Humana Benefit Guide

Transcription

Pflugerville ISD Employee Handbook 2016
Pflugerville ISD
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Humana values our relationship with you, and we take your personal privacy seriously. Humana’s Notice
of Privacy Practices outlines how Humana may use or disclose your personal and health information. It
also tells how we protect this information. The notice provides an explanation of your rights concerning
your information, including how you can access this information and how to limit access to your
information. In addition, it provides instructions on how to file a privacy complaint with Humana or to
exercise any of your rights regarding your information.
If you’d like a copy of Humana’s Notice of Privacy Practices, you can request a copy by:
•
•
•
Visiting Humana.com and clicking the Privacy Practices link at the bottom of the home page
E-mailing us at [email protected]
Sending a written request to:
Humana Privacy Office
P.O. Box 1438
Louisville, KY 40202
PISD Monthly Rate Summary
Effective January 1, 2016
EE Only
EE + Spouse / Qualifying Individual
EE + Child(ren)
EE + Family
EE Only
EE + Child(ren)
EE + Family
EE Only
EE + Child(ren)
EE + Family
EE Only
EE + Child(ren)
EE + Family
iNGAGED Medical LOW Plan
Premium
PISD Contribution
$415
$375
$742
$375
$688
$375
$1,060
$375
Employee Contribution
$40
$367
$313
$685
Non-Engaged Medical LOW Plan
Premium
PISD Contribution
$465
$375
$842
$375
$788
$375
$1,160
$375
$90
$467
$413
$785
iNGAGED Medical MID Plan
Premium
PISD Contribution
$500
$375
$952
$375
$879
$375
$1,324
$375
$125
$577
$504
$949
iNGAGED Medical HIGH Plan
Premium
PISD Contribution
$596
$375
$1,169
$375
$1,078
$375
$1,597
$375
$221
$794
$703
$1,222
Pflugerville ISD
Humana Medical Plan Options for January 1, 2016
Medical Benefits
Low Plan (In-Network) *
Deductible
Individual
Family
Co-Insurance
Medical Out of Pocket Maximum
Individual
Family
Preventive Care
Annual Physical
Routine Mammogram
Routine Colonoscopy
Routine Lab & X-ray
Vision Exam (1 every 12
months)
Office Visit
Primary & Specialist
Urgent Care
Hospital
Inpatient Services
Outpatient Surgery
Emergency - Facility
(true emergency)
Emergency - Physician
Lab / X-Ray
(1)
Billed By Doctors Office
(1)
Billed By Outside Facility
Physical Therapy / Occupational Therapy
/ Chiropractic Services
(Visit Limits Apply)
Mid Plan (In-Network) *
High Plan (In-Network) *
iNGAGED
Non-Engaged
iNGAGED
iNGAGED
$2,150
$4,300
70%
$3,000
$6,000
70%
$1,400
$2,800
80%
$650
$1,300
90%
$6,350
$12,700
$6,350
$12,700
$4,400
$8,800
$2,150
$4,300
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
$30 copay
$45 copay
$30 copay
$30 copay
$30 / $30 copay
$40 copay
$30 / $45 copay
$45 copay
$30 / $30 copay
$40 copay
$30 / $30 copay
$40 copay
70% after deductible
$150 copay
$150 copay
$150 copay
$150 copay
Included in office copay
100% no deductible
100% no deductible
100% no deductible
100% no deductible
$30 copay
$45 copay
$30 copay
$30 copay
Prescriptions
Retail (30 days)
Mail Order (90 days)
Prescription Out of Pocket Maximum
Total Out of Pocket Maximum
(Medical and Prescriptions)
$10 / $40 / $60
$15 / $55 / $75
$10 / $40 / $60
$10 / $30 / $50
$25 / $100 / $150
$37.50 / $137.50 / $187.50
$25 / $100 / $150
$25 / $75 / $125
$5,000 Ind / $10,000 Fam
$5,000 Ind / $10,000 Fam
$5,000 Ind / $10,000 Fam
$5,000 Ind / $10,000 Fam
$6,350 Ind / $12,700 Fam
$6,350 Ind / $12,700 Fam
$6,350 Ind / $12,700 Fam
$6,350 Ind / $12,700 Fam
*See your Humana Summary of Benefits for Out of Network benefit levels
Provider Search: Log on to www.humana.com to find a provider. You will select the NPOS - Open Access network.
(1) Certain Diagnostic Procedures: Bone Scan, Cardiac Stress Test, CT Scan (with or without contrast), Ultrasound, MRI, Myelogram & PET Scan are subject to deductible and coinsurance.
If a procedure is in question, please contact Customer Service at 1-800-4HUMANA (1-800-448-6262) with the diagnosis and procedure code.
This summary is intended only to highlight your benefits and should not be relied upon to fully determine coverage. Please refer to your Summary of Benefits and Summary Plan Description for a complete listing of
services, limitations and exclusions. If there is a conflict in the benefits the Summary Plan Description will prevail.
INGAGED LOW PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2016-12/31/2016
Coverage for: Single & Family | Plan Type: NPOS
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 by calling 1-512-594-0019 or email [email protected]
Important Questions
What is the overall
deductible?
Are there other deductibles
for specific services?
Is there an out–of–pocket
limit on my expenses?
What is not included in the
out–of–pocket limit?
Is there an overall annual
limit on what the plan
pays?
Answers
PAR: $2,150 single/$4,300 family;
NONPAR: $4,000 single/$8,000 family;
PAR Preventive care is not subject to the
deductible. Coinsurance & copayments
don’t apply to the deductible.
No.
Yes. Medical:
PAR: $6,350 single/$12,700family;
NONPAR: $12,000 single/$24,000 family.
Plan Maximum OOP: PAR: $6,350
single/$12,700 family; NONPAR: NA
Premiums, balance-billed charges,
penalties, non-Humana Nat’l Transplant
Network transplants, & health care this
plan doesn’t cover.
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 don’t have to meet deductibles for specific services, but see the chart
starting on page 2 for other costs for services this plan covers.
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-ofpocket limit.
No.
The chart starting on page 2 describes any limits on what the plan will pay
for specific covered services, such as office visits.
Does this plan use a
network of providers?
Yes. See www.humana.com for a list of
PAR providers.
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 in-network, preferred, or participating for providers in
their network. See the chart starting on page 2 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 specialist you choose without permission from this plan.
Are there services this plan
doesn’t cover?
Yes.
Some of the services this plan doesn’t cover are listed on page 5. See your
policy or plan document for additional information about excluded
services.
Questions: Call 1-512-594-0019 or email [email protected].
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
OMB Control Numbers 1545-2229,
1210-0147, and 0938-1146
Corrected on May 11, 2012
1 of 8 INGAGED LOW PLAN: PFLUGERVILLE ISD
Coverage Period: 01/01/2016-12/31/2016
 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
 Coinsurance 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 coinsurance 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 PAR 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
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Limitations & Exceptions
Use a
NONPAR Provider
$30 copay/visit
–––––––––––none–––––––––––
$30 copay/visit
$30 copay/visit
Preventive care/screening/immunization No charge
Hearing exam
$30 copay/visit
–––––––––––none–––––––––––
–––––––––––none–––––––––––
-NONPAR immunizations for age’s
newborn to age 6 are covered at no charge.
Ages 6 to 18 will be covered at 50% after
deductible.
-Immunization limitations for adult and
child are based on the CDC guidelines.
-Vision & hearing exam limited to 1 each.
Diagnostic test (x-ray, blood work)
Clinic
Outpatient
Imaging (CT/PET scans, MRIs)
No charge
–––––––––––none–––––––––––
–––––––––––none–––––––––––
Common
Medical Event
drugs to treat your
illness or condition
Level 1 - Low-cost generic drugs
Retail (up to a 30 day)
Retail (90 day)
Mail order (90 day)
Level 2 - Brand name drugs
Retail (90 day)
Mail order (90 day)
Level 3 - Highest cost drugs
Retail (90 day)
Mail order (90 day)
More information
about prescription
drug coverage is
available at
www.humana.com
-Paid under medical benefits
If you need
immediate medical
attention
Your Cost If You
Use a
NONPAR Provider
PAR copay + 30% +
the difference between
the default rate and
the Non-PAR
pharmacy charge
-Prior auth, Quantity limits and step
therapy may be required for some drugs.
-Your cost for flu and pneumonia
immunizations, HCR Preventative
medications and drugs on the Women’s
Healthcare drug List at PAR pharmacies:
No charge.
-Your cost for Diabetic supplies: $10 copay
-If you request a brand-name drug and a
generic is available, you will be responsible
for the cost differential between the brandname drug and the generic along with any
applicable copayments. Same as Level 1, 2 ,3
Same as Level 1, 2 , 3
Medical benefits apply
-Ambulance NONPAR will be subject to
the PAR deductible.
No Charge
Not applicable
$150 copay/visit
30% coinsurance after
deductible
$150 copay and 30%
coinsurance
$150 copay/visit
30% coinsurance
after deductible
$150 copay and 50%
after deductible
$10 copay
$30 copay
$25 copay
$40 copay
$120 copay
$100 copay
$60 copay
$180 copay
$150 copay
Specialty Drugs
-Drugs purchased at a pharmacy
If you have
outpatient surgery
Your Cost If You
Use a
PAR
Provider
Coverage Period: 01/01/2016-12/31/2016
-Obtained through SpecialtyRx and
office administered by provider
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
Emergency room services True Emergency Facility:
True Emergency Physician Services:
Non-Emergency Facility:
Non-Emergency Physician Services:
Pharmacy out-of-pocket maximum; PAR:
$5,000 single/$10,000 family; NONPAR:
Not Applicable
Prior auth may be required; There is a
$250 penalty for not obtaining prior auth.
–––––––––––none–––––––––––
NONPAR true emergency physician
services are subject to the PAR deductible.
Common
Medical Event
If you have a
hospital stay
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
If you need help
recovering or have
other special health
needs
Your Cost If You
Use a
PAR
Provider
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
Emergency medical transportation
Urgent care
$40 copay/visit
Facility fee (e.g., hospital room)
Physician/surgeon fee
Mental/Behavioral health outpatient
services (Therapies & Exams)
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
$30 copay/visit
$30 copay/visit
Substance use disorder inpatient services
Prenatal and postnatal care
$30 copay
Delivery and all inpatient services
Home health care
Rehabilitation services Physical and Occupational Therapy (at
a clinic or outpatient location):
All other therapies and locations
covered by the plan:
$30 copay/visit
NONPAR is subject to the PAR
deductible.
–––––––––––none–––––––––––
Prior auth required; There is a $250
penalty for not obtaining prior auth.
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
-Dependent daughter maternity care is
covered.
- Office visit copayment applies to the
initial visit only
–––––––––––none–––––––––––
-Limited to 60 visits
- Prior auth required; There is a $250
Physical therapy and occupational therapy
in a clinic or outpatient locations is limited
to 20 visits each.
Common
Medical Event
If your child needs
dental or eye care
Your Cost If You
Use a
PAR
Provider
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
Habilitation servicesPhysical and Occupational Therapy (at
$30 copay/visit
Skilled nursing care
Durable medical equipment
Hospice service
Eye exam
Glasses
Dental check-up
$30 copay
Not covered
Not covered
Not covered
Not covered
to 20 visits each.
–––––––––––none–––––––––––
No coverage for glasses.
No coverage for dental check-ups.
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

Dental care (adult and child)

Private-duty nursing

Bariatric surgery

Infertility treatment


Behavioral health half-way house services

Long-term care
Routine eye care (adult and child, excludes
vision exam and screening )

Non-emergency care when traveling outside
the U.S.

Routine foot care

Weight loss programs
Coverage Period: 01/01/2016-12/31/2016
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 (Limited to 20 visits)

Cosmetic surgery (Requires prior auth.
Services will only be considered if due to a
bodily injury or illness and functional
impairment is present.)

Dependent Daughter Maternity

Hearing aids (Limited to $1,000 per 36
months)
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 1-512-594-0019. 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 1-877267-2323 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: 1-512-594-0019 or email [email protected].
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 coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-512-594-0019.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
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.
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. Coverage Period: 01/01/2016-12/31/2016
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $3,810
 Patient pays $3,730
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,150
$20
$1,410
$150
$3,730
Patient pays:
Deductibles
Copays
Coinsurance
Total
$2,150
$580
$0
$80
$2,810
Coverage Period: 01/01/2016-12/31/2016
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.
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.
What does a Coverage Example
show?
Can I use Coverage Examples
to compare plans?
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.
Yes. When you look at the Summary of
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.
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.
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-ofpocket 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.
8 of 8 NON-ENGAGED LOW PLAN: PFLUGERVILLE ISD
Coverage Period: 01/01/2016-12/31/2016
Important Questions
What is the overall
deductible?
limit on what the plan pays?
Answers
deductible. Coinsurance &
copayments don’t apply to the
deductible.
No.
Yes. Medical:
NONPAR: $15,000 single/$30,000
family. Plan Maximum OOP: PAR:
NA
No.
Does this plan use a network Yes. See www.humana.com for a list of
of providers?
PAR providers.
specialist?
doesn’t cover?
Why this Matters:
The chart starting on page 2 describes any limits on what the plan will pay for
specific covered services, such as office visits.
specialist.
Yes.
policy or plan document for additional information about excluded services.
1210-0147, and 0938-1146
Coverage Period: 01/01/2016-12/31/2016
Common
Medical Event
or clinic
If you have a test
illness
Specialist visit
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
$30 copay/visit
–––––––––––none–––––––––––
$45 copay/visit
$45 copay/visit
Hearing exam
$45 copay/visit
–––––––––––none–––––––––––
–––––––––––none–––––––––––
deductible.
Clinic
Outpatient
No charge
–––––––––––none–––––––––––
–––––––––––none–––––––––––
Common
Medical Event
Drugs to treat your
More information
about prescription
drug coverage is
available at
www.humana.com
Retail (90 day)
Mail order (90 day)
Retail (90 day)
Mail order (90 day)
Retail (90 day)
Mail order (90 day)
Specialty Drugs
If you have
outpatient surgery
If you need
immediate medical
attention
center)
Your Cost If You
Use a
PAR
Provider
$15 copay
$45 copay
$37.50 copay
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
PAR copay + 30% +
the Non-PAR
pharmacy charge
$55 copay
$165 copay
$137.50copay
$75 copay
$225 copay
$187.50 copay
Same as Level 1, 2 ,3
No Charge
Not applicable
$150 copay/visit
deductible
$150 copay and 30%
coinsurance
$150 copay/visit
30% coinsurance
after deductible
$150 copay and 50%
after deductible
No charge.
applicable copayments. -Ambulance NONPAR will be subject to
the PAR deductible.
Not Applicable
–––––––––––none–––––––––––
Common
Medical Event
If you have a
hospital stay
If you have mental
health, behavioral
abuse needs
If you are pregnant
If you need help
recovering or have
needs
Your Cost If You
Use a
PAR
Provider
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
Urgent care
$45 copay/visit
services
$30 copay/visit
$30 copay/visit
$45 copay
Home health care
$45 copay/visit
deductible.
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
penalty for not obtaining prior auth..
–––––––––––none–––––––––––
covered.
initial visit only
–––––––––––none–––––––––––
to 20 visits each.
Common
Medical Event
If your child needs
dental or eye care
Your Cost If You
Use a
PAR
Provider
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
$45 copay/visit
Hospice service
Eye exam
Glasses
Dental check-up
$45 copay
Not covered
Not covered
Not covered
Not covered
to 20 visits each.
–––––––––––none–––––––––––

Acupuncture



Bariatric surgery




Long-term care

the U.S.

Routine foot care

Coverage Period: 01/01/2016-12/31/2016
services.)




months)
Examples:
This is
not a cost
estimator.
different.
Having a baby
(normal delivery)
Sample care costs:
Anesthesia
Laboratory tests
Prescriptions
Radiology
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Education
Laboratory tests
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Total
$3,000
$20
$1,280
$150
$4,450
Patient pays:
Deductibles
Copays
Coinsurance
Total
$3,000
$580
$0
$80
$3,660
Coverage Period: 01/01/2016-12/31/2016
Coverage Examples?







show?
to compare plans?
the plan provides.
plans?
expenses.
8 of 8 INGAGED MID PLAN: PFLUGERVILLE ISD
Coverage Period: 01/01/2016-12/31/2016
Important Questions
What is the overall
deductible?
Answers
deductible.
Coinsurance & copayments don’t apply
to the deductible.
No.
Yes. Medical:
No.
of providers?
PAR providers.
specialist?
doesn’t cover?
Why this Matters:
specialist.
Yes.
1210-0147, and 0938-1146
Coverage Period: 01/01/2016-12/31/2016
Common
Medical Event
or clinic
If you have a test
illness
Specialist visit
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
$30 copay/visit
–––––––––––none–––––––––––
$30 copay/visit
$30 copay/visit
Hearing exam
$30 copay/visit
–––––––––––none–––––––––––
–––––––––––none–––––––––––
deductible.
Clinic
Outpatient
No charge
–––––––––––none–––––––––––
–––––––––––none–––––––––––
Common
Medical Event
drugs to treat your
More information
about prescription
drug coverage is
available at
www.humana.com
Retail (90 day)
Mail order (90 day)
Retail (90 day)
Mail order (90 day)
Retail (90 day)
Mail order (90 day)
Specialty Drugs
If you have
outpatient surgery
If you need
immediate medical
attention
center)
Your Cost If You
Use a
PAR
Provider
$10 copay
$30 copay
$25 copay
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
PAR copay + 30% +
the Non-PAR
pharmacy charge.
$40 copay
$120 copay
$100 copay
$60 copay
$180 copay
$150 copay
No Charge
Not applicable
$150 copay/visit
deductible
$150 copay and 20%
coinsurance
$150 copay/visit
20% coinsurance
after deductible
$150 copay and 40%
after deductible
No charge.
the PAR deductible.
Not Applicable
–––––––––––none–––––––––––
Common
Medical Event
If you have a
hospital stay
If you have mental
health, behavioral
abuse needs
If you are pregnant
If you need help
recovering or have
needs
Your Cost If You
Use a
PAR
Provider
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
Urgent care
$40 copay/visit
services
$30 copay/visit
$30 copay/visit
$30 copay
Home health care
$30 copay/visit
deductible.
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
covered.
initial visit only
–––––––––––none–––––––––––
to 20 visits each.
Common
Medical Event
If your child needs
dental or eye care
Your Cost If You
Use a
PAR
Provider
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
$30 copay/visit
Hospice service
Eye exam
Glasses
Dental check-up
$30 copay
Not covered
Not covered
Not covered
Not covered
to 20 visits each.
–––––––––––none–––––––––––

Acupuncture



Bariatric surgery




Long-term care

the U.S.

Routine foot care

Coverage Period: 01/01/2016-12/31/2016
services.)




months)
Examples:
This is
not a cost
estimator.
different.
Having a baby
(normal delivery)
Sample care costs:
Anesthesia
Laboratory tests
Prescriptions
Radiology
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Education
Laboratory tests
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Total
$1,400
$20
$1,090
$150
$2,660
Patient pays:
Deductibles
Copays
Coinsurance
Total
$1,400
$740
$0
$80
$2,220
Coverage Period: 01/01/2016-12/31/2016
Coverage Examples?







show?
to compare plans?
the plan provides.
plans?
expenses.
8 of 8 INGAGED HIGH PLAN: PFLUGERVILLE ISD
Coverage Period: 01/01/2016-12/31/2016
Important Questions
What is the overall
deductible?
Answers
PAR: $650 single/$1,300 family;
deductible.
Coinsurance & copayments don’t apply
to the deductible.
No.
Yes. Medical:
No.
of providers?
PAR providers.
specialist?
doesn’t cover?
Why this Matters:
specialist.
Yes.
1210-0147, and 0938-1146
Coverage Period: 01/01/2016-12/31/2016
Common
Medical Event
or clinic
If you have a test
illness
Specialist visit
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
$30 copay/visit
–––––––––––none–––––––––––
$30 copay/visit
$30 copay/visit
Hearing exam
$30 copay/visit
–––––––––––none–––––––––––
–––––––––––none–––––––––––
deductible.
Clinic
Outpatient
No charge
–––––––––––none–––––––––––
–––––––––––none–––––––––––
Common
Medical Event
drugs to treat your
More information
about prescription
drug coverage is
available at
www.humana.com
Retail (90 day)
Mail order (90 day)
Retail (90 day)
Mail order (90 day)
Retail (90 day)
Mail order (90 day)
Specialty Drugs
If you have
outpatient surgery
If you need
immediate medical
attention
center)
Your Cost If You
Use a
PAR
Provider
$10 copay
$30 copay
$25 copay
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
PAR copay + 30% +
the Non-PAR
pharmacy charge.
$30 copay
$90 copay
$75 copay
$50 copay
$150 copay
$125 copay
No Charge
Not applicable
$150 copay/visit
deductible
$150 copay and 10%
coinsurance
$150 copay/visit
10% coinsurance
after deductible
$150 copay and 30%
after deductible
No charge.
the PAR deductible.
Not Applicable
–––––––––––none–––––––––––
Common
Medical Event
If you have a
hospital stay
If you have mental
health, behavioral
abuse needs
If you are pregnant
If you need help
recovering or have
needs
Your Cost If You
Use a
PAR
Provider
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
Urgent care
$40 copay/visit
services
$30 copay/visit
$30 copay/visit
$30 copay
Home health care
$30 copay/visit
deductible.
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
covered.
initial visit only
–––––––––––none–––––––––––
to 20 visits each.
Common
Medical Event
If your child needs
dental or eye care
Your Cost If You
Use a
PAR
Provider
Coverage Period: 01/01/2016-12/31/2016
Your Cost If You
Use a
NONPAR Provider
$30 copay/visit
Hospice service
Eye exam
Glasses
Dental check-up
$30 copay
Not covered
Not covered
Not covered
Not covered
to 20 visits each.
–––––––––––none–––––––––––

Acupuncture



Bariatric surgery




Long-term care

the U.S.

Routine foot care

Coverage Period: 01/01/2016-12/31/2016
services.)




months)
Spanish (Español): Para obtener asistencia en Español, llame al 1-512-594-0019. ––––––––––––––––––––––
To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Examples:
This is
not a cost
estimator.
different.
Having a baby
(normal delivery)
Sample care costs:
Anesthesia
Laboratory tests
Prescriptions
Radiology
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Education
Laboratory tests
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Total
$650
$20
$620
$150
$1,440
Patient pays:
Deductibles
Copays
Coinsurance
Total
$650
$910
$0
$80
$1,640
Coverage Period: 01/01/2016-12/31/2016
Coverage Examples?







show?
to compare plans?
the plan provides.
plans?
expenses.
8 of 8 Life made easier
Who can use EAP and Work-Life?
All employees as well as household family members.
Who pays for these services?
Your company pays all costs when you and
members of your household use the program.
If additional assistance or services are needed,
you will receive referrals that consider your
preferences, medical plan, and financial
circumstances. Please refer to your insurance
plan booklet or your human resources department
for specific information about your medical plan.
How do I access these services?
EAP and
Work-Life
Services
EAP and Work-Life are convenient, confidential,
and provided at no cost to you and members of
your household. We’re here 24 hours a day, seven
days a week, so call or sign in anytime.
For free and confidential
assistance, call 1-866-440-6556
or visit us at Humana.com/eap
Username: eap3
Password: eap3
Personal information about participants remains confidential
according to all applicable state and federal laws, unless
disclosure is required by such laws. Services provided by
Humana EAP and Work-Life Services.
GCHHSKQEN 0214
Your company understands that when your life is in balance and your personal
needs are being met, it’s easier to be happy and productive at work. That’s why
your company offers free access to EAP and Work-Life – to help you manage
life’s challenges and maintain a happy and well-balanced life.
What is an EAP?
What is Work-Life?
An Employee Assistance Program (EAP) offers
short-term counseling up to 3 visits per issue per
year to help you and members of your household
manage everyday life issues. Caring counselors are
available to assist you with:
Work-Life offers extensive
assistance, information, and
support to help you achieve a
better balance between work,
life, and family to help make your life easier.
You can access information and self-search
locators to find resources and providers that
can help you with:
• Everyday needs and life events
• Emotional issues
• Relationship concerns
• Family relationships
• Coping with a serious illness
• Weight control
• Sleeping difficulties
• Loss of a loved one
• Eating disorders
• Workplace concerns
• Smoking cessation
• Convenience services
• Housing options
• Child care
• Financing college
• Home ownership
• Caregiving from a distance
• Moving and relocation
• Finding colleges and universities
• Services and education for children with
special needs
What is the Legal and Financial Program?
As part of the EAP, you also have access to a free
30-minute consultation with a local attorney or
financial counselor on issues such as real estate,
retirement planning, divorce and separation,
budgeting/debt reconstruction, and trusts and
estates. Further legal and tax preparation services
are discounted 25 percent.
What if I’m just looking for information?
You can access many useful articles, tip sheets,
and checklists by calling or signing in to the EAP
and Work-Life website. Many helpful topics are
available, including relationships, communication,
life in the workplace, and emotional well-being.
• Adoption, pregnancy, and infertility
What else does the website offer?
• Adjusting to retirement
It includes dozens of locators that allow you to
search for health and wellness information, child
care providers, adoption services, schools and
colleges, daily living needs, older adult care, and
much more. The site also offers calculators that
can help you with everything from mortgage
payment calculations to how much to save for
your children’s college education.
• Locating services and care for older adults
• Pet care
• Finding schools
• Tutors and test prep
• Child development
• Recreational activities
• Consumer education
What to know, before you get your
medicine – prior authorization
Understanding your pharmacy benefits
You may take prescription medicines to stay healthy. You may take some medicines for a short
time, like an antibiotic to treat an infection. You may take other medicines all the time to treat
problems like high blood pressure. Either way, it’s important to know if your medicines need prior
authorization before you get your prescription.
What is pharmacy prior authorization?
Some medicines need to be approved in advance to be covered under your pharmacy. For these
medicines to be covered, your doctor must get approval from Humana. When this happens, it’s
called pre-approval – or “prior authorization.”
Why do some medicines need prior authorization?
We ask for prior authorization to make sure medicines won’t interfere with other medicines
you’re taking or add unnecessary costs. Prior authorization helps keep you safe, which is very
important if you’re taking certain medicines.
Medicines requiring prior authorization are typically costly, are only approved for certain
conditions and may require patient monitoring. For example, if you have diabetes, and your
doctor wants you to try a new medicine, we may need to authorize this medicine before you fill
the prescription.
GCHHD6HHH 0814
Continued on back.
How do I know if my medicine needs prior authorization?
Each time your doctor prescribes a new medicine, ask them if it needs prior authorization. You also can:
• Sign in to MyHumana, your personal, secure online account on Humana.com, and click “Drug Pricing” under
“Plan Tools” at the bottom of the page
• Call Humana Customer Care at the number on the back of your Humana member ID card
• Visit Humana.com/DrugList
What should I do if my medicine needs prior authorization?
If your medicine needs prior authorization, your doctor must contact Humana Clinical Pharmacy Review (HCPR)
at 1-800-555-2546 to ask for approval. HCPR is available Monday - Friday, 8 a.m. - 6 p.m., Eastern time. Your
doctor also can use tools available on Humana.com/Providers. We will notify your doctor once the request has
been processed.
What happens after my doctor asks for prior authorization?
A team of pharmacists will review your doctor’s request and either approve or deny it.
If your doctor’s request is approved, your pharmacy benefits will cover your medicine. You’ll pay any applicable
coinsurance or copayment amounts if you buy the medicine.
If your doctor’s request is denied, your pharmacy benefits won’t cover your medicine. You can still purchase
the medicine but you’ll pay the full cost. Or, you can ask your doctor if there’s another medicine that’s right
for you. There may be other medicines covered by your benefits that will work just as well but don’t need prior
authorization.
How long will it take to get prior authorization for my medicine?
After your doctor gets us all of the information we need, the request will be approved or denied within five
business days. We’ll mail letters to you and to your doctor with our decision.
Please contact your doctor to discuss other options. Your doctor can ask for an exception to our decision by
contacting Humana Clinical Pharmacy Review (HCPR) at 1-800-555-2546, Monday - Friday, 8 a.m. - 6 p.m.,
Eastern time.
“Humana” is the brand name for plans, products, and services provided by one or more of the subsidiaries and affiliate
companies of Humana Inc. (“Humana Entities”). Plans, products, and services are solely and only provided by the one or
more Humana Entities specified on the plan, product, or service contract, not Humana Inc. Not all plans, products, and
services are available in each state.
GCHHD6HHH 0814
Humana.com
Your link to smart choices
For more information,
visit Humana.com.
Click “Register” on
the left side of the
page and follow the
instructions.
As a Humana member, you have powerful resources at your
fingertips to help when you’re making decisions that affect
your health.
At Humana.com, you can:
• Find in-network doctors, hospitals, and
pharmacies near you
AfteryoureceiveyourHumanaID
card, you can register for immediate
access to MyHumana – your secure
Website.
• Takeahealthassessmentandprintthe
results to share with your doctor
At MyHumana, you can:
• Createyourownhealthrecord,including
family history, immunizations, allergies,
and medications
• ViewandprintyourHumanaclaims
• OrderreplacementIDcards
• Investigatepossiblelower-priced
alternatives to your prescription drugs
• Viewandprintyourplancertificateand
a summary of your plan benefits
• FindoutaboutHumana’shealthand
wellness programs
• VisitConditionCenterstoexplore
symptoms, treatments, and tests; track
your condition; and print reports to
discuss with your doctor
• Savemoneyonmedicines,supplements,
and other health and wellness products
withtheSavingsCenter
• SearchHumana’sDrugListfor prescription drugs and their estimated
retail prices
• Viewandprintaletterofcoverageto
give the doctor as proof of coverage
• UsePlanningToolstotrackyour spending and estimate costs for a
procedure or prescription
Humana Plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana
Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas,
Inc. - A Health Maintenance Organization, or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana
Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, Humana Insurance of Puerto Rico, Inc. License # 00187-0009, or administered by Humana
Insurance Company or Humana Health Plan, Inc.
Statements in languages other than English contained in the advertisement do not necessarily reflect the exact contents of the policy written in English, because of possible linguistic differences.
In the event of a dispute, the policy as written in English is considered the controlling authority.
For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company.
Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on the company providing your benefits. Our health benefit
plans have limitations and exclusions.
Humana.com
GN14110HH_1112
GN14110HH_1112
Know where to get care
What’s the right level of care?
How do you decide where to seek medical care for yourself or a family member? The right
decision depends on your symptoms. Call HumanaFirst® Nurse Advice Line at
1-800-622-9529 for help in choosing the right level of care.
Home care
Minor health issues are often
easy to take care of at home.
Call HumanaFirst for advice.
Also, remember your out-of-pocket costs can vary significantly by the place of service.
Home Care
Care at home is an important consideration. You can visit the Conditions section under the
Get Healthy header on MyHumana, your secure website on Humana.com. You
also can call HumanaFirst for self-care advice. In addition, a variety of books provide selfcare guidelines.
Doctor’s Office
Your doctor should be your first call when you’re sick. Your doctor not only knows you,
but has all of your medical records in one place. Because of this, he or she can make an
informed decision about the care you need.
Retail Clinic
Put simply, these clinics make life easier when you need routine healthcare services for
common illnesses – like colds, flu, or sore throats – as well as screenings and vaccinations.
They usually cost less than an urgent care center or emergency room. Because they’re
in grocery stores, drugstores, and other retailers, you won’t have to make multiple trips
for medicine or supplies. Advanced Registered Nurse Practitioners (ARNPs) and Physician
Assistants (PAs) generally provide care at these facilities.
Urgent Care
Go to an urgent care center when your doctor isn’t available. Infections, injuries, cuts,
sprains, flu, fever, allergies, asthma, rash, and sore throat are some instances when you
should consider going to an urgent care center instead of an emergency room. Urgent
care centers have:
• Evening and weekend hours; usually a short wait
• Experienced, trained nurses and doctors
• Lower out-of-pocket costs for you than an emergency room
To find a location near you, visit your MyHumana.com page and click on the Find a Doctor
link, which will give you the option to choose urgent care providers close to you. You also
can call HumanaFirst for assistance.
Emergency Room
Use the “ER” for emergencies only. If you’re facing a serious situation – like uncontrolled
bleeding, chest pain, heart attack, difficulty breathing, possible stroke, or any threat to life
or limb – head straight to the ER. But the emergency room is not an appropriate place to
treat non-emergencies.
ERs aren’t “first come, first served.” Instead, a non-emergency must wait until all
emergencies are seen. At the ER, you could face:
• A long wait, and a crowded waiting area
• A hefty bill with high out-of-pocket costs
Doctor’s office
Your doctor knows the best
treatment for you.
$
Retail clinic
These clinics are usually in
retail stores, supermarkets,
and drugstores.
$
Urgent care center
Urgent care is a bridge
between your doctor and
the emergency room.
$$
Emergency room
When you think you’re having
an emergency, trust your
instincts and go to the ER.
$$$
Always be sure to check your plan details to confirm coverage.
Humana.com
GCA08DGHH 1013
ER or urgent care center?
How to know where to go
Emergency rooms treat serious or life-threatening conditions.
For non-emergency conditions, it’s better to go to your doctor or
an urgent care center.
When you can’t see your doctor right away, an urgent care center is a good medical
and financial alternative to an emergency room.
Here’s why:
• Your wait will probably be shorter.
• Urgent care centers are often open evenings and weekends.
• You don’t need an appointment.
• An urgent care center may be closer to your home or workplace.
• Your cost is usually lower than it would be at an emergency room. In fact, if you go to an
emergency room for non-emergency care, you may have to pay the entire bill yourself.
The choice is yours. But remember: For treatment of a minor illness or injury, an urgent
care center can save you time and money.
To find an urgent care center near you, log on to Humana.com and:
• Click “find a doctor”
• Select “Urgent Care Centers” under Provider Search at the right of the page
• Use your member ID or ZIP code on the pop-up window to find an urgent care center near you
Humana.com
Cost of care and out-of-pocket fees are dependent on facility charges. Health Plans are offered/administered by the Humana Family of
Insurance and Health Plan Companies. Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance) for more information
on the company providing your benefits. Our health plans have Limitations and Exclusions.
GN14455HH 513
Savings Center
One more reason to choose Humana
The Savings Center is a great place to find ways to lower the cost of staying healthy. Take advantage of these Humana
member discounts as often as you like:
Vision discount programs
• E
yeMed – 1-866-392-6056 Discounts on routine exams, eyeglass frames and lenses – including a wide range of lens
options – contact lenses, and laser correction.
To receive your EyeMed discount:
• Visit Physician Finder Plus on Humana.com to locate an EyeMed Vision provider near you
• Tell the EyeMed provider you’re a Humana member with EyeMed Vision benefits
• P
rint the discount ID card – you’ll find a link on the EyeMed, TruVision, and Alternative Medicine pages – or present your
Humana medical or dental ID card to your EyeMed provider
Your EyeMed provider will apply the discount directly to your purchase.
• T
ruVision – 1-877-580-2020 Traditional and custom LASIK to correct problems such as nearsightedness,
farsightedness, and astigmatism, offered at more than 200 TruVision centers nationwide for less than $1,000 per eye.
Services include:
• Telephone screening
• Comprehensive eye exam
• LASIK procedure on an FDA-approved excimer laser
• Postoperative care
• Retreatment warranty
To schedule an exam, determine price, find a location in your area, or get more information, call a Customer Care
specialist at 1-877-580-2020.
Cut out this card
and keep it in
your wallet for
handy reference.
Discount card
Subscriber name:
Subsciber ID:
ANSI/BIN#
VISION:
Alternative Medicine
610649
EyeMed and TruVision
HWHN
These discount programs are not part of your insurance.
Discounts are available only at participating providers.
Humana.com
GN20545HH 513
Page 1 of 2
Complementary and Alternative Medicine (CAM) discount program*
• Provided by Healthways WholeHealth Networks (HWHN), with more than 25,000 practitioners.
To access CAM services:
• Participating providers can be found at http://humana.wholehealthmd.com.
• Select a provider through the Health & Wellness link of the Savings Center or call the Customer Care number
on your member ID card.
• Present the Humana discount card below to receive the specified discount
It’s that easy!
You don’t need a referral to visit a participating massage therapist, acupuncturist, or chiropractor. However,
some Humana health plans offer coverage for some CAM services, so use your insured benefits whenever
possible.
*Not available in Arkansas, Tennessee, Oklahoma and where prohibited by law.
Medication Savings
• Save on over-the-counter (OTC) medications for a wide range of conditions
• Visit the drug coverage search to find alternatives and compare estimated costs for your prescriptions
• Sign up for RightSourceRxSM to get your prescriptions by mail and save time and money
Stretch your health care dollars
Get special discounts just for Humana members on a wide variety of products and programs, from fitness facilities and
weight management programs to tobacco cessation and herbal teas and supplements. Check out the Health & Wellness
link for a complete list.
These discount programs are not part of your insurance product. Discounts are only available at participating providers.
Service providers are solely responsible for the provision of products and services. Humana and it’s affiliates are not liable
for product defects, provider negligence or other errors in the delivery of discount products or services. The insured/
administered benefits that make these discount services available are offered by Humana Medical Plan, Inc., Humana
Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana
Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health
Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. – A Health Maintenance Organization or insured
by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana,
Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, or Humana Insurance of Puerto Rico, Inc.
License # 00187-0009 or administered by Humana Insurance Company.
For Arizona Residents: Offered by Humana Health Plan, Inc. or insured or administered by Humana Insurance Company
Please refer to your Certificate of Coverage/Insurance or Summary Plan Description for more information on the company
providing your benefits.
Our health benefit plans have limitations and exclusions.
Humana.com
GN20545HH 513
Page 2 of 2
Explanation of Benefits
A savvy consumer’s guide
You want to get the most out of
your health plan.
Here’s a good place to start.
One of the most important plan documents you’ll see is
your Explanation of Benefits (EOB). It’s important to know
that an EOB isn’t a bill. It’s simply a form you receive from
Humana that explains the services and procedures you
received, what they cost, and what – if anything – you owe.
Get familiar with just a few sections on this form and you’ll be well on your way to a better healthcare experience.
Here’s what you need to know:
• Patient information shows which member of your health plan received care. All information on the EOB will
refer to this person.
• Servicing provider tells you the doctor, dentist, or healthcare facility you visited.
• Charge lists the total amount the provider charged for services received.
• Amount paid by Humana shows the amount your plan pays for services received. In many cases, Humana
has negotiated with providers to give you a discounted rate for certain services ... helping you save money.
• Estimated member responsibility tells you what you need to pay out-of-pocket. The provider will bill you
for this amount. Examples include your deductible or coinsurance amount, any denied service amount, or any
amount over the Maximum Allowable fee if you see a non-participating provider.
• Remark codes explain how your claim was processed or considered. You can find a description of the code on
page 2, which provides details on this process.
• Service code is a number used in the healthcare business to process claims more efficiently. The Service code
remarks section will tell you what this number means.
All information on your EOB should match the information that appears on statements you receive from your
healthcare provider. If it doesn’t, contact your provider immediately.
Keeping track
Once you understand how to read your EOB, you’ll be better prepared to track expenses, understand your
benefits, and avoid paying too much for your healthcare. It’s a good idea to keep your EOBs in a safe place should
you have questions later. You always can view your past 18 months of EOBs anytime on MyHumana, your secure
Website on Humana.com.
GH16646HH 509
Quick and easy
If you’d like your EOBs as quickly as possible, you can view or
download them online. Here’s what to do:
• Log in or register for MyHumana, your secure Website
on Humana.com
•
Select “Claims & Spending”
•
Click “Claims” for a list of all your claims
•
Select “Details” from the claim list
•
Select “(PDF) Download Explanation of Benefits” to view or
download your EOB
If you have questions, just give us a call at the number on the back
of your Humana ID card or visit us online at Humana.com.
GH16646HH 509
2016 Annual Disclosure Notices
If you (and/or your dependents) have Medicare or will become eligible for Medicare
in the next 12 months, a Federal law gives you more choices about your
prescription drug coverage. Please see pages 5 - 6 for details.
Table of Contents
Special Enrollment
Newborn Act Disclosure
Women’s Health & Cancer Rights
Page 2
Page 2
Page 2
Medicaid & CHIP Offer Free or Low-Cost Health Coverage to
Page 3 - 4
Children & Families
Medicare Part D Creditable Coverage
Page 5 - 6
SPECIAL ENROLLMENT NOTICE
This notice is being provided so that you understand your right to apply for group health insurance coverage
outside of Pflugerville ISD’s open enrollment period. You should read this notice regardless of whether or not you
are currently covered under Pflugerville ISD’s Group Health Plan. The Health Insurance Portability and
Accountability Act (HIPAA) requires that employees be allowed to enroll themselves and/or their dependent(s) in
an employer’s Group Health Plan under certain circumstances, described below, provided that the employee
notifies the employer within 60 days of the following events:

Loss of health coverage under another employer plan (including exhaustion of COBRA coverage);

Acquiring a spouse through marriage; or

Acquiring a dependent child through birth, adoption, placement for adoption or foster care placement.
Effective April 1, 2009, two new special enrollment rights were created under the Children’s Health Insurance
Program Reauthorization Act of 2009. All group health plans must also permit employees and dependents, who
are otherwise eligible for the group health plan, to enroll in the plan within 60 days of the following events:

Losing eligibility for coverage under a State Medicaid or CHIP program; or

Becoming eligible for State premium assistance under Medicaid or CHIP.
The employee or dependent must request coverage within 60 days of being terminated from Medicaid or CHIP
coverage or within 60 days of being determined to be eligible for premium assistance.
NEWBORN ACT DISCLOSURE
Under federal law, group health plans and health insurance issuers offering health insurance coverage generally
may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn
child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean
section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician,
nurse, midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn
earlier.
Also, under federal law, plan or issuers may not set the level of benefits or out-of-pocket costs so that the later
portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or the newborn than
the earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider
obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain
providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain pre-certification. For
information on pre-certification, contact your plan administrator.
WOMEN’S HEALTH & CANCER RIGHTS NOTICE
As required by the Women’s Health and Cancer Rights Act of 1998 (WHCRA), this medical plan provides
coverage for:

All stages of reconstruction of the breast of which the mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance;

Prostheses and physical complications of mastectomy, including lymphedemas, in a manner determined
in consultation with the attending physician and the patient.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and
surgical benefits provided under this plan. If you would like more information of WHCRA benefits, call your plan
administrator.
Page
2
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your
employer, your state may have a premium assistance program that can help pay for coverage, using funds from
their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible
for these premium assistance programs but you may be able to buy individual insurance coverage through the
Health Insurance Marketplace. For more information, visit www.healthcare.gov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact
your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a
program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under
your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled.
This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being
determined eligible for premium assistance. If you have questions about enrolling in your employer plan,
contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health
plan premiums. The following list of states is current as of July 31, 2015. Contact your State for more
information on eligibility –
ALABAMA – Medicaid
Website: www.myalhipp.com
Phone: 1-855-692-5447
ALASKA – Medicaid
Website:
http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
COLORADO – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
LOUISIANA – Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html
Phone: 1-800-977-6740
TTY 1-800-977-6741
GEORGIA – Medicaid
Website: http://dch.georgia.gov/
- Click on Programs, then Medicaid, then Health Insurance
Premium Payment (HIPP) Phone: 40-656-4507
INDIANA – Medicaid
Website: http://www.in.gov/fssa
Phone: 1-800-889-9949
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
NEW HAMPSHIRE – Medicaid
Website:
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
NEW YORK – Medicaid
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
Page
3
MASSACHUSETTS – Medicaid and CHIP
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
MINNESOTA – Medicaid
NORTH DAKOTA – Medicaid
Website: http://www.dhs.state.mn.us/id_006254
Click on Health Care, then Medical Assistance
Phone: 1-800-657-3739
Website:
http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-755-2604
MISSOURI – Medicaid
OKLAHOMA – Medicaid and CHIP
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
MONTANA – Medicaid
Website: http://medicaid.mt.gov/member
Phone: 1-800-694-3084
NEBRASKA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
NEVADA – Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
SOUTH CAROLINA – Medicaid
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS – Medicaid
Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
UTAH – Medicaid and CHIP
Website:
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-866-435-7414
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
NORTH CAROLINA – Medicaid
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
OREGON – Medicaid
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov Phone: 1-800-6999075
PENNSYLVANIA – Medicaid
Website: http://www.dhs.state.pa.us/hipp
Phone: 1-800-692-7462
RHODE ISLAND – Medicaid
Website: www.eohhs.ri.gov
Phone: 401-462-5300
VIRGINIA – Medicaid and CHIP
Medicaid Website:
http://www.coverva.org/programs_premium_assistance.cfm
Medicaid Phone: 1-800-432-5924
CHIP Website:
http://www.coverva.org/programs_premium_assistance.cfm
CHIP Phone: 1-855-242-8282
WASHINGTON – Medicaid
Website:
http://www.hca.wa.gov/medicaid/premiumpymt/pages/
index.aspx
Phone: 1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid
Website: www.dhhr.wv.gov/bms/
Medicaid%20Expansion/Pages/default.aspx
Phone: 1-877-598-5820, HMS Third Party Liability
WISCONSIN – Medicaid and CHIP
Website:
https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone: 1-800-362-3002
WYOMING – Medicaid
Website: http://wyequalitycare.acs-inc.com/
Phone: 307-777-7531
To see if any other states have added a premium assistance program since July 31, 2015, or for more information on special
enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
Page
4
Important Notice from Pflugerville ISD About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information
about your current prescription drug coverage with Pflugerville ISD and about your options under
Medicare’s prescription drug coverage. This information can help you decide whether or not you
want to join a Medicare drug plan. If you are considering joining, you should compare your
current Humana coverage, including which drugs are covered at what cost, with the coverage and
costs of the plans offering Medicare prescription drug coverage in your area. Information about
where you can get help to make decisions about your prescription drug coverage is at the end of
this notice.
There are two important things you need to know about your current coverage and Medicare’s
prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You
can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage
Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide
at least a standard level of coverage set by Medicare. Some plans may also offer more coverage
for a higher monthly premium.
2. Pflugerville ISD has determined that the prescription drug coverage offered by Pflugerville ISD
is, on average for all plan participants, expected to pay out as much as standard Medicare
prescription drug coverage pays and is therefore considered Creditable Coverage. Because your
existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher
premium (a penalty) if you later decide to join a Medicare drug plan.
____________________________________________________________________________________
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from
October 15th through December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you
will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug
Plan?
If you decide to join a Medicare drug plan, your current coverage MAY be affected. If you decide to
join a Medicare drug plan, your current Pflugerville ISD Humana coverage may be affected by the
coordination of benefits provision in the Humana health plan. If you choose to drop Pflugerville ISD
plan coverage to join a Medicare drug plan, you MAY be able to get this plan back. However the
Pflugerville ISD drug plan is included in the Pflugerville ISD group health plan and is not available as a
separate benefit.
Page
5
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Pflugerville ISD and don’t join a
Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher
premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly
premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month
that you did not have that coverage. For example, if you go nineteen months without creditable coverage,
your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You
may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug
coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug
Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will
also get it before the next period you can join a Medicare drug plan, and if this coverage through
Pflugerville ISD changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug
Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare &
You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also
be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
 Visit www.medicare.gov
 Call your State Health Insurance Assistance Program (see the inside back cover of your copy of
the “Medicare & You” handbook for their telephone number) for personalized help
 Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is
available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov,
or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the
Medicare drug plans, you may be required to provide a copy of this notice when you
join to show whether or not you have maintained creditable coverage and, therefore,
whether or not you are required to pay a higher premium (a penalty).
Date:
Name of Entity/Sender:
Contact--Position/Office:
Address:
Phone Number:
10/5/15
Pflugerville ISD
Kristin Baum, Risk Mgmt/Leave and Benefits Coordinator
1401 West Pecan Street
Pflugerville, TX 78660
512-594-0026
Page
6
2016 Aviso Importante
Si usted (y/o sus dependientes) tienen Medicare o van a ser elegibles para Medicare
en los próximos 12 meses, la ley Federal le da más opciones sobre su cobertura de
prescripción. Por favor lea las paginas 5-6 para más detalles.
Indice
Aviso Especial de Inscripción
Información sobre la Ley de los Recién Nacidos
Aviso sobre los Derechos de la Mujer respecto a Salud Cáncer
Asistencia con las primas bajo Medicaid y el Programa de Seguro de Salud
para Menores (CHIP)
Medicare parte D - Cobertura Acreditable
p. 2
p. 2
p. 2
p. 3 – 4
p. 5 – 6
AVISO ESPECIAL DE INSCRIPCIÓN
Este mensaje se envía para que usted entienda su derecho a solicitar una cobertura de seguro médico colectivo fuera
del período de inscripción abierta de Pflugerville ISD. Usted debe leer este aviso esté o no inscrito(a) actualmente en
el Plan de Salud Colectivo de Pflugerville ISD. La Ley de Portabilidad y Responsabilidad de los Seguros de Salud
(HIPAA, por sus siglas en inglés) dicta que los empleados puedan inscribirse a sí mismos y/o a su(s) dependiente(s)
en un Plan de Salud Colectivo de un empleador bajo ciertas circunstancias descritas a continuación, siempre que el
empleado notifique al empleador dentro de 60 días de los siguientes eventos:

Pérdida de cobertura de salud en otro plan del empleador (incluyendo la terminación de la cobertura COBRA);

Incorporación de un cónyuge por matrimonio; o

Incorporación de un(a) niño(a) dependiente por nacimiento, adopción, entrega en adopción o tutela temporal.
A partir del 1º de abril de 2009 se crearon dos derechos especiales de inscripción según la Ley de Reautorización del
Programa de Seguro Médico para Niños (Children’s Health Insurance Program Reauthorization Act o CHIP [por sus
siglas en inglés]) del 2009. Todos los planes de salud colectivos también deben permitir que los empleados y
dependientes que de otra forma no tengan derecho al plan de salud colectivo puedan inscribirse en el plan dentro de
60 días de los siguientes eventos:

Pérdida de elegibilidad para cobertura bajo un Medicaid estatal o un programa CHIP; o

Adquirir el derecho a asistencia de primas del estado por Medicaid o CHIP.
El empleado o dependiente debe solicitar la cobertura dentro de los 60 días posteriores a haber sido desvinculado de
la cobertura de Medicaid o CHIP o dentro de los 60 días de haber sido determinado elegible para recibir ayuda para
primas.
INFORMACIÓN SOBRE LA LEY DE LOS RECIÉN NACIDOS
Según la ley federal, los planes de salud colectivos y los emisores de seguros de salud que ofrecen cobertura médica
por lo general no pueden limitar los beneficios para estadías en hospitales relacionadas con nacimientos para la
madre o el recién nacido a menos de 48 horas tras un parto natural o menos de 96 horas tras un parto por cesárea.
Sin embargo, el plan o el emisor puede pagar una estadía de menor duración si el proveedor al cual se acude (por ej.
su médico, enfermera, partera o asistente médico) tras ser consultado con la madre, da de alta a la madre o al recién
nacido antes.
Además, según la ley federal, el plan o los emisores no pueden determinar el nivel de beneficios o gastos por cuenta
propia para que la porción posterior de la estadía de 48 horas (o 96 horas) se considere de una forma menos
favorable a la madre o al recién nacido que la porción anterior de la estancia.
También, un plan o emisor no puede, según la ley federal, requerir que un médico u otro proveedor de atención
médica obtenga autorización para indicar una estadía de hasta 48 horas (o 96 horas). Sin embargo, para usar ciertos
proveedores o instalaciones, o reducir sus gastos por cuenta propia, puede que usted deba obtener una
precertificación. Para información sobre la precertificación contacte al administrador de su plan.
AVISO SOBRE LOS DERECHOS DE LA MUJER RESPECTO A SALUD Y CÁNCER
Según dicta la Ley de Derechos sobre la Salud y el Cáncer de la Mujer de 1998 (Women’s Health and Cancer Rights
Act of 1998 o WHCRA, por sus siglas en inglés), este plan médico provee cobertura para:

Todos los niveles de reconstrucción del seno al que se le practicado una mastectomía;

Cirugía y reconstrucción del otro seno para crear una apariencia simétrica;

Prótesis y complicaciones físicas de la mastectomía, incluyendo linfoedemas, de la forma determinada en la
consulta con el médico responsable y la paciente.
Estos beneficios serán provistos sujetos a los mismos deducibles y coaseguro aplicables a otros beneficios médicos y
quirúrgicos brindados dentro de este plan. Si usted desea más información sobre los beneficios de WHCRA, llame al
administrador de su plan.
2
Asistencia con las primas bajo Medicaid y el Programa de Seguro de Salud para Menores (CHIP)
Si usted o sus hijos son elegibles para Medicaid o CHIP y usted es elegible para cobertura médica de su empleador,
su estado puede tener un programa de asistencia con las primas que puede ayudar a pagar por la cobertura,
utilizando fondos de sus programas Medicaid o CHIP. Si usted o sus hijos no son elegibles para Medicaid o CHIP,
usted no será elegible para estos programas de asistencia con las primas, pero es probable que pueda comprar
cobertura de seguro inividual a través del mercado de seguros médicos. Para obtener más información, visite
www.healthcare.gov.
Si usted o sus dependientes ya están inscritos en Medicaid o CHIP y usted vive en uno de los estados enumerados a
continuación, comuníquese con la oficina de Medicaid o CHIP de su estado para saber si hay asistencia con primas
disponible.
Si usted o sus dependientes NO están inscritos actualmente en Medicaid o CHIP, y usted cree que usted o cualquiera
de sus dependientes puede ser elegible para cualquiera de estos programas, comuníquese con la oficina de Medicaid
o CHIP de su estado, llame al 1-877-KIDS NOW o visite www.insurekidsnow.gov para información sobre como
presentar su solicitud. Si usted es elegible, pregunte a su estado si tiene un programa que pueda ayudarle a pagar
las primas de un plan patrocinado por el empleador.
Si usted o sus dependientes son elegibles para asistencia con primas bajo Medicaid o CHIP, y también son elegibles
bajo el plan de su empleador, su empleador debe permitirle inscribirse en el plan de su empleador, si usted aún no
está inscrito. Esto se llama oportunidad de “inscripción especial”, y usted debe solicitar la cobertura dentro de los
60 días de haberse determinado que usted es elegible para la asistencia con las primas. Si tiene preguntas
sobre la inscripción en el plan de su empleador, comuníquese con el Departamento del Trabajo electrónicamente a
través de www.askebsa.dol.gov o llame al servicio telefónico gratuito 1-866-444-EBSA (3272).
Si usted vive en uno de los siguientes estados, tal vez sea elegible para asistencia para pagar las primas del
plan de salud de su empleador. La siguiente es una lista de estados actualizada al 31 de julio de 2015.
Comuníquese con su estado para obtener más información sobre la elegibilidad –
ALABAMA – Medicaid
Sitio web: http://www.myalhipp.com Teléfono: 1‐855‐692‐5447
GEORGIA – Medicaid
Sitio web: http://dch.georgia.gov/ Haga clic en “Programs,” luego en “Medicaid,” luego en “Health Insurance Premium Payment (HIPP)” Teléfono: 404‐656‐4507 ALASKA – Medicaid
Sitio web: http://health.hss.state.ak.us/dpa/programs/medicaid/ Teléfono (Fuera de Anchorage): 1‐888‐318‐8890 Teléfono (Anchorage): 907‐269‐6529
INDIANA - Medicaid
Sitio web: http://www.in.gov/fssa Teléfono: 1‐800‐889‐9949
COLORADO – Medicaid
Sitio web de Medicaid: http://www.colorado.gov/ Medicaid Phone (fuera de estado): 1‐800‐221‐3943
IOWA – Medicaid
Sitio web: www.dhs.state.ia.us/hipp/ Teléfono: 1‐888‐346‐9562 FLORIDA – Medicaid
Sitio web: https://www.flmedicaidtplrecovery.com/ Teléfono: 1‐877‐357‐3268
KANSAS – Medicaid
Sitio web: http://www.kdheks.gov/hcf/ Teléfono: 1‐800‐792‐4884
KENTUCKY – Medicaid
Sitio web: http://chfs.ky.gov/dms/default.htm Teléfono: 1‐800‐635‐2570 NUEVO HAMPSHIRE – Medicaid
Sitio web: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Teléfono: 603‐271‐5218 LOUISIANA – Medicaid
Sitio web: http://dhh.louisian.gov/index.cfm/subhome/1/n/331 Teléfono: 1‐888‐695‐2447
NUEVA JERSEY – Medicaid y CHIP
Sitio web de Medicaid: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Teléfono de Medicaid: 609‐631‐2392 Sitio web de CHIP: http://www.njfamilycare.org/index.html Teléfono de CHIP: 1‐800‐701‐0710 3
MAINE – Medicaid
Sitio web: http://www.maine.gov/dhhs/ofi/public‐
assistance/index.html Teléfono: 1‐800‐977‐6740 TTY: 1‐800‐977‐6741 NUEVA YORK – Medicaid
Sitio web: http://www.nyhealth.gov/health_care/medicaid/ Teléfono: 1‐800‐541‐2831 MASSACHUSETTS – Medicaid y CHIP
Sitio web: http://www.mass.gov/MassHealth Teléfono: 1‐800‐462‐1120 CAROLINA DEL NORTE – Medicaid
Sitio web: http://www.ncdhhs.gov/dma Teléfono: 919‐855‐4100 MINNESOTA – Medicaid
Sitio web: http://www.dhs.state.mn.us/ Haga clic en "Health Care” y luego en “Medical Assistance” Teléfono: 1‐800‐657‐3629 DAKOTA DEL NORTE – Medicaid
Sitio web: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Teléfono: 1‐800‐755‐2604 MISSOURI – Medicaid
Sitio web: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Teléfono: 573‐751‐2005
OKLAHOMA – Medicaid y CHIP
Sitio web: http://www.insureoklahoma.org Teléfono: 1‐888‐365‐3742
MONTANA – Medicaid
Sitio web: http://medicaid.mt.gov.member Teléfono: 1‐800‐694‐3084
OREGON – Medicaid
Sitio web: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Teléfono: 1‐800‐699‐9075 NEBRASKA – Medicaid
Sitio web: www.ACCESSNebraska.ne.gov Teléfono: 1‐855‐632‐7633
PENSILVANIA – Medicaid
Sitio web: http://www.dhs.state.pa.us/hipp Teléfono: 1‐800‐692‐7462 NEVADA – Medicaid
Sitio web de Medicaid: http://dwss.nv.gov/ Teléfono de Medicaid: 1‐800‐992‐0900 RHODE ISLAND – Medicaid
Sitio web: www.eohhs.ri.gov Teléfono: 401‐462‐5300 CAROLINA DEL SUR – Medicaid
Sitio web: http://www.scdhhs.gov Teléfono: 1‐888‐549‐0820 VIRGINIA – Medicaid y CHIP
Sitio web de Medicaid: http://www.coverva.org/programs_premium_assistance.cfm Teléfono de Medicaid: 1‐800‐432‐5924 Sitio web de CHIP: http://www.coverva.org/programs_premium_assistance.cfm Teléfono de CHIP: 1‐855‐242‐8282 DAKOTA DEL SUR- Medicaid
Sitio web: http://dss.sd.gov Teléfono: 1‐888‐828‐0059 WASHINGTON – Medicaid
Sitio web: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx Teléfono: 1‐800‐562‐3022 ext. 15473 TEXAS – Medicaid
Sitio web: https://www.gethipptexas.com/ Teléfono: 1‐800‐440‐0493 WEST VIRGINIA – Medicaid
Sitio web: www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx Teléfono: 1‐877‐598‐5820, HMS Third Party Liability UTAH – Medicaid y CHIP
Sitio web de Medicaid: http://health.utah.gov/medicaid Sitio web: http://health.utah.gov/upp Teléfono: 1‐866‐435‐7414
WISCONSIN – Medicaid
Sitio web: http://www.badgercareplus.org/pubs/p‐10095.htm Teléfono: 1‐800‐362‐3002 VERMONT– Medicaid
Sitio web: http://www.greenmountaincare.org/ Teléfono: 1‐800‐250‐8427
WYOMING – Medicaid y CHIP
Sitio web: http://health.wyo.gov/healthcarefin/equalitycare Teléfono: 307‐777‐7531 Para saber si otros estados han agregado el programa de asistencia con primas desde el 31 de julio de 2015, o para obtener más información sobre derechos de inscripción especial, comuníquese con alguno de los siguientes: Departamento del Trabajo de EE.UU. Administración de Seguridad de Beneficios de los Empleados www.dol.gov/ebsa 1‐866‐444‐EBSA (3272) Departamento de Salud y Servicios Humanos de EE.UU. Centros para Servicios de Medicare y Medicaid www.cms.hhs.gov 1‐877‐267‐2323, opción de menú 4, Ext. 61565 Número de Control de OMB 1210‐0137 (vence al 31 de octubre de 2016)
4
Aviso Importante de Pflugerville ISD Sobre su Cobertura
para Recetas Médicas y Medicare
Por favor lea este aviso cuidadosamente y guárdelo donde pueda encontrarlo. Este aviso contiene
información sobre su cobertura actual para recetas médicas con Pflugerville ISD y sus opciones bajo la
cobertura de Medicare para medicamentos recetados. Además, le menciona dónde encontrar más
información que le ayude a tomar decisiones sobre su cobertura para medicinas. Si usted está considerando
inscribirse, debe comparar su cobertura actual, incluyendo los medicamentos que están cubiertos a qué
costo, con la cobertura y los costos de los planes que ofrecen cobertura de medicinas recetadas en su área.
Información sobre dónde puede obtener ayuda para tomar decisiones sobre su cobertura de medicamentos
recetados se encuentra al final de este aviso.
Hay dos cosas importantes que usted necesita saber sobre su cobertura actual de Medicare y la
cobertura de medicamentos recetados:
1. La nueva cobertura de Medicare para recetas médicas está disponible desde el 2006 para todas las
personas con Medicare. Usted puede obtener esta cobertura si se inscribe en un Plan de Medicare para
Recetas Médicas, o un Plan Medicare Advantage (como un PPO o HMO) que ofrece cobertura para
medicamentos recetados. Todos los planes de Medicare para recetas médicas proporcionan por lo menos
un nivel estándar de cobertura establecido por Medicare. Además, algunos planes pueden ofrecer más
cobertura por una prima mensual más alta.
2. Pflugerville ISD ha determinado que la cobertura para recetas médicas ofrecida por el Pflugerville ISD en
promedio se espera que pague tanto como lo hará la cobertura estándar de Medicare para recetas médicas
para todos los participantes del plan y por lo tanto es considerada Cobertura Acreditable. Debido a que su
cobertura actual es Acreditable, usted puede mantener esta cobertura y no pagar una prima más alta (una
penalidad), si más tarde decide inscribirse en un plan de Medicare.
¿Cuándo puede inscribirse en un plan de Medicare de medicamentos?
Usted puede inscribirse en un plan de Medicare de medicamentos la primera vez que es elegible para
Medicare y cada año del 15 de octubre al 7 de diciembre.
Sin embargo, si pierde su cobertura actual acreditable, y no es su culpa, usted será elegible para dos (2)
meses en el Período de Inscripción Especial (SEP) para subscribirse en un Plan Medicare de medicinas.
¿Qué sucede con su cobertura actual si decide inscribirse en un plan de Medicare de
medicamentos?
Si decide inscribirse en un plan de Medicare de medicamentos recetados, su cobertura actual puede ser
afectada. Si decide inscribirse en un plan de Medicare de medicamentos recetados, su cobertura actual en el
plan de Humana de Pflugerville ISD puede ser afectada debido a una provisión de coordinación de beneficios
incluida en el plan médico de Pflugerville ISD. Si decide dejar la cobertura del plan médico de Pflugerville
ISD para inscribirse en el plan de prescripción de Medicare, es posible que se le permita regresar a la misma
cobertura de su plan anterior. Sin embargo, el plan de prescripción de Pflugerville ISD está incluido en el plan
médico de Pflugerville ISD y no es un beneficio que está disponible fuera del plan.
¿Cuándo usted pagará una prima más alta (penalidad) para inscribirse en un plan de
Medicare de medicamentos?
Usted debe saber también que si cancela o pierde su cobertura actual con Pflugerville ISD y deja de
inscribirse en una cobertura de Medicare para recetas médicas después de que su cobertura actual termine,
5
podría pagar más (una penalidad) por inscribirse más tarde en una cobertura de Medicare para recetas
médicas.
Si usted lleva 63 días o más sin cobertura acreditable para recetas médicas que sea por lo menos tan buena
como la cobertura de Medicare para recetas médicas, su prima mensual aumentará por lo menos un 1% al
mes por cada mes que usted no tuvo esa cobertura. Por ejemplo, si usted lleva diecinueve meses sin
cobertura acreditable, su prima siempre será por lo menos 19% más alta de lo que la mayoría de la gente
paga. Usted tendrá que pagar esta prima más alta (penalidad) mientras tenga la cobertura de Medicare. Además,
usted tendrá que esperar hasta el siguiente mes de octubre para inscribirse.
Para más información sobre este aviso o su cobertura actual para recetas médicas…
Llame a nuestra oficina para más información. NOTA: Usted recibirá este aviso cada año. Recibirá el aviso
antes del próximo período en el cual usted puede inscribirse en la cobertura de Medicare para recetas
médicas, y en caso de que esta cobertura con [Inserte el Nombre de la Entidad] cambie. Además, usted
puede solicitar una copia de este aviso en cualquier momento.
Para más información sobre sus opciones bajo la cobertura de Medicare para recetas
médicas…
Revise el manual “Medicare y Usted” para información más detallada sobre los planes de Medicare que
ofrecen cobertura para recetas médicas. Medicare le enviará por correo un ejemplar del manual. Tal vez los
planes de Medicare para recetas médicas le llamen directamente. Asimismo, usted puede obtener más
información sobre los planes de Medicare para recetas médicas de los siguientes lugares:
Visite www.medicare.gov por Internet para obtener ayuda personalizada,
Llame a su Programa Estatal de Asistencia sobre Seguros de Salud (consulte su manual Medicare y Usted
para obtener los números telefónicos)
Llame GRATIS al 1-800-MEDICARE (1-800-633-4227). Los usuarios con teléfono de texto (TTY) deben
llamar al 1-877-486-2048.
Para las personas con ingresos y recursos limitados, hay ayuda adicional que paga por un plan de Medicare
para recetas médicas. El Seguro Social (SSA, por sus siglas en inglés) tiene disponible información sobre
esta ayuda adicional. Para más información sobre esta ayuda adicional, visite la SSA en línea en
www.socialsecurity.gov por Internet, o llámeles al 1-800-772-1213 (Los usuarios con teléfono de texto (TTY)
deberán llamar al 1-800-325-0778.
Fecha:
Nombre de la Entidad/Remitente:
Contacto--Puesto/Oficina:
Dirección:
Número de Teléfono:
10/5/15
Pflugerville ISD
Kristin Baum / Risk Mgmt/Leave and Benefits Coordinator
1401 West Pecan Street
Pflugerville, TX 78660
512-594-0026
6

Humana Benefit Guide

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