City Barbeque, Inc.: Plan A PPOPlanCoverage Period: 01/01/2015 – 12/31/2015
Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: Individual / Family|Plan Type: PPO
/ 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 ator by calling1-800-521-2654/614-863-8780.Important Questions / Answers / Why this Matters:
What is the overall deductible? / In-Network: $1,000Individual / $2,000Family
Out-of-Network: $2,000Individual /$4,000Family
Doesn’t apply to prenatal care if treatment begins during 1st trimester, in-network preventive care, second surgical opinion requested by BAC/preadmission testing, centers of excellence, optional benefits, hospice care, and CAP benefits. Copays are in addition to the deductible. / You must pay all the costs up to the deductibleamount before thisplanbegins to pay for covered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific services? / No. / You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers.
Is there an out–of–pocket limit on my expenses? / Yes. For in-networkmedical providers: Individual: $3,000 / Family: $6,000
There is a cap of $6,600/individual and
$13, 200/family for in-network benefits.
For out-of-network medical providers: Individual: $8,000 / Family: $16,000
There is no cap for out-of-network benefits. / The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. The out-of-pocket limit includes the overall deductible. This limit helps you plan for health care expenses.
What is not included in
the out–of–pocket limit? / Premiums, balance-billed charges, out-of-network provider charges in excess of Target Pricing,out-of-network Rx charges exceeding the covered coinsurance, out-of-network skilled nursing facility charges, obesity surgery charges, and health care this plan doesn’t cover. / Even though you pay these expenses, they don’t count toward the out-of-pocket limit. See the chart starting on page 3 for how much you may pay for covered services.
Is there an overall annual limit on what theplan pays? / Yes. $500 per covered person for chiropractic services. / This plan will pay for covered services only up to these limits during each coverage period, even if your own need is greater. You are responsible for all expenses above this limit. The chart starting on page 3 describes specific coverage limits, such as limits on the number of office visits.
Does this plan use a network of providers? / Yes. Refer to your I.D. card to identify the network logo. Please visit , click on LINKS and select the appropriate network logo that matches your I.D. card. See your plan document for more information on your in-network provider.You may also call 1-800-521-2654/614-863-8780if you have any questions. / If you use an in-network doctor or other health care provider, thisplan will pay some or all of the costs of covered services after any applicable deductible is met.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 participatingfor providersin their network. See the chart starting on page 3 for how this plan pays different kinds of providers.
Do I need a referral to see a specialist? / No. You don’t need a referral to see a specialist. / You can see the specialistyou choose without permission from this plan.Remember, benefits are greater if you choose an in-network specialist.
Are there services this plan doesn’t cover? / Yes. / Some of the services thisplan doesn’t cover are listed on page 6. See your policy or plan document for additional information about excluded services.
/
- Copaymentsare fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
- Coinsuranceis your share of the costs of a covered service, calculated as a percent of the allowed amountfor the service. For example, if the plan’s allowed amountfor an overnight hospital stay is $1,000, your coinsurancepayment 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-networkprovidercharges 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 amountis $1,000, you may have to pay the $500 difference. (This is called balance billing.)
- This plan may encourage you to use in-networkprovidersby charging you lower deductibles, copaymentsand coinsuranceamounts.
- Target Prices (also referred to as Target Price or Target in your plan document) are used as the maximum allowed amount for out-of-network providers. The Target Price fee schedule applies to provider billing codes (CPT’s, DRG’s, etc.) and will cover most charges made by providers. The Target fee schedule is 115% of the Medicare reimbursement rate, which means that the maximum allowed amount is set at 15% more under this plan than is paid for providing the same service to a Medicare patient. Any provider charge in excess of the Target Price will not be a covered ex-pense (allowed amount) under the terms of this plan and will be the responsibility of the covered person. Allowed amounts for covered services that do not have Medicare equivalent pricing will be a lower percentage which is described in the schedule of benefits in your plan document.
Common
Medical Event / Services You May Need / Your Cost If You Use anIn-network
Provider
(after applicable deductible) / Your Cost If You Use an Out-of-
network Provider
(after applicable deductible) / Limitations & Exceptions
If you visit a health care provider’s office or clinic / Primary care visit to treat an injury or illness
Specialist visit
Other practitioner office visit
Provider services other than time of office visit / $40 copay/office visit
$40 copay/office visit
$40 copay/office visit
20% coinsurance (includes chiropractic services) / 30% Target Prices / Chiropractic services are limited to $500per covered person per year. You are responsible for out-of-network charges over Target Pricing.
Preventive care/Screening/Immunization / No charge / 30% Target Prices / You are responsible for out-of-network charges over Target Pricing.
If you have a test / Diagnostic test (x-ray, blood work) / Imaging (CT/PET scans, MRIs) / 20% coinsurance / 30% Target Prices / You are responsible for out-of-network charges over Target Pricing.
If you need drugs to treat your illness or condition
More information about prescription drug coverageis availableby contacting the Rx vendor listed on your I.D. card, or referring to your plan document. / Generic drugs
Preferred brand drugs
Non-preferred brand drugs / $10 copay/prescription (retail)
$20 copay/prescription (mail order)
$35 copay/prescription (retail)
$70 copay/prescription (mail order)
$60 copay/prescription (retail)
$120 copay/prescription (mail order) / 60% coinsurance / Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription). Out-of-network Rx charges are not eligible for 100% increased coinsurance.If non-preferred or preferred brand drugs are purchased when generic equivalents are available, the copay will be the generic retail or mail order listed under the in-network column, plus the difference between the non-preferred or preferred brand and generic equivalent.
Specialty drugs / 20% coinsurance / 30% Target Prices / You are responsible for out-of-network charges over Target Pricing.
If you have outpatient surgery / Facility fee (e.g., ambulatory surgery center)
Physician/surgeon fees / 20% coinsurance / 30% Target Prices / Bariatric surgery is limited to 50% coinsurance in-network (not covered out-of-network) and is not eligible for 100% increased coinsurance. You are responsible for out-of-network charges over Target Pricing.
If you need immediate medical attention / Emergency room service
Urgent care / 20% coinsurance / Same as in-network / –––––––––––none–––––––––––
Emergency medical transportation / 20% coinsurance / 30% Target Prices / You are responsible for out-of-network charges over Target Pricing.
If you have a hospital stay / Facility fee (e.g., hospital room)
Physician/surgeon fees / 20% coinsurance / 30% Target Prices / Bariatric surgery is limited to 50% coinsurance in-network (not covered out-of-network) and is not eligible for 100% increased coinsurance. You are responsible for out-of-network charges over Target Pricing.
If you have mental health, behavioral health, or substance abuse needs / Mental/behavioral health outpatient services
Mental/behavioral health inpatient services / $40 copay/office visit and 20% coinsurance other outpatient services
20% coinsurance / 30% Target Prices / You are responsible for out-of-network charges over Target Pricing.
Substance use disorder outpatient services
Substance use disorder inpatient services / $40 copay/office visit and 20% coinsurance other outpatient services
20% coinsurance / 30% Target Prices / You are responsible for out-of-network charges over Target Pricing.
If you are pregnant / Prenatal and postnatal care
Delivery and all related inpatient services / 20% coinsurance / 30% Target Prices / When treatment is initiated during the 1st trimester, the deductible does not apply to prenatal care or routine newborn charges during the initial hospital con-finement. You are responsible for out-of-network charges over Target Pricing.
If you need help recovering or have other special health needs / Home health care / Rehabilitation service / Durable medical equipment / 20% coinsurance / 30% Target Prices / You are responsible for out-of-network charges over Target Pricing.
Habilitation service / Not covered / Not covered / Not Covered
Common
Medical Event / Services You May Need / Your Cost If You Use anIn-network
Provider
(after applicable deductible) / Your Cost If You Use an Out-of-
network Provider
(after applicable deductible) / Limitations & Exceptions
If you need help recovering or have other special health needs (continued) / Skilled nursing care / 20% coinsurance / 30% Target Prices / Limited to 120 days beginning no later than 14 days after the hospital confine-ment. The out-of-network benefit is not eligible for 100% increased coinsurance.You are responsible for out-of-network charges over Target Pricing.
Hospice service / No charge / 0% Target Prices / Terminal illness with death expectancy in 6 months or less. You are responsible for out-of-network charges over Target Pricing.
If your child needs dental or eye care / Eye exam / Not covered / Not covered / Not Covered
Glasses / Not covered / Not covered / Not Covered
Dental check-up / Not covered / Not covered / Not Covered
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for otherexcluded services.)- Acupuncture
- Cosmetic surgery
- Dental care (adult & child)
- Experimental treatments or procedures
- Habilitation services
- Hearing aids(unless the result of sickness or injury)
- Infertility treatment
- Long-term care
- Non-emergency care when traveling outside the U.S.
- Private-duty nursing
- Routine eye care (adult & child)
- Routine foot care
- Temporomandibular Joint Dysfunction Syndrome (TMJ) limited to $1,000 per covered person/lifetime
- Weight loss programs (unless plan provisions are met)
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.)
- Bariatric surgery (50% coinsurance in-network/not covered out-of-network). This benefit not eligible for 100% increased coinsurance.
- Chiropractic care limited to $500 per covered person/year
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 1-800-521-2654/614-863-8780. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or or the U.S. Department of Health and Human Services at 1-877-267-2323 x-61565 or
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 toappealor file agrievance. For questions about your rights, this notice, or assistance, you can contact: Business Administrators & Consultants, Inc. (BAC) at 6331 East Livingston Avenue, P.O. Box 107, Reynoldsburg, Ohio 43068, 1-800-521-2654/614-863-8780, or the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or
Does this Coverage Provide Minimum Essential Coverage?
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 coveragedoes meet the minimum value standard for the benefits it provides.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call1-800-521-2654/614-863-8780or visit us at.If you aren’t clear about any of
the underlined terms used in this form, see the Glossary. You can view the Glossary ator call
1-800-521-2654/614-863-8780 to request a copy.
City Barbeque, Inc.: Plan A PPO PlanCoverage Period: 01/01/2015 – 12/31/2015
Coverage ExamplesCoverage for: Individual / Family|Plan Type: PPO
Questions: Call1-800-521-2654/614-863-8780or visit us at.If you aren’t clear about any of
the underlined terms used in this form, see the Glossary. You can view the Glossary ator call
1-800-521-2654/614-863-8780 to request a copy.
City Barbeque, Inc.: Plan A PPO PlanCoverage Period: 01/01/2015 – 12/31/2015
Coverage ExamplesCoverage for: Individual / Family|Plan Type: PPO
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 financial protection a sample patient might get if they are covered under different plans.
Amount owed to providers: $7,540
Plan pays $6,040
Patient pays $1,500
Sample care costs:
Hospital charges (mother) / $2,700Routine obstetric care / $2,100
Hospital charges (baby) / $900
Anesthesia / $900
Laboratory tests / $500
Prescriptions / $200
Radiology / $200
Vaccines, other preventive / $40
Total / $7,540
Patient pays:(based on individual coverage)
Deductibles / $0Copays / $0
Coinsurance / $1,500
Limits or exclusions / $0
Total / $1,500
Amount owed to providers: $5,400
Plan pays $4,600
Patient pays $800
Sample care costs:
Prescriptions / $2,900Medical Equipment and Supplies / $1,300
Office Visits andProcedures / $700
Education / $300
Laboratory tests / $100
Vaccines, other preventive / $100
Total / $5,400
Patient pays:(based on individual coverage)
Deductibles / $100Copays / $700
Coinsurance / $0
Limits or exclusions / $0
Total / $800
Questions: Call1-800-521-2654/614-863-8780or visit us at.If you aren’t clear about any of
the underlined terms used in this form, see the Glossary. You can view the Glossary ator call
1-800-521-2654/614-863-8780 to request a copy.
City Barbeque, Inc.: Plan A PPO PlanCoverage Period: 01/01/2015 – 12/31/2015
Coverage ExamplesCoverage for: Individual / Family|Plan Type: PPO
Questions: Call1-800-521-2654/614-863-8780or visit us at.If you aren’t clear about any of
the underlined terms used in this form, see the Glossary. You can view the Glossary ator call
1-800-521-2654/614-863-8780 to request a copy.
City Barbeque, Inc.: Plan A PPO PlanCoverage Period: 01/01/2015 – 12/31/2015
Coverage ExamplesCoverage for: Individual / Family|Plan Type: PPO
Questions and answers about the Coverage Examples:
Questions: Call1-800-521-2654/614-863-8780or visit us at.If you aren’t clear about any of
the underlined terms used in this form, see the Glossary. You can view the Glossary ator call
1-800-521-2654/614-863-8780 to request a copy.
City Barbeque, Inc.: Plan A PPO PlanCoverage Period: 01/01/2015 – 12/31/2015
Coverage ExamplesCoverage for: Individual / Family|Plan Type: PPO
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.
- 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 in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.
What does a Coverage Example show?
For each treatment situation, the Coverage Example helps you see how deductibles,copayments, and coinsurancecan 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 receivefor thiscondition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.