* s, see the plan or policy do all 1-800-479-9502. ADV-SBC-OH001(2020 Rev.03/20)BHSA-Bronze Limited 2 of 8 OH-EXCM-1042bAll cop and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies CommonMedical Event Services Yo What You Will Pay Limitations, Exceptions, & Other Important Information* Indian Health Care Provider (IHCP) (You wil pay the least) Non-IHCP In- Network Provider (You will pay more) Non-IHCP Out-of-Network Provider (You will pay the most) If you visit a health care provider222s office or c Primary care visit to treat an injury or illness No charge 50% coinsurance after deductible Not covered Specia visit No charge 50% coinsurance after deductible Not covered Plan covers 100% of allowed amount in excess of the copayment. Copayment waived when the only injections/serum. If you receive services in addition to office visits, additional copayments, deductibles, or coinsurance may apply. Other practitioner office visitNo charge Not covered Nurse practitioner/retail clinic 50% coinsurance after deductible None Chiropractor 50% coinsurance after deductible Manipulation therapy-12 visits per benefit year Preventive care/screening / immunization No charge No charge Not covered You may have to pay for services that aren222t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay f If you have a test Diagnostic test(xblood work) No charge X-ray: 50%coinsurance after deductibleLab: 50%coinsurance after deductible Not covered May require prior authorization May require prior authorization Imaging (CT/PET scans, MRIs) No charge 50% coinsurance after deductible Not covered Prior authorization required * s, see the plan or policy do all 1-800-479-9502. ADV-SBC-OH001(2020 Rev.03/20)BHSA-Bronze Limited 3 of 8 OH-EXCM-1042bCommonMedical Event Services Yo What You Will Pay Limitations, Exceptions, & Other Important Information* Indian Health Care Provider (IHCP) (You wil pay the least) Non-IHCP In- Network Provider (You will pay more) Non-IHCP Out-of-Network Provider (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.caresou marketplace. Preventive drugs Retail: No charge Mail-Order: No charge Not covered Retail: Up to a 30-day supplyMail-Order: UPreventive, Low Cost, and Brand drugs/Up to a 30-day supply for Specialty drugs Certain drugs may require a prior authorization. Low cost drugs No charge Retail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductible Not covered Preferred brand drugs Retail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductible Not covered Non-preferred brand drugs No charge Retail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductible Not covered Specialty drugs preferred No charge Retail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductible Not coveredSpecialty drugs non-preferred No chargeRetail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductibleNot covered * s, see the plan or policy do all 1-800-479-9502. ADV-SBC-OH001(2020 Rev.03/20)BHSA-Bronze Limited 4 of 8 OH-EXCM-1042bCommonMedical Event Services Yo What You Will Pay Limitations, Exceptions, & Other Important Information* Indian Health Care Provider (IHCP) (You wil pay the least) Non-IHCP In- Network Provider (You will pay more) Non-IHCP Out-of-Network Provider (You will pay the most) If you have outpatient s Facility fee (e.g., ambulatory surgery center) No charge 50% coinsurance after deductible Not covered PhysicNo charge 50% coinsurance after deductible Not covered May require prior authorization If you need immediate medical attention Emergency room careNo charge 50% coinsurance after deductible 50% coinsurance after deductibleC hDepa Emergency medical transportationNo charge 50% coinsurance after deductible50% coinsurance after deductiblePrior authorization is not required for emergency ambulance transportation or for facility to facility transfers. All other ambulance transportation requires prior authorization. Urgent care No charge 50% coinsurance after deductible 50% coinsurance after deductible If you receive services in addition to urgent care, additional copayment coinsurance may apply. If you have a hospital stay Facility fee (e.g., hospital room) No charge 50% coinsurance after deductible Not covered Prior authorization required Physic50% coinsurance after deductible Not covered If you need mental health, behavioral health, or substance abuse services Outpatient services No charge 50% coinsurance after deductible for office visits and 50% coinsurance after deductible for other outpatient services Not covered Prior authorization is requir stays and residential treatment programs. Partial hospitalization programs and intensive outpatient services may require prior authorization. Inpatient services 50% coinsurance after deductible Not covered * s, see the plan or policy do all 1-800-479-9502. ADV-SBC-OH001(2020 Rev.03/20)BHSA-Bronze Limited 5 of 8 OH-EXCM-1042bCommonMedical Event Services Yo What You Will Pay Limitations, Exceptions, & Other Important Information* Indian Health Care Provider (IHCP) (You wil pay the least) Non-IHCP In- Network Provider (You will pay more) Non-IHCP Out-of-Network Provider (You will pay the most) If you are pregnant Office visits No charge 50% coinsurance after deductible Not covered Copayment covers initial physician visit and all subsequent prenatal visits, postnatal visit and physic the Global Maternity Fee. A copayments, deductibles, or coinsurance may apply depending on services rendered in addition to the Global Maternity Fee. Depending on the type of services, a copayment, coi a services desc ultrasound.) Childbirth/delivery professional s No charge 50% coinsurance after deductible Not covered Childbirth/delivery facility services No charge 50% coinsurance after deductible Not covered Your cost for inpatient services only. See above for physician deliver If you need help recovering or have other special health needs Home health careNo charge 50% coinsurance after deductible Not covered Prior authorization required 100 combined visits per benefit year. A visit e quals at leas Autism Physical therapy No charge 50% coinsurance after deductible Not covered 20 visits per benefit year Occupational therapy 50% coinsurance after deductible20 visits per benefit yearSpeech therapy 50% coinsurance after deductible20 visits per benefit yearBehavioral therapy 50% coinsurance after deductibleNoneRehabNo charge Not coveredPhysical therapy 50% coinsurance after deductible 20 visits per benefit year Occupational therapy 50% coinsurance after deductible 20 visits per benefit year Speech therapy 50% coinsurance after deductible 20 visits per benefit year *an or policy do cument at www.caresource.com/marketplall 1-800-479-9502. ADV-SBC-OH001(2020 Rev.03/20)BHSA-Bronze Limited 6 of 8 OH-EXCM-1042bCommonMedical Event Services Yo What You Will Pay Limitations, Exceptions, & Other Important Information* Indian Health Care Provider (IHCP) (You wil pay the least) Non-IHCP In- Network Provider (You will pay more) Non-IHCP Out-of-Network Provider (You will pay the most) Cardiac reh No charge 50% coinsurance after deductible Not covered 36 visits per benefit year Pulmonary rehabilitation 50% coinsurance after deductible 20 visits per benefit year Chiropractic services 50% coinsurance after deductible Manipulation therapy-12 visits per benefit year Habilitation sNo charge Not covered Physical therapy 50% coinsurance after deductible20 visits per benefit yearOccupational therapy 50% coinsurance after deductible20 visits per benefit yearSpeech therapy 50% coinsurance after deductible20 visits per benefit yearSkilled nursing care No charge 50% coinsurance after deductible Not covered Prior authorization required 90 day limit per benefit year Private duty nursing No charge 50% coinsurance after deductible Not covered Prior authorization required 100 vi hours. Durable medical equipmentNo charge 50% coinsurance after deductible Not coveredHospice servicesNo charge 50% coinsurance after deductible Not covered Prior authorization is requir respite, or continuous care levels of care.If your child needs dental or eye care Children222s ey50% coinsurance after deductible Not covered Low vision testing and aidsNo charge No charge Not covered Limited to one evaluation and aid per benefit year. Children222s ey50% coinsurance after deductible Not covered Limited to one pair of glasses or contact lenses once per benefit year. If medically necessary, a replacement pair of glasses is allowed. Children222s dental check-up No charge 50% coinsurance after deductible Not covered 2 dental chec * s, see the plan or policy do all 1-800-479-9502. ADV-SBC-OH001(2020 Rev.03/20)BHSA-Bronze Limited 7 of 8 OH-EXCM-1042bExcluded Services & Other Covered Services: Services Yo Plan Generally Does NOT Cover (Check your po plan dtion and a list of any other excluded services.) Abortion (Except in cases of rape, incest, or when the life of the mother is endangered) Cosmetic surgeryDental care (Adult) Non-emergency care when tra veling outside the U.S.Routine eye c Acupuncture Hearing aids Routine foot care Bariatric surgery Long term care Weight loss programs Chiropractic care Infertility treatment Private duty nursing Your Rights to Continue Coverage: T here are agencies that can help if you wa nt to continue your coverage after it ends. The contact information for those agencies is: 1-800-686-1526. Other co verage 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 App eals 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 ex planation of benefits you will receivclaim . Your plan documents also provide complete information to submit a claim, appeal, grievance for any reason to your plan. For more information about your ri ghts, this notice, or assistance, contact the Ohio Department of Insurance: 1-800-686-1526. Does this plan provide Minimum Essential Coverage? YesIf you don222t have Minimum Essential Cov for a month, you222ll ha ment when you file your tax return unless you qualif requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn222t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Languag eSpanis ia en Espa361ol, llame al 1-800-479-9502. Tagalog (Tagalog): Kung kailangan niny long sa Tagalog tumawag sa 1-800-479-9502. Chines ): 1-800-479-9502. Navajo (Dine): Dinek’ehgo shika at’ohwol ninisholne’ 1-226226226226226226226226226226226226226226226226226226226226226226 To see examples of how this plan might cover costs for a sample medical situation, see the next section. 226226226226226226226226226226226 Other Covered Services (Limitations may apply to these services. This isn222t a complete list. Please see your plan document.) The plan wou ADV-SBC-OH001(2020 Rev.03/20) BHSA-Bronze Limited8 of 8 OH-EXCM-1042bPeg is Having a Baby(9 months of in-network prenatal care and a hospital delivery) Mia222s Simp(in-network emergency room visit and follow up care) Managing Joe222s type 2 Diab(a year of routine in-network of a well-controlled condition)The plan222s overall deductible $5,300 Specialist coinsurance 50% Hospital (facility) coinsurance 50% Other coinsurance 50% This EXAMPLE event incl udes services like: Specialist office visits ( prenatal care) Childbirth/Delivery Professional Servic esChildbirth/Delivery Facility SDiagnostic tests ( ultrasounds and blood work) Specia (anesthesia) Total Example Cost $12,840 In this example, Peg would pay: Cost Sharing Deductibles $1,720 Copayments $0 Coinsuranc$5,030 What isnt covered Limits or exclusions $60 The total Peg would pay is $6,810 The plan222s overall deductible $5,300 Specialist coinsurance 50% Hospital (facility) coinsurance 50% Other coinsurance 50% This EXAMPLE event incl udes services like: Primary care physician office visits ( including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)Total Example Cost $7,460 In this example, Joe would pay: Cost Sharing Deductibles $3,350 Copayments $0 Coinsuranc$3,400 What isnt covered Limits or exclusions $55 The total Joe would pay is $6,805 The plan222s overall deductible $5,300 Specialist coinsurance 50% Hospital (facility) coinsurance 50% Other coinsurance 50% This EXAMPLE event incl udes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehab (physical therapy)Total Example Cost $2,010 In this example, Mia would pay: Cost Sharing Deductibles $963 Copayments $0 Coinsuranc$963 What isnt covered Limits or exclusions $0 The total Mia$1,926 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 underplan. Use this informati costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 12/31/2020 CareSource Marketplace HSA Eligible Bronze Coverage for: Individual + Family | Plan Type: HMO 1 of 8 ADV-SBC-OH001(2020)BHSA-Bronze OH-EXCM-1039 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, contact www.caresource.com/marketplace or call 1-800-479-9502. 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.caresource.com/marketplace or call 1-800-479-9502 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $5,300 individual/$10,600 family per benefit 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. Are there services covered before you meet your deductible? Yes. Preventive care. This plan covers some items and services even if you havent yet met the deductible amount. But a copayment or coinsurance may apply. Are there other deductibles for specific services? No You dont have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $6,750 individual/ $13,500 family 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. What is not included in the out-of-pocket limit? Premiums, balance-billing charges and health care this plan doesnt cover. Even though you pay these expenses, they dont count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See www.caresource.com/marketplace or call 1-800-479-9502 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plans 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 providers 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. Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. 2 of 8 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BHSA-Bronze OH-EXCM-1039 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care providers office or clinic Primary care visit to treat an injury or illness 50% coinsurance after deductible Not covered None Specialist visit 50% coinsurance after deductible Not covered Plan covers 100% of allowed amount in excess of the copayment. Copayment waived when the only charge is for allergy injections/serum. If you receive services in addition to office visits, additional copayments, deductibles, or coinsurance may apply. Other practitioner office visit Not covered Nurse practitioner/retail clinic 50% coinsurance after deductible None Chiropractor 50% coinsurance after deductible Manipulation therapy-12 visits per benefit year Preventive care/screening/ immunization No charge Not covered You may have to pay for services that arent preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) X-ray: 50% coinsurance after deductible Lab: 50% coinsurance after deductible Not covered May require prior authorization May require prior authorization Imaging (CT/PET scans, MRIs) 50% coinsurance after deductible Not covered Prior authorization required If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.caresouce.com/ marketplace. Preventive drugs Retail: No charge Mail-Order: No charge Not covered Retail: Up to a 30-day supply Mail-Order: Up to a 90-day supply for Preventive, Low Cost, and Brand drugs/Up to a 30-day supply for Specialty drugs Certain drugs may require a prior authorization. Low cost drugs Retail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductible Not covered 3 of 8 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BHSA-Bronze OH-EXCM-1039 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Preferred brand drugs Retail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductible Not covered Retail: Up to a 30-day supply Mail-Order: Up to a 90-day supply for Preventive, Low Cost, and Brand drugs/Up to a 30-day supply for Specialty drugs Certain drugs may require a prior authorization. Non-preferred brand drugs Retail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductible Not covered Specialty drugs preferred Retail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductible Not covered Specialty drugs non-preferred Retail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductible Not covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 50% coinsurance after deductible Not covered May require prior authorization Physician/surgeon fees 50% coinsurance after deductible Not covered May require prior authorization If you need immediate medical attention Emergency room care 50% coinsurance after deductible 50% coinsurance after deductible Copayment waived if you are admitted to the hospital directly from the Emergency Department. Emergency medical transportation 50% coinsurance after deductible 50% coinsurance after deductible Prior authorization is not required for emergency ambulance transportation or for facility to facility transfers. All other ambulance transportation requires prior authorization. Urgent care 50% coinsurance after deductible 50% coinsurance after deductible If you receive services in addition to urgent care, additional copayments, deductibles, or coinsurance may apply. 4 of 8 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BHSA-Bronze OH-EXCM-1039 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you have a hospital stay Facility fee (e.g., hospital room) 50% coinsurance after deductible Not covered Prior authorization required Physician/surgeon fees 50% coinsurance after deductible Not covered Prior authorization required If you need mental health, behavioral health, or substance abuse services Outpatient services 50% coinsurance after deductible for office visits and 50% coinsurance after deductible for other outpatient services Not covered Prior authorization is required for all inpatient stays and residential treatment programs. Partial hospitalization programs and intensive outpatient services may require prior authorization. Inpatient services 50% coinsurance after deductible Not covered If you are pregnant Office visits 50% coinsurance after deductible Not covered Copayment covers initial physician visit and all subsequent prenatal visits, postnatal visits, and physician delivery charges covered under the Global Maternity Fee. Additional copayments, deductibles, or coinsurance may apply depending on services rendered in addition to the Global Maternity Fee. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Childbirth/delivery professional services 50% coinsurance after deductible Not covered Childbirth/delivery facility services 50% coinsurance after deductible Not covered Your cost for inpatient services only. See above for physician delivery charges. 5 of 8 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BHSA-Bronze OH-EXCM-1039 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care 50% coinsurance after deductible Not covered Prior authorization required 100 combined visits per benefit year. A visit equals at least 4 hours. Autism Physical therapy 50% coinsurance after deductible Not covered 20 visits per benefit year Occupational therapy 50% coinsurance after deductible 20 visits per benefit year Speech therapy 50% coinsurance after deductible 20 visits per benefit year Behavioral therapy 50% coinsurance after deductible None Rehabilitation services Not covered Physical therapy 50% coinsurance after deductible 20 visits per benefit year Occupational therapy 50% coinsurance after deductible 20 visits per benefit year Speech therapy 50% coinsurance after deductible 20 visits per benefit year Cardiac rehabilitation 50% coinsurance after deductible 36 visits per benefit year Pulmonary rehabilitation 50% coinsurance after deductible 20 visits per benefit year Chiropractic services 50% coinsurance after deductible Manipulation therapy-12 visits per benefit year Habilitation services Not covered Physical therapy 50% coinsurance after deductible 20 visits per benefit year Occupational therapy 50% coinsurance after deductible 20 visits per benefit year Speech therapy 50% coinsurance after deductible 20 visits per benefit year Skilled nursing care 50% coinsurance after deductible Not covered Prior authorization required 90 day limit per benefit year 6 of 8 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BHSA-Bronze OH-EXCM-1039 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Private duty nursing 50% coinsurance after deductible Not covered Prior authorization required 100 visits per benefit year. A visit equals 8 hours. Durable medical equipment 50% coinsurance after deductible Not covered May require prior authorization Hospice services 50% coinsurance after deductible Not covered Prior authorization is required for inpatient, respite, or continuous care levels of care. If your child needs dental or eye care Childrens eye exam 50% coinsurance after deductible Not covered 1 routine eye exam per benefit year Low vision testing and aids No charge Not covered Limited to one evaluation and aid per benefit year. Childrens eyewear 50% coinsurance after deductible Not covered Limited to one pair of glasses or contact lenses once per benefit year. If medically necessary, a replacement pair of glasses is allowed. Childrens dental check-up 50% coinsurance after deductible Not covered 2 dental check-ups per benefit year 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.) Abortion (Except in cases of rape, incest, or when the life of the mother is endangered) Cosmetic surgery Dental care (Adult) Non-emergency care when traveling outside the U.S. Routine eye care (Adult) Acupuncture Hearing aids Routine foot care Bariatric surgery Long term care Weight loss programs Chiropractic care Infertility treatment Private duty nursing Other Covered Services (Limitations may apply to these services. This isnt a complete list. Please see your plan document.) 7 of 8 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BHSA-Bronze OH-EXCM-1039 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: 1-800-686-1526. 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, this notice, or assistance, contact the Ohio Department of Insurance: 1-800-686-1526. Does this plan provide Minimum Essential Coverage? Yes If you dont have Minimum Essential Coverage for a month, youll 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 the Minimum Value Standards? Yes If your plan doesnt 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 (Espaol): Para obtener asistencia en Espaol, llame al 1-800-479-9502. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-479-9502. Chinese (): 1-800-479-9502. Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-479-9502. To see examples of how this plan might cover costs for a sample medical situation, see the next section. 8 of 8 The plan would be responsible for the other costs of these EXAMPLE covered services. ADV-SBC-OH001(2020)BHSA-Bronze OH-EXCM-1039 Peg is Having a Baby (9 months of in-network prenatal care and a hospital delivery) Mias Simple Fracture (in-network emergency room visit and follow up care) Managing Joes type 2 Diabetes (a year of routine in-network care of a well-controlled condition) The plans overall deductible $5,300 Specialist coinsurance 50% Hospital (facility) coinsurance 50% Other coinsurance 50% 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 $12,840 In this example, Peg would pay: Cost Sharing Deductibles $1,720 Copayments $0 Coinsurance $5,030 What isnt covered Limits or exclusions $60 The total Peg would pay is $6,810 The plans overall deductible $5,300 Specialist coinsurance 50% Hospital (facility) coinsurance 50% Other coinsurance 50% 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) Total Example Cost $7,460 In this example, Joe would pay: Cost Sharing Deductibles $3,350 Copayments $0 Coinsurance $3,400 What isnt covered Limits or exclusions $55 The total Joe would pay is $6,805 The plans overall deductible $5,300 Specialist coinsurance 50% Hospital (facility) coinsurance 50% Other coinsurance 50% 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 $2,010 In this example, Mia would pay: Cost Sharing Deductibles $963 Copayments $0 Coinsurance $963 What isnt covered Limits or exclusions $0 The total Mia would pay is $1,926 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.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 12/31/2020 CareSource Marketplace Low Deductible Silver 3 Coverage for: Individual + Family | Plan Type: HMO 1 of 7ADV-SBC-OH001(2020)BLD-Silver 3 OH-EXCM-0977 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, contact www.caresource.com/marketplace or call 1-800-479-9502. 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.caresource.com/marketplace or call 1-800-479-9502 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $350 individual/$700 family per benefit 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. Are there services covered before you meet your deductible? Yes. Preventive care. This plan covers some items and services even if you havent yet met the deductible amount. But a copayment or coinsurance may apply. Are there other deductibles for specific services? No You dont have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $700 individual/ $1,400 family 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. What is not included in the out-of-pocket limit? Premiums, balance-billing charges and health care this plan doesnt cover. Even though you pay these expenses, they dont count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See www.caresource.com/marketplace or call 1-800-479-9502 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plans 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 providers 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. Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. 2 of 7 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BLD-Silver 3 OH-EXCM-0977 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care providers office or clinic Primary care visit to treat an injury or illness No charge Not covered None Specialist visit $15 copay Not covered Plan covers 100% of allowed amount in excess of the copayment. Copayment waived when the only charge is for allergy injections/serum. If you receive services in addition to office visits, additional copayments, deductibles, or coinsurance may apply. Other practitioner office visit Not covered Nurse practitioner/retail clinic No charge None Chiropractor 5% coinsurance after deductible Manipulation therapy-12 visits per benefit year Preventive care/screening/ immunization No charge Not covered You may have to pay for services that arent preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) X-ray: $50 copay after deductible Lab: 5% coinsurance after deductible Not covered May require prior authorization May require prior authorization Imaging (CT/PET scans, MRIs) $100 copay after deductible Not covered Prior authorization required If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.caresouce.com/ marketplace. Preventive drugs Retail: No charge Mail-Order: No charge Not covered Retail: Up to a 30-day supply Mail-Order: Up to a 90-day supply for Preventive, Low Cost, and Brand drugs/Up to a 30-day supply for Specialty drugs Certain drugs may require a prior authorization. Low cost drugs Retail: No charge Mail-Order: No charge Not covered Preferred brand drugs Retail: $10 copay Mail-Order: $25 copay Not covered 3 of 7 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BLD-Silver 3 OH-EXCM-0977 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Non-preferred brand drugs Retail: 5% coinsurance after deductible Mail-Order: 5% coinsurance after deductible Not covered Retail: Up to a 30-day supply Mail-Order: Up to a 90-day supply for Preventive, Low Cost, and Brand drugs/Up to a 30-day supply for Specialty drugs Certain drugs may require a prior authorization. Specialty drugs preferred Retail: 5% coinsurance after deductible Mail-Order: 5% coinsurance after deductible Not covered Specialty drugs non-preferred Retail: 50% coinsurance after deductible Mail-Order: 50% coinsurance after deductible Not covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 5% coinsurance after deductible Not covered May require prior authorization Physician/surgeon fees 5% coinsurance after deductible Not covered May require prior authorization If you need immediate medical attention Emergency room care $150 copay after deductible $150 copay after deductible Copayment waived if you are admitted to the hospital directly from the Emergency Department. Emergency medical transportation 5% coinsurance after deductible 5% coinsurance after deductible Prior authorization is not required for emergency ambulance transportation or for facility to facility transfers. All other ambulance transportation requires prior authorization. Urgent care $25 copay $25 copay If you receive services in addition to urgent care, additional copayments, deductibles, or coinsurance may apply. If you have a hospital stay Facility fee (e.g., hospital room) $150 copay after deductible Not covered Prior authorization required Physician/surgeon fees $150 copay after deductible Not covered Prior authorization required 4 of 7 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BLD-Silver 3 OH-EXCM-0977 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need mental health, behavioral health, or substance abuse services Outpatient services No charge for office visits and 5% coinsurance after deductible for other outpatient services Not covered Prior authorization is required for all inpatient stays and residential treatment programs. Partial hospitalization programs and intensive outpatient services may require prior authorization. Inpatient services $150 copay after deductible Not covered If you are pregnant Office visits $15 copay Not covered Copayment covers initial physician visit and all subsequent prenatal visits, postnatal visits, and physician delivery charges covered under the Global Maternity Fee. Additional copayments, deductibles, or coinsurance may apply depending on services rendered in addition to the Global Maternity Fee. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Childbirth/delivery professional services $150 copay after deductible Not covered Childbirth/delivery facility services $150 copay after deductible Not covered Your cost for inpatient services only. See above for physician delivery charges. If you need help recovering or have other special health needs Home health care 5% coinsurance after deductible Not covered Prior authorization required 100 combined visits per benefit year. A visit equals at least 4 hours. Autism Physical therapy No charge Not covered 20 visits per benefit year Occupational therapy No charge 20 visits per benefit year Speech therapy 5% coinsurance after deductible 20 visits per benefit year Behavioral therapy No charge None 5 of 7 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BLD-Silver 3 OH-EXCM-0977 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Rehabilitation services Not covered Physical therapy No charge 20 visits per benefit year Occupational therapy No charge 20 visits per benefit year Speech therapy 5% coinsurance after deductible 20 visits per benefit year Cardiac rehabilitation 5% coinsurance after deductible 36 visits per benefit year Pulmonary rehabilitation 5% coinsurance after deductible 20 visits per benefit year Chiropractic services 5% coinsurance after deductible Manipulation therapy-12 visits per benefit year Habilitation services Not covered Physical therapy No charge 20 visits per benefit year Occupational therapy No charge 20 visits per benefit year Speech therapy 5% coinsurance after deductible 20 visits per benefit year Skilled nursing care $150 copay after deductible Not covered Prior authorization required 90 day limit per benefit year Private duty nursing 5% coinsurance after deductible Not covered Prior authorization required 100 visits per benefit year. A visit equals 8 hours. Durable medical equipment 5% coinsurance after deductible Not covered May require prior authorization Hospice services 5% coinsurance after deductible Not covered Prior authorization is required for inpatient, respite, or continuous care levels of care. If your child needs dental or eye care Childrens eye exam No charge Not covered 1 routine eye exam per benefit year Low vision testing and aids No charge Not covered Limited to one evaluation and aid per benefit year. Childrens eyewear No charge Not covered Limited to one pair of glasses or contact lenses once per benefit year. If medically necessary, a replacement pair of glasses is allowed. Childrens dental check-up $5 copay Not covered 2 dental check-ups per benefit year 6 of 7 * For more information about limitations and exceptions, see the plan or policy document at www.caresource.com/marketplace or call 1-800-479-9502. ADV-SBC-OH001(2020)BLD-Silver 3 OH-EXCM-0977 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.) Abortion (Except in cases of rape, incest, or when the life of the mother is endangered) Cosmetic surgery Dental care (Adult) Non-emergency care when traveling outside the U.S. Routine eye care (Adult) Acupuncture Hearing aids Routine foot care Bariatric surgery Long term care Weight loss programs Chiropractic care Infertility treatment Private duty nursing 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: 1-800-686-1526. 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, this notice, or assistance, contact the Ohio Department of Insurance: 1-800-686-1526. Does this plan provide Minimum Essential Coverage? Yes If you dont have Minimum Essential Coverage for a month, youll 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 the Minimum Value Standards? Yes If your plan doesnt 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 (Espaol): Para obtener asistencia en Espaol, llame al 1-800-479-9502. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-479-9502. Chinese (): 1-800-479-9502. Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-479-9502. To see examples of how this plan might cover costs for a sample medical situation, see the next section. Other Covered Services (Limitations may apply to these services. This isnt a complete list. Please see your plan document.) 7 of 7 The plan would be responsible for the other costs of these EXAMPLE covered services. ADV-SBC-OH001(2020)BLD-Silver 3 OH-EXCM-0977 Peg is Having a Baby(9 months of in-network prenatal care and a hospital delivery) Mias Simple Fracture(in-network emergency room visit and follow up care) Managing Joes type 2 Diabetes(a year of routine in-network care of a well-controlled condition) The plans overall deductible $350 Specialist copayment $15 Hospital (facility) copayment $150 Other coinsurance 5% 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 $12,840 In this example, Peg would pay: Cost Sharing Deductibles $350 Copayments $186 Coinsurance $164 What isnt covered Limits or exclusions $60 The total Peg would pay is $760 The plans overall deductible $350 Specialist copayment $15 Hospital (facility) copayment $150 Other coinsurance 5% 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) Total Example Cost $7,460 In this example, Joe would pay: Cost Sharing Deductibles $350 Copayments $160 Coinsurance $93 What isnt covered Limits or exclusions $55 The total Joe would pay is $658 The plans overall deductible $350 Specialist copayment $15 Hospital (facility) copayment $150 Other coinsurance 5% 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 $2,010 In this example, Mia would pay: Cost Sharing Deductibles $350 Copayments $145 Coinsurance $69 What isnt covered Limits or exclusions $0 The total Mia would pay is $564 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.ARABIC . .CareSource . . .AMHARIC CareSource 1-800-479-9502 TTY:711 BURMESE CareSource GUJARATI . CareSource . . . . 1-800-479-9502 TTY:711 .HINDI CareSource , 1-800-479-9502 TTY:711. ITALIAN Questa comunicazione contiene informazioni importanti. Questa comunicazione contiene informazioni importanti circa la sua iscrizione o copertura tramite CareSource. Cerchi le date principali in questa comunicazione. Potrebbe dover intraprendere delle azioni entro certe scadenze per mantenere la Sua copertura sanitaria o per contribuire ai costi. Ha il diritto di avere queste informazioni e supporto nella Sua lingua, senza alcun costo. Chiami il 1-800-479-9502 TTY:711. JAPANESE M3T*/&aoI’a 6QbJtCareSource M3T*/&aM8t!gu7KI]2CU1-800-479-9502 TTY:711 KOREAN . CareSource . . . . : 1-800-479-9502 TTY:711. PENNSYLVANIA DUTCH Die Bekanntmaching gebt wichdichi Auskunft. Die Bekanntmaching gebt wichdichi Auskunft baut dei Application oder Coverage mit CareSource. Geb Acht fer wichdiche Daadem in die Bekanntmachung. Es iss meeglich, ass du ebbes duh muscht, an beschtimmde Deadlines, so ass du dei Health Coverage bhalde kannscht, odder bezaahle helfe kannscht. Du hoscht es Recht fer die Information un Hilf in deinre eegne Schprooch griege, un die Hilf koschtet nix. 1-800-479-9502 TTY:711. RUSSIAN -, , CareSource, . , 1-800-479-9502 TTY:711. SPANISH Este aviso incluye informacin importante. Este aviso incluye informacin importante sobre su solicitud o su cobertura de CareSource. Busque las fechas clave en este aviso. Es probable que deba realizar acciones dentro de determinado plazo para mantener su cobertura mdica o recibir ayuda con los costos. Tiene derecho a recibir esta informacin y ayuda en su propio idioma sin costo. Llame al 1-800-479-9502 TTY:711. UKRAINIAN . CareSource. . , . . 1-800-479-9502 TTY:711. VIETNAMESE Thng bo ny c thng tin quan trng. Thng bo ny c thng tin quan trng v n xin hoc bo him ca bn thng qua CareSource. Hy xem nhng ngy quan trng trong thng bo ny.Bn c th cn phi hnh ng trc mt s thi hn nht nh duy tr bo him sc khe ca mnh hay c tr gip c tr ph. Bn c quyn c nhn thng tin ny v c tr gip bng ngn ng ca mnh min ph. Vui lng gi s 1-800-479-9502 TTY:711.This Notice has Important Information. This notice has important information about your application or coverage through CareSource. Look for key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 1-800-479-9502 TTY:711.1-800-479-9502 TTY:711. OH-EXCM-0461 2016 CareSource. All Rights Reserved MPNon-DDTagline(OH2018)-04613.0)/v4%#0@ 1-800-479-9502 TTY:711 30 -#02.030/# @ %'z )E %'#@CHINESE =bJt%&d"p2 =bJt%&$!37IG^!t&Y &