St Lawrence-Lewis Counties School District Employees Medical

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St Lawrence-Lewis Counties School District Employees Medical Plan Plan B Rider 9-Coverage Period: 07/01/2014–06/30/2015
Summary of Benefits and Coverage-What this Plan Covers & What it Cost-Coverage for Individual,2-Person,Family|PlanType:PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.sllboces.org or by calling 1-800-722-0782.
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?
Does this plan use a
network of providers?
Answers
Why this Matters:
$200 person
$600 family
For out-of-network services
only.
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).
None
$ 800 person
$2400 family
For out-of-network services
only.
Premiums, in-network copays
(with the exception of $50 or
higher copays), prescription
drug copays, balanced billed
charges.
The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health
care expenses.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
No
Yes, however use of
participating providers is totally
voluntary.
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.
Do I need a referral to see a
specialist?
No
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 6. See your policy or plan
document for additional information about excluded services.
Questions: Call 1-800-722-0782 or visit us at www.sllboces.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.sllboces.org or call 1-800-722-0782 to request a copy.
OMB Control Numbers 1545-2229,
1210-0147, and 0938-1146
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Co-payments are fixed dollar amounts (for example, $25) you pay for covered health care, usually when you receive the
service from an in-network provider.
Co-insurance is your share of the costs of a covered out-of-network 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 would 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 would have to pay the $500 difference. (This is called
balance billing.)
Common
Medical Event
Your cost if you use an
Services You May Need
Primary care visit to treat an injury or illness
Specialist visit
If you visit a health
care provider’s office
or clinic
Other practitioner office visit
Preventive care/screening/immunization
If you have a test
Diagnostic test ( blood/lab work)
In-network
Provider
Out-of-network
Provider
After deductible, 20%
coinsurance + any
$25.00
amount in excess of
UCR.
coinsurance + any
$25.00
amount in excess of
UCR.
coinsurance + any
$25.00
amount in excess of
UCR.
coinsurance + any
$0.00
amount in excess of
UCR
Preferred Lab -$0.00
coinsurance + any
Non Preferred Labamount in excess of
$25.00
UCR
Limitations & Exceptions
Benefits provided in
accordance with the Affordable
Care Act.
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Common
In-network
Out-of-network
Medical Event
Provider
Provider
coinsurance + any
Imaging (X-ray, CT/PET scans, MRIs)
$0.00
amount in excess of
UCR
Generic drugs
If you need drugs to
$13.00 Retail
Retail = 30 day fill
Not covered
treat your illness or
$13.00 Mail Order
Mail Order = 90 day fill
Plan Caps out of pocket costs
condition
Preferred brand drugs
for Prescriptions as follows:
$30.00 Retail
Not covered
Individual - $420
More information
$60.00
Mail
Order
Two-person - $840
about prescription
Family $1,260
Non-preferred brand drugs
drug coverage is
$60.00 Retail
Not covered
available at
$120.00 Mail Order
www.sllboces.org.
$60.00 (30 day fill)
Specialty drugs
Not covered
coinsurance + any
Ambulatory Surgery
$40.00
amount in excess of
UCR
coinsurance + any
If you have
Physician/surgeon fees
$0.00
amount in excess of
outpatient surgery
UCR
coinsurance + any
Anesthesia services
$0.00
amount in excess of
UCR
NYS Emergency care mandate
Emergency room services
$75.00
$75.00
applies. Copay waived if
If you need
admitted.
immediate medical
attention
Emergency medical transportation
$25.00
coinsurance + amount
in excess of UCR
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Common
In-network
Out-of-network
Medical Event
Provider
Provider
Urgent care
$25.00
in excess of UCR
Hospital Room and Board
$200.00
in excess of UCR
If you have a
hospital stay
Physician/surgeon
$0.00
in excess of UCR
Mental/Behavioral health outpatient services
$25.00
in excess of UCR
Mental/Behavioral health inpatient services
$200.00
If you have mental
in excess of UCR
health, behavioral
health, or substance
abuse needs
Substance use disorder outpatient services
$25.00
in excess of UCR
Substance use disorder inpatient services
$200.00
in excess of UCR
$25.00 Copay
Prenatal and postnatal care
Initial visit only
in excess of UCR
If you are pregnant
Hospital Room and Board
$200.00
in excess of UCR
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Common
In-network
Out-of-network
Medical Event
Provider
Provider
Home health care
Therapy services
If you need help
recovering or have
other special health
needs
$25.00
in excess of UCR
Inpatient skilled nursing care
$200.00
Durable medical equipment
In excess of $200 $50.00 Less than $200
- $25.00
Hospice Care
If your child needs
dental or eye care
$25.00
in excess of UCR
Eye exam
Glasses
Dental check-up
in excess of UCR
in excess of UCR
$0.00
in excess of UCR
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Maximum benefit limited to 40
visits per calendar year. Four
hours of care constitutes one
home health aide visit.
Limited to 365 days a calendar
year. Admission must be within
30 days of a prior hospital stay.
Care for terminally ill. Benefit
limited to 210 days maximum
per lifetime. Bereavement
counseling limited to
immediate family for up to 5
days.
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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.)
Reversal of sterilization
Hearing aids
Cosmetic surgery
Routine foot care
Routine dental services
Routine eye care
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
Chemo/Radiation/Cardiac Therapy
Organ/Tissue Transplants
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and state laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you
pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800-722-0782. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa or the U.S. Department of Health and
Human Services at 1-877-267-2323 x 61565 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: The St. Lawrence-Lewis Counties School District Employees Medical Plan
Administrator at: 1-800-722-0782.
––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––
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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.
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays Contracted fee allowances
 Patient pays $ 251.00
 Amount owed to providers: $4,100
 Plan pays Contracted fee allowances
 Patient pays $215.00
Sample care costs: In-network providers
Hospital charges (mother)
$2,700
($200)
$2,100
Routine obstetric care ($25)
$900
Hospital charges (baby) ($0)
$900
Anesthesia ($0)
Laboratory tests ($0) Preferred
$500
Lab
$200
Prescriptions – 2 generic ($26)
$200
Radiology ($0)
$40
Vaccines, other preventive ($0)
$7,540
Total
Sample care costs: In-network providers
$1,500
Prescriptions (5 generic) ($65)
Medical Equipment ($1000) and
$1,300
Supplies ($300) ($50)
Office Visits (2) and Procedures
$730
($50)
$290
Education (2 visits) ($50)
Laboratory tests (12
$140
tests)Preferred Lab ($0)
Vaccines, other preventive
$140
(2)($0)
$4,100
Total
Patient pays:
Deductibles
Co-pays
Co-insurance
Limits or exclusions - None
Total
Patient pays:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total
$0.00
$251.00
$0.00
$0.00
$251.00
$0.00
$215.00
$0.00
$0.00
$215.00
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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?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments, and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example predict my own
care needs?
 No. Treatments shown are just examples. The
care you would receive for this condition
could be different based on your doctor’s
advice, your age, how serious your condition
is, and many other factors.
Are there other costs I should consider when
comparing plans?
Yes. An important cost is the premium you
pay. Generally, the lower your premium, the
more you’ll pay in out-of-pocket costs, such
as co-payments, 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.
Does the Coverage Example predict my
future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your own
costs will be different depending on the care
you receive, the prices your providers
charge, and the reimbursement your health
plan allows.
Can I use Coverage Examples to compare
plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans, you’ll
find the same Coverage Examples. When
you compare plans, check the “Patient Pays”
box in each example. The smaller that
number, the more coverage the plan
provides.
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St Lawrence-Lewis Counties School District Employees Medical

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