SBCCA14AKR1 Summary of Benefits and Coverage


UnitedHealthcare Core AKR1 /396. Coverage for: ... would share the cost for covered health care services. NOTE: .... penalty of $1,000 per transport. Network ...

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services UnitedHealthcare Core AKR1 /396

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?

Answers

Why this Matters:

Network: $6,500 Individual / $13,000 Family Non-Network: $9,000 Individual / $18,000 Family Per calendar year.

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 plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. You will have to meet the deductible before the plan pays for any services. 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 services covered before you meet your deductible? 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?

Yes. Preventive care is covered before you meet your deductible.

Do you need a referral to see a specialist?

No.

SBCCA14AKR1

No. Network: $6,500 Individual / $13,000 Family Non-Network: $13,000 Individual / $26,000 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

If you have a test

What You Will Pay Services You May Need Network Provider (You will pay the least) 0% coinsurance

Non-Network Provider (You will pay the most) 50% coinsurance

Specialist visit Preventive care/screening/immunization

0% coinsurance No Charge

50% coinsurance Not Covered

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

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

Primary care visit to treat an injury or illness

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Limitations, Exceptions, & Other Important Information None

None 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 or you will incur a penalty of $1,000 per visit Preauthorization required for non-network or you will incur a penalty of $1,000 per visit.

Common Medical Event

What You Will Pay Services You May Need Network Provider (You will pay the least) 0% coinsurance

Tier 1 - Generic drugs Your Lowest-Cost Option Tier 2 - Preferred brand 0% coinsurance drugs - Your Midrange-Cost Option More information about prescription Tier 3 - Non-preferred brand 0% coinsurance drugs - Your Midrange-Cost drug coverage is Option available at uhc.welcometouhc.- Tier 4 Specialty Drugs 0% coinsurance com/pharmacy-be- Additional High-Cost nefits Options If you need drugs to treat your illness or condition

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

If you have a hospital stay

Urgent care Facility fee (e.g., hospital room)

Non-Network Provider (You will pay the most) 0% coinsurance 0% coinsurance

0% coinsurance 0% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance 0% coinsurance

50% coinsurance 0% coinsurance

0% coinsurance

0% coinsurance

0% coinsurance 0% coinsurance

50% coinsurance 50% coinsurance

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Limitations, Exceptions, & Other Important Information Provider means pharmacy for purposes of this section. Up to a 31 day supply. Mail-Order: Up to a 90 day supply. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us. Certain drugs may not be covered until prior authorization is obtained. 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. All medically necessary outpatient 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, unless the higher tier drug is medically necessary. Certain preventive medications and Tier 1 contraceptives are covered at No Charge. Preauthorization required for non-network or you will incur a penalty of $1,000 per surgery. None Copayment and Coinsurance waived if admitted directly to hospital. Network deductible applies. Preauthorization required for non-network or you will incur a penalty of $1,000 per transport. Network deductible applies. None Preauthorization required for non-network or you will incur a penalty of $1,000 per admission.

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

Inpatient services

Network Non-Network Provider (You Provider (You will pay the will pay the least) most) 0% coinsurance 50% coinsurance Outpatient Office 50% coinsurance Visits: 0% coinsurance . All other outpatient Treatment: 0% coinsurance 0% coinsurance 50% coinsurance

Office visits

No Charge

50% coinsurance

Childbirth/delivery professional services Childbirth/delivery facility services

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

Home health care

0% coinsurance

50% coinsurance

Rehabilitation services

0% coinsurance

50% coinsurance

Habilitation services

0% coinsurance

50% coinsurance

Skilled nursing care

0% coinsurance

50% coinsurance

Physician/surgeon fees Outpatient services

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Limitations, Exceptions, & Other Important Information None Preauthorization required for non-network or you will incur a penalty of $1,000 per visit.

Preauthorization required for non-network or you will incur a penalty of $1,000 per admission. Cost sharing does not apply for preventive services. Depending on the type of service a copayment, deductibles, or coinsurance may apply. Applies to routine prenatal care and office visits. One post-natal office visit is covered at No Charge. Additional postnatal visits - subject to primary care or specialist office visit copay depending on the type of provider. Depending on the type of service a copayment, deductibles, or coinsurance may apply. Preauthorization required for non-network inpatient stays over 48 hours following a normal vaginal delivery, or over 96 hours following a cesarean section delivery or you will incur a penalty of $1,000 per admission. Limited to 100 visits per calendar year. Preauthorization required for non-network or you will incur a penalty of $1,000 per visit. Manipulative Treatments are limited to 24 visits per year. Preauthorization required for non-network or you will incur a penalty of $1,000 per visit. Manipulative Treatments are limited to 24 visits per year. Preauthorization required for non-network or you will incur a penalty of $1,000 per visit. Skilled Nursing is limited to 100 days per benefit period. Preauthorization required for non-network or you will incur a penalty of $1,000 per visit.

Common Medical Event

What You Will Pay Services You May Need

Durable medical equipment

Network Provider (You will pay the least) 0% coinsurance

Non-Network Provider (You will pay the most) 50% coinsurance

Hospice services

0% coinsurance

50% coinsurance

No Charge

50% coinsurance

0% coinsurance No Charge

50% coinsurance 20% coinsurance, deductible does not apply

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

Limitations, Exceptions, & Other Important Information Preauthorization required for non-network or you will incur a penalty of $1,000 per item. Preauthorization required for non-network before admission for an Inpatient Stay in a hospice facility or you will incur a penalty of $1,000 per admission. One exam per year. One pair per year. 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.) Cosmetic Surgery

Dental Care (Adult)

Routine Foot Care

Weight Loss Programs

Long-Term Care

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

Private-Duty Nursing

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture

Bariatric surgery

Chiropractic care - 24 visits per calendar year

Hearing aids - 1 every 3 years; $2500 per calendar year

Infertility treatment $2000 lifetime

Routine eye care (Adult) - 1 exam per calendar year 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 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. 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.

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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: 1-866-673-6293 ; or the Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform or the California Department of Insurance at 1-800-927-4357 or www.insurance.ca.gov. 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 page.

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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 Coinsurance Hospital (facility) Coinsurance Other coinsurance

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-controlled condition) $ 6,500 0% 0% 0%

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 Coinsurance Hospital (facility) Coinsurance Other coinsurance

$ 6,500 0% 0% 0%

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

$6,500 $0 $0 $60 $6,560

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

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$7,400

$6,500 $0 $0 $30 $6,530

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

$ 6,500 0% 0% 0%

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

$1,900

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

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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