Example Cost In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is

$7,400

$2,500 $800 $10 $30 $3,340

Mia’s Simple Fracture (in-network emergency room visit and follow up care) The plan’s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance

$ 2,500 $45 10% 10%

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is

The plan would be responsible for the costs of these EXAMPLE covered services 7 of 7

$1,900

$1,900 $0 $0 $0 $1,900

Notice of Non-Discrimination We do not treat members differently because of sex, age, race, color, disability or national origin. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online: [email protected] Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130 You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC), TTY 711, Monday through Friday, 8 a.m. to 8 p.m. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: http://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the number contained within this Summary of Benefits and Coverage (SBC), TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

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