Humana Benefit Guide
Transcription
Humana Benefit Guide
Pflugerville ISD Employee Handbook 2016 Pflugerville ISD Relationships are built on trust. Respect for an individual’s privacy goes a long way toward building trust. 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 + Spouse / Qualifying Individual EE + Child(ren) EE + Family EE Only EE + Spouse / Qualifying Individual EE + Child(ren) EE + Family EE Only EE + Spouse / Qualifying Individual 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 Employee Contribution $90 $467 $413 $785 iNGAGED Medical MID Plan Premium PISD Contribution $500 $375 $952 $375 $879 $375 $1,324 $375 Employee Contribution $125 $577 $504 $949 iNGAGED Medical HIGH Plan Premium PISD Contribution $596 $375 $1,169 $375 $1,078 $375 $1,597 $375 Employee Contribution $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 70% after deductible 70% after deductible 70% after deductible 80% after deductible 80% after deductible 90% after deductible 90% after deductible $150 copay $150 copay $150 copay $150 copay 70% after deductible 70% after deductible 80% after deductible 90% after deductible Included in office copay 100% no deductible Included in office copay 100% no deductible Included in office copay 100% no deductible Included in office copay 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 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 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 50% after deductible –––––––––––none––––––––––– $30 copay/visit $30 copay/visit 50% after deductible 50% after deductible Preventive care/screening/immunization No charge Hearing exam $30 copay/visit 50% after deductible 50% after deductible –––––––––––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) 50% after deductible 50% after deductible 50% after deductible No charge 30% after deductible 30% after deductible 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. –––––––––––none––––––––––– –––––––––––none––––––––––– 2 of 8 INGAGED LOW PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event Services You May Need 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 (up to a 30 day) Retail (90 day) Mail order (90 day) Level 3 - Highest cost drugs Retail (up to a 30 day) 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 Limitations & Exceptions 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 Medical benefits apply -Ambulance NONPAR will be subject to the PAR deductible. No Charge Not applicable 30% after deductible 50% after deductible 30% after deductible 50% after deductible $150 copay/visit 30% coinsurance after deductible $150 copay and 30% coinsurance 30% after deductible $150 copay/visit 30% coinsurance after deductible $150 copay and 50% after deductible 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 Coverage for: Single & Family | Plan Type: NPOS -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. 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. 3 of 8 INGAGED LOW PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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 Services You May Need Your Cost If You Use a PAR Provider Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider Emergency medical transportation 30% after deductible 30% after deductible Urgent care $40 copay/visit 50% after deductible Facility fee (e.g., hospital room) 30% after deductible 50% after deductible Physician/surgeon fee Mental/Behavioral health outpatient services (Therapies & Exams) Mental/Behavioral health inpatient services Substance use disorder outpatient services (Therapies & Exams) 30% after deductible 50% after deductible $30 copay/visit 50% after deductible 30% after deductible 50% after deductible $30 copay/visit 50% after deductible Substance use disorder inpatient services 30% after deductible 50% after deductible Prenatal and postnatal care $30 copay 50% after deductible Delivery and all inpatient services 30% after deductible 50% after deductible Home health care 30% after deductible 50% after deductible Rehabilitation services Physical and Occupational Therapy (at a clinic or outpatient location): All other therapies and locations covered by the plan: $30 copay/visit 50% after deductible 30% after deductible 50% after deductible NONPAR is subject to the PAR deductible. –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth. –––––––––––none––––––––––– –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth. –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth. -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 penalty for not obtaining prior auth. Physical therapy and occupational therapy in a clinic or outpatient locations is limited to 20 visits each. 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. 4 of 8 INGAGED LOW PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event If your child needs dental or eye care Your Cost If You Use a PAR Provider Services You May Need Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider Habilitation servicesPhysical and Occupational Therapy (at a clinic or outpatient location): All other therapies and locations covered by the plan: $30 copay/visit 50% after deductible 30% after deductible 50% after deductible Skilled nursing care 30% after deductible 50% after deductible Durable medical equipment 30% after deductible 50% after deductible Hospice service 30% after deductible 50% after deductible Eye exam Glasses Dental check-up $30 copay Not covered Not covered 50% after deductible Not covered Not covered Physical therapy and occupational therapy in a clinic or outpatient locations is limited to 20 visits each. -Limited to 60 visits - Prior auth required; There is a $250 penalty for not obtaining prior auth. Prior auth required; There is a $250 penalty for not obtaining prior auth. Prior auth required; There is a $250 penalty for not obtaining prior auth. –––––––––––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 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. 5 of 8 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 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.–––––––––––––––––––––– 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. 6 of 8 INGAGED LOW PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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 Coverage for: Single & Family | Plan Type: NPOS 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 Amount owed to providers: $5,400 Plan pays $2,590 Patient pays $2,810 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 Vaccines, other preventive 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 Limits or exclusions Total $2,150 $580 $0 $80 $2,810 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. 7 of 8 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 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. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. 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. 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. 8 of 8 NON-ENGAGED 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: $3,000 single/$6,000 family; NONPAR: $5,000 single/$10,000 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/$12,700 family; NONPAR: $15,000 single/$30,000 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. No. Does this plan use a network Yes. See www.humana.com for a list of of providers? PAR providers. Do I need a referral to see a specialist? Are there services 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. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term 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. No. You don’t need a referral to see a specialist. You can see the specialist you choose without permission from this plan. 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 NON-ENGAGED 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 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 50% after deductible –––––––––––none––––––––––– $45 copay/visit $45 copay/visit 50% after deductible 50% after deductible Preventive care/screening/immunization No charge Hearing exam $45 copay/visit 50% after deductible 50% after deductible –––––––––––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) 50% after deductible 50% after deductible 50% after deductible No charge 30% after deductible 30% after deductible 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. –––––––––––none––––––––––– –––––––––––none––––––––––– 2 of 8 NON-ENGAGED LOW PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event Drugs to treat your illness or condition More information about prescription drug coverage is available at www.humana.com Services You May Need 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 (up to a 30 day) Retail (90 day) Mail order (90 day) Level 3 - Highest cost drugs Retail (up to a 30 day) Retail (90 day) Mail order (90 day) Specialty Drugs -Drugs purchased at a pharmacy -Paid under medical benefits If you have outpatient surgery If you need immediate medical attention -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: Your Cost If You Use a PAR Provider $15 copay $45 copay $37.50 copay Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider PAR copay + 30% + the difference between the default rate and the Non-PAR pharmacy charge $55 copay $165 copay $137.50copay $75 copay $225 copay $187.50 copay Same as Level 1, 2 ,3 Same as Level 1, 2 , 3 Medical benefits apply Medical benefits apply No Charge Not applicable 30% after deductible 50% after deductible 30% after deductible 50% after deductible $150 copay/visit 30% coinsurance after deductible $150 copay and 30% coinsurance 30% after deductible $150 copay/visit 30% coinsurance after deductible $150 copay and 50% after deductible 50% after deductible -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: $15 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. -Ambulance NONPAR will be subject to the PAR deductible. 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. 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. 3 of 8 NON-ENGAGED LOW PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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 Services You May Need Your Cost If You Use a PAR Provider Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider Emergency medical transportation 30% after deductible 30% after deductible Urgent care $45 copay/visit 50% after deductible Facility fee (e.g., hospital room) 30% after deductible 50% after deductible Physician/surgeon fee Mental/Behavioral health outpatient services (Therapies & Exams) Mental/Behavioral health inpatient services Substance use disorder outpatient services (Therapies & Exams) 30% after deductible 50% after deductible $30 copay/visit 50% after deductible 30% after deductible 50% after deductible $30 copay/visit 50% after deductible Substance use disorder inpatient services 30% after deductible 50% after deductible Prenatal and postnatal care $45 copay 50% after deductible Delivery and all inpatient services 30% after deductible 50% after deductible Home health care 30% after deductible 50% after deductible Rehabilitation services Physical and Occupational Therapy (at a clinic or outpatient location): All other therapies and locations covered by the plan: $45 copay/visit 50% after deductible 30% after deductible 50% after deductible NONPAR is subject to the PAR deductible. –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth. –––––––––––none––––––––––– –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth.. –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth. -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 penalty for not obtaining prior auth.. Physical therapy and occupational therapy in a clinic or outpatient locations is limited to 20 visits each. 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. 4 of 8 NON-ENGAGED LOW PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event If your child needs dental or eye care Your Cost If You Use a PAR Provider Services You May Need Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider Habilitation servicesPhysical and Occupational Therapy (at a clinic or outpatient location): All other therapies and locations covered by the plan: $45 copay/visit 50% after deductible 30% after deductible 50% after deductible Skilled nursing care 30% after deductible 50% after deductible Durable medical equipment 30% after deductible 50% after deductible Hospice service 30% after deductible 50% after deductible Eye exam Glasses Dental check-up $45 copay Not covered Not covered 50% after deductible Not covered Not covered Physical therapy and occupational therapy in a clinic or outpatient locations is limited to 20 visits each. -Limited to 60 visits - Prior auth required; There is a $250 penalty for not obtaining prior auth. Prior auth required; There is a $250 penalty for not obtaining prior auth.. Prior auth required; There is a $250 penalty for not obtaining prior auth. –––––––––––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 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. 5 of 8 NON-ENGAGED 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 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.–––––––––––––––––––––– 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. 6 of 8 NON-ENGAGED LOW PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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 Coverage for: Single & Family | Plan Type: NPOS Having a baby Managing type 2 diabetes (normal delivery) (routine maintenance of a well-controlled condition) Amount owed to providers: $7,540 Plan pays $3,090 Patient pays $4,450 Amount owed to providers: $5,400 Plan pays $1,740 Patient pays $3,660 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 Vaccines, other preventive Total $2,900 $1,300 $700 $300 $100 $100 $5,400 Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $3,000 $20 $1,280 $150 $4,450 Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $3,000 $580 $0 $80 $3,660 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. 7 of 8 NON-ENGAGED 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 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. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. 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. 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. 8 of 8 INGAGED MID 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: $1,400 single/$2,800 family; NONPAR: $3,000 single/$6,000 family; PAR Preventive care is not subject to the deductible. Coinsurance & copayments don’t apply to the deductible. No. Yes. Medical: PAR: $4,400 single/$8,800 family; NONPAR: $9,000 single/$18,000 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. No. Does this plan use a network Yes. See www.humana.com for a list of of providers? PAR providers. Do I need a referral to see a specialist? Are there services 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. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term 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. No. You don’t need a referral to see a specialist. You can see the specialist you choose without permission from this plan. 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 MID 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 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 40% after deductible –––––––––––none––––––––––– $30 copay/visit $30 copay/visit 40% after deductible 40% after deductible Preventive care/screening/immunization No charge Hearing exam $30 copay/visit 40% after deductible 40% after deductible –––––––––––none––––––––––– –––––––––––none––––––––––– -NONPAR immunizations for age’s newborn to age 6 are covered at no charge. Ages 6 to 18 will be covered at 40% 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) 40% after deductible 40% after deductible 40% after deductible No charge 20% after deductible 20% after deductible 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. –––––––––––none––––––––––– –––––––––––none––––––––––– 2 of 8 INGAGED MID PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event drugs to treat your illness or condition More information about prescription drug coverage is available at www.humana.com Services You May Need 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 (up to a 30 day) Retail (90 day) Mail order (90 day) Level 3 - Highest cost drugs Retail (up to a 30 day) Retail (90 day) Mail order (90 day) Specialty Drugs -Drugs purchased at a pharmacy -Paid under medical benefits If you have outpatient surgery If you need immediate medical attention -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: Your Cost If You Use a PAR Provider $10 copay $30 copay $25 copay Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider PAR copay + 30% + the difference between the default rate and the Non-PAR pharmacy charge. $40 copay $120 copay $100 copay $60 copay $180 copay $150 copay Same as Level 1, 2 ,3 Same as Level 1, 2 , 3 Medical benefits apply Medical benefits apply No Charge Not applicable 20% after deductible 40% after deductible 20% after deductible 40% after deductible $150 copay/visit 20% coinsurance after deductible $150 copay and 20% coinsurance 20% after deductible $150 copay/visit 20% coinsurance after deductible $150 copay and 40% after deductible 40% after deductible -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. -Ambulance NONPAR will be subject to the PAR deductible. 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. 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. 3 of 8 INGAGED MID PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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 Services You May Need Your Cost If You Use a PAR Provider Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider Emergency medical transportation 20% after deductible 20% after deductible Urgent care $40 copay/visit 40% after deductible Facility fee (e.g., hospital room) 20% after deductible 40% after deductible Physician/surgeon fee Mental/Behavioral health outpatient services (Therapies & Exams) Mental/Behavioral health inpatient services Substance use disorder outpatient services (Therapies & Exams) 20% after deductible 40% after deductible $30 copay/visit 40% after deductible 20% after deductible 40% after deductible $30 copay/visit 40% after deductible Substance use disorder inpatient services 20% after deductible 40% after deductible Prenatal and postnatal care $30 copay 40% after deductible Delivery and all inpatient services 20% after deductible 40% after deductible Home health care 20% after deductible 40% after deductible Rehabilitation services Physical and Occupational Therapy (at a clinic or outpatient location): All other therapies and locations covered by the plan: $30 copay/visit 40% after deductible 20% after deductible 40% after deductible NONPAR is subject to the PAR deductible. –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth. –––––––––––none––––––––––– –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth.. –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth. -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 penalty for not obtaining prior auth.. Physical therapy and occupational therapy in a clinic or outpatient locations is limited to 20 visits each. 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. 4 of 8 INGAGED MID PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event If your child needs dental or eye care Your Cost If You Use a PAR Provider Services You May Need Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider Habilitation servicesPhysical and Occupational Therapy (at a clinic or outpatient location): All other therapies and locations covered by the plan: $30 copay/visit 40% after deductible 20% after deductible 40% after deductible Skilled nursing care 20% after deductible 40% after deductible Durable medical equipment 20% after deductible 40% after deductible Hospice service 20% after deductible 40% after deductible Eye exam Glasses Dental check-up $30 copay Not covered Not covered 40% after deductible Not covered Not covered Physical therapy and occupational therapy in a clinic or outpatient locations is limited to 20 visits each. -Limited to 60 visits - Prior auth required; There is a $250 penalty for not obtaining prior auth. Prior auth required; There is a $250 penalty for not obtaining prior auth.. Prior auth required; There is a $250 penalty for not obtaining prior auth. –––––––––––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 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. 5 of 8 INGAGED MID 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 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.–––––––––––––––––––––– 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. 6 of 8 INGAGED MID PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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 Coverage for: Single & Family | Plan Type: NPOS Having a baby Managing type 2 diabetes (normal delivery) (routine maintenance of a well-controlled condition) Amount owed to providers: $7,540 Plan pays $4,880 Patient pays $2,660 Amount owed to providers: $5,400 Plan pays $3,180 Patient pays $2,220 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 Vaccines, other preventive Total $2,900 $1,300 $700 $300 $100 $100 $5,400 Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $1,400 $20 $1,090 $150 $2,660 Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $1,400 $740 $0 $80 $2,220 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. 7 of 8 INGAGED MID 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 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. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. 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. 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. 8 of 8 INGAGED HIGH 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: $650 single/$1,300 family; NONPAR: $2,000 single/$4,000 family; PAR Preventive care is not subject to the deductible. Coinsurance & copayments don’t apply to the deductible. No. Yes. Medical: PAR: $2,150 single/$4,300 family; NONPAR: $6,000 single/$12,000 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. No. Does this plan use a network Yes. See www.humana.com for a list of of providers? PAR providers. Do I need a referral to see a specialist? Are there services 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. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term 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. No. You don’t need a referral to see a specialist. You can see the specialist you choose without permission from this plan. 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 HIGH 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 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 30% after deductible –––––––––––none––––––––––– $30 copay/visit $30 copay/visit 30% after deductible 30% after deductible Preventive care/screening/immunization No charge Hearing exam $30 copay/visit 30% after deductible 30% after deductible –––––––––––none––––––––––– –––––––––––none––––––––––– -NONPAR immunizations for age’s newborn to age 6 are covered at no charge. Ages 6 to 18 will be covered at 30% 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) 30% after deductible 30% after deductible 30% after deductible No charge 10% after deductible 10% after deductible 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. –––––––––––none––––––––––– –––––––––––none––––––––––– 2 of 8 INGAGED HIGH PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event drugs to treat your illness or condition More information about prescription drug coverage is available at www.humana.com Services You May Need 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 (up to a 30 day) Retail (90 day) Mail order (90 day) Level 3 - Highest cost drugs Retail (up to a 30 day) Retail (90 day) Mail order (90 day) Specialty Drugs -Drugs purchased at a pharmacy -Paid under medical benefits If you have outpatient surgery If you need immediate medical attention -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: Your Cost If You Use a PAR Provider $10 copay $30 copay $25 copay Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider PAR copay + 30% + the difference between the default rate and the Non-PAR pharmacy charge. $30 copay $90 copay $75 copay $50 copay $150 copay $125 copay Same as Level 1, 2 ,3 Same as Level 1, 2 , 3 Medical benefits apply Medical benefits apply No Charge Not applicable 10% after deductible 30% after deductible 10% after deductible 30% after deductible $150 copay/visit 10% coinsurance after deductible $150 copay and 10% coinsurance 10% after deductible $150 copay/visit 10% coinsurance after deductible $150 copay and 30% after deductible 30% after deductible -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. -Ambulance NONPAR will be subject to the PAR deductible. 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. 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. 3 of 8 INGAGED HIGH PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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 Services You May Need Your Cost If You Use a PAR Provider Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider Emergency medical transportation 10% after deductible 10% after deductible Urgent care $40 copay/visit 30% after deductible Facility fee (e.g., hospital room) 10% after deductible 30% after deductible Physician/surgeon fee Mental/Behavioral health outpatient services (Therapies & Exams) Mental/Behavioral health inpatient services Substance use disorder outpatient services (Therapies & Exams) 10% after deductible 30% after deductible $30 copay/visit 30% after deductible 10% after deductible 30% after deductible $30 copay/visit 30% after deductible Substance use disorder inpatient services 10% after deductible 30% after deductible Prenatal and postnatal care $30 copay 30% after deductible Delivery and all inpatient services 10% after deductible 30% after deductible Home health care 10% after deductible 30% after deductible Rehabilitation services Physical and Occupational Therapy (at a clinic or outpatient location): All other therapies and locations covered by the plan: $30 copay/visit 30% after deductible 10% after deductible 30% after deductible NONPAR is subject to the PAR deductible. –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth. –––––––––––none––––––––––– –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth. –––––––––––none––––––––––– Prior auth required; There is a $250 penalty for not obtaining prior auth. -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 penalty for not obtaining prior auth. Physical therapy and occupational therapy in a clinic or outpatient locations is limited to 20 visits each. 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. 4 of 8 INGAGED HIGH PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event If your child needs dental or eye care Your Cost If You Use a PAR Provider Services You May Need Coverage Period: 01/01/2016-12/31/2016 Coverage for: Single & Family | Plan Type: NPOS Your Cost If You Limitations & Exceptions Use a NONPAR Provider Habilitation servicesPhysical and Occupational Therapy (at a clinic or outpatient location): All other therapies and locations covered by the plan: $30 copay/visit 30% after deductible 10% after deductible 30% after deductible Skilled nursing care 10% after deductible 30% after deductible Durable medical equipment 10% after deductible 30% after deductible Hospice service 10% after deductible 30% after deductible Eye exam Glasses Dental check-up $30 copay Not covered Not covered 30% after deductible Not covered Not covered Physical therapy and occupational therapy in a clinic or outpatient locations is limited to 20 visits each. -Limited to 60 visits - Prior auth required; There is a $250 penalty for not obtaining prior auth. Prior auth required; There is a $250 penalty for not obtaining prior auth. Prior auth required; There is a $250 penalty for not obtaining prior auth. –––––––––––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 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. 5 of 8 INGAGED HIGH 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 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.–––––––––––––––––––––– 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. 6 of 8 INGAGED HIGH PLAN: PFLUGERVILLE ISD Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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 Coverage for: Single & Family | Plan Type: NPOS Having a baby Managing type 2 diabetes (normal delivery) (routine maintenance of a well-controlled condition) Amount owed to providers: $7,540 Plan pays $6,100 Patient pays $1,440 Amount owed to providers: $5,400 Plan pays $3,760 Patient pays $1,640 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 Vaccines, other preventive Total $2,900 $1,300 $700 $300 $100 $100 $5,400 Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $650 $20 $620 $150 $1,440 Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $650 $910 $0 $80 $1,640 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. 7 of 8 INGAGED HIGH 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 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. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. 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. 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. 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