BST_NAIC_BW 72600 Fl72600
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Coventry Health Care of Florida, Inc.: Gold $5 Copay HMO Carelink Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period : 01/01/2014 - 12/31/2014 Coverage for: EE only, EE/Spouse, EE/Child(ren), EE/Family | Plan Type: HMO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at chcflorida.com or by calling 1-855-449-2889. Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? Answers In network: $1,750 person/$3,500 family. Does not apply to PCP, First 5 Specialist visits, Urgent Care, First 3 visits ER visits, ER Transportation/Ambulance, Prenatal office visits, Advanced Imaging in freestanding facility, Preventive Care and Pediatric Vision Screening and Eye Out of network: Not Covered Yes $250 Prescription. There are no other specific deductibles. In network: Yes $5,000 person/$10,000 family Out of network: Not Covered Premiums, excluded services and health care this plan does not cover. No What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a Yes network of providers? For a list of participating providers, see chcflorida.com or call 1-855-449-2889. Do I need a referral to see a Yes specialist? Why This Matters: 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. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. 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. Even though you pay these expenses, they don't count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. 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 innetwork, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist. SNO: 1202018 SBC Name: 017_72600 017_15971 017_4051 Page 1 of 8 Questions: Call 1-855-449-2889 or visit us at chcflorida.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 http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. Important Questions Are there services this plan doesn't cover? Answers Why This Matters: Yes. Some of the services this plan doesn't Some of the services this plan doesn’t cover are listed on page 5. See your policy or cover are listed in Services Your Plan plan document for additional information about excluded services. Does Not Cover. See your Certificate of Coverage for additional information about excluded services. • Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use In network providers by charging you lower deductibles, copayments and coinsurance amounts. • • Common Medical Event If you visit a health care provider's office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/ Screening/Immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Your cost if you use a In-network Out-of-network Provider Provider $5 co-payment (coNot Covered pay)/occurrence $50 co-pay/occurrence Not Covered $50 co-pay/occurrence (chiropradtic care). No Charge Limitations & Exceptions ----------none-------------------none---------- Not Covered Limited: 26 visits/year Not Covered ----------none---------- $0 in PCP office x-ray Not Covered x-ray $0 in PCP office lab Not Covered lab $250 co-pay/occurrence Not Covered at freestanding facility ----------none---------Not covered without preauthorization (preauth) SNO: 1202018 SBC Name: 017_72600 017_15971 017_4051 Page 2 of 8 Questions: Call 1-855-449-2889 or visit us at chcflorida.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 http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. Common Medical Event Services You May Need Generic drugs If you need drugs to treat Preferred brand drugs your illness or condition. More information about prescription drug coverage is available at Non-preferred brand drugs chcflorida.com. Specialty drugs If you have outpatient surgery If you need immediate medical attention Your cost if you use a In-network Out-of-network Provider Provider $5 co-pay/fill retail Not Covered preferred , $10 copay/fill retail non preferred , $10 copay/fill mail. $30 co-pay/fill retail Not Covered preferred, $75 co-pay/fill mail. $60 co-pay/fill retail preferred, $180 copay/fill mail. Not Covered Limitations & Exceptions Includes $3 co-pay/fill retail preferred generics, $10 co-pay/fill retail non preferred, $6 copay/fill mail. Limited: 30-day supply retail, 90day supply mail. May require preauth for coverage. $40 co-pay/fill retail non preferred, $75 copay/fill mail. Limited: 30-day supply retail, 90day supply mail. May require preauth for coverage. $75 co-pay/fill retail non preferred, $180 copay/fill mail. Limited: 30-day supply reatil, 90day supply mail. May require preauth for coverage. 30% co-ins retail non preferred. Limited: 30day supply. May require preauth for coverage. ----------none---------- Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees 20% co-ins retail Not Covered preferred $250 co-pay/occurrence Not Covered at Freestanding Facility 20% co-ins Not Covered Emergency room services $250 co-pay/occurrence $250 co-pay/occurrence Must meet emergency room criteria. Emergency medical transportation Urgent care $500 co-pay/occurrence $500 co-pay/occurrence ----------none---------- ----------none---------- $75 co-pay/occurrence Not Covered ----------none---------- Facility fee (e.g., hospital If you have a hospital stay room) Physician/surgeon fee 20% co-ins Not Covered Consequence for no preauth if required. 20% co-ins Not Covered Consequence for no preauth if required. Mental/Behavioral health outpatient services If you have mental health, Mental/Behavioral health behavioral health, or inpatient services substance abuse needs Substance use disorder outpatient services $50 co-pay/occurrence Not Covered Limited: 20 visits/year. 20% co-ins Not Covered $50 co-pay/occurrence Not Covered Limited: 30 days/year and consequence for no preauth if required. Limited: 20 visits/year. SNO: 1202018 SBC Name: 017_72600 017_15971 017_4051 Page 3 of 8 Questions: Call 1-855-449-2889 or visit us at chcflorida.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 http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. Common Medical Event Services You May Need If you have mental health, Substance use disorder behavioral health, or inpatient services substance abuse needs Prenatal and postnatal care If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Your cost if you use a In-network Out-of-network Provider Provider 20% co-ins Not Covered Limitations & Exceptions Limited: 30 days/year and consequence for no preauth if required. $0 Not Covered One time $250 Co-pay Physician Services/Ultrasound Consequense for no preauth if required. Delivery and all inpatient services Home health care 20% co-ins Not Covered 20% co-ins Not Covered Rehabilitation services Inpatient 20% co-ins Outpatient 20% co-ins Habilitation services 20% co-ins Inpatient Not Covered Outpatient Not Covered Not Covered Skilled nursing care 20% co-ins Not Covered Durable medical equipment 20% co-ins Not Covered Limited: 60 days/year and consequence for no preauth if required. Consequence for no preauth if required. Hospice Service 20% co-ins Not Covered Consequence for no preauth if required. Eye exam $0 Not Covered Limited: 1 routine eye exam/year. Glasses $0 Not Covered Dental check-up Not Covered Not Covered Limited: 1 pair eyeglasses/lenses/year. 1 frame/year. Excluded Service Limited: 20 visits/year and consequence for no preauth if required. Consequense for no preauth if required. Consequence for no preauth if required. SNO: 1202018 SBC Name: 017_72600 017_15971 017_4051 Page 4 of 8 Questions: Call 1-855-449-2889 or visit us at chcflorida.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 http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) • Acupuncture • Bariatric Surgery • Child/Dental Check-up • Cosmetic Surgery • Dental Care (Adult) • Hearing Aids • Infertility Treatment • Long-Term Care • Non-Emergency Care when Traveling Outside the U.S. • Private-Duty Nursing • Routine Eye Care (Adult) • Routine Foot Care • Weight Loss Programs Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • Chiropractic Care 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 health coverage. 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 while covered 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 1-855-449-2889. 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 Human Services 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 questions about your rights, this notice, or assistance, you can contact: For group health coverage subject to ERISA, you may contact 1-855-449-2889. 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 Florida Department of Financial Services Division of Consumer Services 200 E. Gaines St. Tallahassee, FL 32399-0322 877-693-5236 www.myfloridacfo.com/Division/Consumers/NeedOurHelp.htm. For non-federal governmental group health plans and church plans that are group health plans, you may contact 1-855-449-2889 or your state department of insurance at Florida Department of Financial Services Division of Consumer Services 200 E. Gaines St. Tallahassee, FL 32399-0322 877-693-5236 www.myfloridacfo.com/Division/Consumers/NeedOurHelp.htm. Does this Coverage Provide Minimum Essential Coverage? SNO: 1202018 SBC Name: 017_72600 017_15971 017_4051 Page 5 of 8 Questions: Call 1-855-449-2889 or visit us at chcflorida.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 http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Espanol): Para obtener asistencia en Espanol, llame al 1-855-449-2889. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-449-2889. Chinese ĩᷕ㔯ĪĻơġ⤪㝄暨天ᷕ㔯䘬ⷖ≑炻実㊐ㇻ征᷒⎟䞩ġ1-855-449-2889. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-449-2889. ––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––– SNO: 1202018 SBC Name: 017_72600 017_15971 017_4051 Page 6 of 8 Questions: Call 1-855-449-2889 or visit us at chcflorida.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 http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. Having a baby About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much insurance protection you might get from different plans. This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Managing type 2 diabetes (normal delivery) Amount owed to providers: Plan pays: You pay: (routine maintenance of a well-controlled condition) $7,540 $4,930 $2,610 Sample care costs: Hospital charges (mother) $2,700 Routine Obstetric Care $2,100 Hospital Charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive Total $40 $7,540 You pay: Deductibles Co-pays $1,800 $10 Coinsurance $600 Limits or exclusions $200 Total $2,610 Amount owed to providers: Plan pays: $3,760 You pay: $1,640 $5,400 Sample care costs: Prescriptions Medical equipment and supplies Office Visits and Procedures Education Laboratory tests Vaccine, other preventive Total $2,900 $1,300 $700 $300 $100 $100 $5,400 You pay: Deductibles Co-pays Coinsurance Limits or exclusions Total $300 $1,300 $0 $40 $1,640 Note: These numbers assume the patient is participating in our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may be higher. For more information about the diabetes wellness program, please contact: 1-855-449-2889 SNO: 1202018 SBC Name: 017_72600 017_15971 017_4051 Page 7 of 8 Questions: Call 1-855-449-2889 or visit us at chcflorida.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 http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don’t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. The patient’s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium , the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance . You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. SNO: 1202018 SBC Name: 017_72600 017_15971 017_4051 Page 8 of 8 Questions: Call 1-855-449-2889 or visit us at chcflorida.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 http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
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