2016 AWANE NH Comp

7/24/2019 2016 AWANE NH Comp

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Awane: New Hampshire Comprehensive EPO Coverage Period: 01/01/2016 - 12/1/2016

!"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: EPO

'his is on&# a s"mmar#( If you want more detail about your coverage and costs, you can get the complete

terms in the policy or plan document at https://eoc.anthem.com/eocdps/aso or by calling 1-855-271-4549.

)mpor%an% *"es%ions Answers +h# %his ,a%%ers:

What is theoveralldeductible?

For in-networkproviders

1.20 individual / 2.00family

Doesn’t apply to in-network preventive careand routine eye eams.

!ou must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. "heck your policy orplan document to see when the deductible starts over #usually, butnot always, $anuary %st&. 'ee the chart starting on page ( for howmuch you pay for covered services after you meet the deductible.

Are there otherdeductibles for

specic services?

!es. 20 deductible forDurable )edical*+uipment per memberper calendar year.

!ou must pay all of the costs for these services up to the specicdeductible amount before this plan begins to pay for these services.

Is there an outofpoc!et li"iton "# e$penses?

!es. For in-networkproviders

6.0 individual /12.00 family

he out-of-poc!et li"it is the most you could pay during a coverageperiod #usually one year& for your share of the cost of coveredservices. his limit helps you plan for health care epenses.

What is notincluded in the

outofpoc!etli"it?

alance-illed charges,ealth "are this plandoesn’t cover,

0remiums, and 1ut-of-network pharmacyclaims.

*ven though you pay these epenses, they don’t count toward the

out-of-poc!et li"it.

Is there anoverall annualli"it on %hat theplan pa#s?

2o.he chart starting on page ( describes any limits on what the planwill pay for specifc covered services, such as o3ice visits.

&uestions' "all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re+uest a copy.

https://eoc.anthem.com/eocdps/aso

https://eoc.anthem.com/eocdps/aso

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)oes this planuse a net%or! ofproviders?

!es. For a list ofpreferred providers,see www.anthem.com orcall %-566-(7%-8689

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. e aware,

your in-network doctor or hospital may use an out-of-networkprovider for some services. 0lans use the term in-network,preferred, or participating for providers in their net%or! . 'ee the

chart starting on page ( for how this plan pays di3erent kinds ofproviders.

)o I need areferral to see aspecialist?

2o. !ou can see the specialist you choose without permission from thisplan.

Are thereservices this plandoesn*t cover?

!es.'ome of the services this plan doesn’t cover are listed on page 5. 'ee

your policy or plan document for additional information aboute$cluded services.

•

+opa#"ents are ed dollar amounts #for eample, :%6& you pay for covered health care, usually when youreceive the service.

• +oinsurance is your share of the costs of a covered service, calculated as a percent of the allo%ed

a"ount for the service. For eample, if the plan’s allo%ed a"ount for an overnight hospital stay is:%,;;;, your coinsurance payment of (;< would be :(;;. his may change if you haven’t met yourdeductible.

• he amount the plan pays for covered services is based on the allo%ed a"ount. If an out-of-network

provider charges more than the allo%ed a"ount, you may have to pay the di3erence. For eample, if anout-of-network hospital charges :%,6;; for an overnight stay and the allo%ed a"ount is :%,;;;, you mayhave to pay the :6;; di3erence. #his is called balance billin,.&

• his plan may encourage you to use In-2etwork providers by charging you lower deductibles,

copa#"ents and coinsurance amounts.

Common

,edia& Even%!ervies o" ,a# Need

o"r Cos% )f o" 3se an)n-ne%worProvider

o"r Cos% )f o" 3se an

O"%-of-ne%worProvider

5imi%a%ions E7ep%ions

0rimary care visit to treat anin=ury or illness

:>; copay/visit 2ot "overed ????????????none????????????


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Common






If #ou visit ahealth careprovider*soice or clinic

'pecialist visit :6; copay/visit 2ot "overed ????????????none????????????

1ther practitioner o3ice visit

"hiropractor:6; copay/visit

@cupuncturist2ot covered

"hiropractor2ot "overed

@cupuncturist2ot covered

"hiropractic care is limitedto %( visits per member percalendar year.

0reventivecare/screening/immuniAation

2o "ost 'hare 2ot "overed ????????????none????????????

If #ou have atest

Diagnostic test #-ray, bloodwork&

2o cost sharefor labs ino3ice or

independentlabB otherservices ;<coinsurance

2ot "overed

Deductible waived when lab

services performed in o3iceor independent lab. "ostsmay vary by site of service.

Imaging #"/0* scans, )CIs&;<coinsurance

2ot "overed ????????????none????????????

If #ou needdru,s to treat #our illness orcondition

)oreinformationaboutprescriptiondru, covera,e is available atwww.medco.com

4eneric drugs #Cetail/>; day )ail/9;day&

:%6 Cetail/:>;)ail

2ot "overed)aintenance )eds are re+uired to belled mail order after > lls at retail#penalty applies&. If pre-auth re+uired Enot obtained, drug may not be covered."ertain 0reventive meds no copay. If ageneric e+uivalent is available E brand isprescribed/member will pay brand namecost di3erence. 0lan uses preferred druglist to identify coverage.

0referred brand drugs #Cetail/>; day)ail/9; day&

:8; Cetail/:%;;)ail

2ot "overed

2on-preferred brand #Cetail/>;day)ail/9;day&

:7; Cetail/:%76)ail

2ot "overed

'pecialty drugs

@ll 'pecialtymeds process

through @ccredo at the

mail ordercosts.

2ot "overed

he mail order cost will bebased on the medication tier#generic, preferred, non-preferred&. 'pecialty medscan not be lled at retailpharmacies.


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Common






If #ou haveoutpatientsur,er#

Facility fee #e.g., ambulatorysurgery center&

:76 copay/visitfor ambulatorysurgicalcenterB othersites of service;<coinsurance

2ot "overed"osts may vary by site ofservice.

0hysician/surgeon fees;<coinsurance

2ot "overedDeductible waived whenperformed in an ambulatorysurgical center.

If #ou needi""ediate"edicalattention

*mergency room services

:(6; copay

/visitBprofessionaland otherservicessub=ect todeductible

:(6;

copay/visitBprofessionaland otherservicessub=ect todeductible

:(6; copay waived ifadmitted. )ember may bebalance billed for out ofnetwork services.

*mergency medicaltransportation

;<coinsurance

;<coinsurance

)ember may be balancebilled for out of networkservices.

rgent care :6; copay/visit 2ot "overed ????????????none????????????

If #ou have ahospital sta#

Facility fee #e.g., hospital room&;<coinsurance

2ot "overed

0hysical )edicine andCehabilitation limited to %;;days per member percalendar year.

0hysician/surgeon fee;<coinsurance

2ot "overed ????????????none????????????


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Common






If #ou have"ental health.behavioralhealth. orsubstanceabuse needs

)ental/ehavioral healthoutpatient services

)ental/ehavi

oral ealth13ice Gisit

:>; copay/visit

)ental/ehavioral ealth

Facility Gisit

;<coinsurance

)ental/ehavioralealth

13ice Gisit

2ot"overed

)ental/ehavioral ealth

Facility

Gisit 2ot"overed

????????????none????????????

)ental/ehavioral healthinpatient services

;<coinsurance

2ot "overed ????????????none????????????

'ubstance use disorderoutpatient services

'ubstance @buse 13ice

Gisit:>; copay/visit

'ubstance @buse Facility

Gisit;<coinsurance

'ubstance @buse 13ice

Gisit 2ot

"overed

'ubstance @buse Facility

Gisit 2ot"overed

????????????none????????????

'ubstance use disorder inpatientservices

;<coinsurance

2ot "overed ????????????none????????????


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Common






If #ou arepre,nant

0renatal and postnatal care;<coinsurance

2ot "overed ????????????none????????????

Delivery and all inpatient services;<coinsurance

2ot "overed ????????????none????????????


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Common






If #ou needhelp recoverin,

or have otherspecial healthneeds

ome health care;<coinsurance

2ot "overed ????????????none????????????

Cehabilitation services

:6; copay/visitfor outpatientservices.Inpatientservicessub=ect todeductible.

2ot "overed

Himited to ; visits permember per calendar yearfor physical therapy,occupational therapy, andspeech therapy combined.

abilitation services

:6; copay/visitfor outpatient

services.Inpatientservicessub=ect todeductible.

2ot "overed

@ll rehabilitation and

habilitation visits counttoward your rehabilitation

visit limit.

'killed nursing care;<coinsurance

2ot "overedHimited to %;; days percalendar year.

Durable medical e+uipment

:(6;deductiblethen (;<

coinsurance

2ot "overed

'upplies are sub=ect to :(6;deductible per member per

year. )$ @ppliances are

not covered.ospice service

;<coinsurance

2ot "overed ????????????none????????????

If #our childneeds dental or e#e care

*ye eam 2o "ost 'hare 2ot "overed 1ne eam each calendar year for members ages %5 years and younger. 1neeam every two calendar

years for members %9 yearsand older.


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Common






4lasses 2ot "overed 2ot "overed?????????????none????????????

Dental check-up 2ot "overed 2ot "overed?????????????none????????????

E7&"ded !ervies O%her Covered !ervies:

!ervies o"r P&an 9oes NO' Cover /0his isn*t a co"plete list( +hec! #our polic# or plan docu"ent for othere$cluded services(

J @cupuncture

J "osmetic surgery

J Dental care #@dult&

J earing aids

J Infertility treatment

J Hong-term care

J Coutine foot care

J Keight loss programs

O%her Covered !ervies /0his isn*t a co"plete list( +hec! #our polic# or plan docu"ent for other covered

services and #our costs for these services(

J ariatric surgery #Himitations )ay @pply&

J "hiropractic care #Himitations )ay @pply&

J )ost coverage provided outside thenited 'tates. 'eewww."'.com/bluecardworldwide

J 0rivate-duty nursing #coveredunder ome ealth "are&

J Coutine eye care #@dult ?Himitations )ay @pply&


http://www.bcbs.com/bluecardworldwide

http://www.bcbs.com/bluecardworldwide

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o"r ;igh%s %o Con%in"e Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and 'tate laws may provide

protections that allow you to keep health coverage. @ny such rights may be limited in duration and will re+uire you

to pay a pre"iu", which may be signicantly higher than the premium you pay while covered under the plan.

1ther limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at %-5;;-(65-6>%5. !ou may also contact

your state insurance department, the .'. Department of Habor, *mployee enets 'ecurity @dministration at %-5-888->(7( or www.dol.gov/ebsa, or the .'. Department of ealth and uman 'ervices at %-577-(7-(>(> %66 orwww.cciio.cms.gov.

o"r <rievane and Appea&s ;igh%s:

If you have a complaint or are dissatised with a denial of coverage for claims under your plan, you may be able to appeal or le a ,rievance. For +uestions about your rights, this notice, or assistance, you can contact

@nthem lue "ross lue 'hield"linical @ppeals 0.1. o %;665 @tlanta, 4@ >;>851perational @ppeals 0.1. o %;665 @tlanta, 4@ >;>85

For grievances and/or appeals regarding you prescription drug coverage, call the number listed on the back ofprescription member ID card or visit www.epress-scripts.com.

For *CI'@ information contact

Department of Habor’s *mployee enets 'ecurity @dministration%-5-888-*'@ #>(7(&www.dol.gov/ebsa/healthreform

@dditionally, a consumer assistance program can help you le your appeal. "ontact


http://www.dol.gov/ebsa

http://www.cciio.cms.gov/

http://www.express-scripts.com/

http://www.dol.gov/ebsa

http://www.cciio.cms.gov/

http://www.express-scripts.com/

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!"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: EPO2ew ampshire Department of Insurance(% 'outh Fruit 'treet, 'uite %8"oncord, 2 ;>>;%#5;;& 56(->8%www.nh.gov/insuranceconsumerservicesLins.nh.gov

9oes %his Coverage Provide ,inim"m Essen%ia& Coverage=

he @3ordable "are @ct re+uires most people to have health care coverage that +ualies as Mminimum essentialcoverage.N This plan or policy does provide minimum essential coverage.

9oes %his Coverage ,ee% %he ,inim"m >a&"e !%andard=

he @3ordable "are @ct establishes a minimum value standard of benets of a health plan. he minimum value

standard is ;< #actuarial value&. This health coverage does meet the minimum value standard for the

benets it provides.

5ang"age Aess !ervies:


mailto:[email protected]

mailto:[email protected]

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??????????????????????To see examples o how this plan might cover costs or a sample medical situation, see the nextpage.–––––––––––???????????


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Having a ?a?##normal delivery&

,anaging %#pe 2 dia?e%es#routine maintenance of

a well-controlled condition&

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Coverage E7amp&es

Coverage for: Individual/Family | P&an '#pe: EPO

A?o"% %hese CoverageE7amp&es:

hese eamples show how this planmight cover medical care in givensituations. se these eamples tosee, in general, how much nancialprotection a sample patient mightget if they are covered underdi3erent plans.

Amo"n% owed %o providers: $7,54

P&an pa#s $!,"#

Pa%ien% pa#s $",4#

!amp&e are os%s:

ospital charges #mother&:(,7;

;

Coutine obstetric care:(,%;

;

ospital charges #baby& :9;; @nesthesia :9;;

Haboratory tests :6;;

0rescriptions :(;;

Cadiology :(;;

Gaccines, other preventive :8;

0otal7.54

3

Pa%ien% pa#s:

Deductibles :%,(6;

"opays :(;

"oinsurance :;

Himits or eclusions :%6;

0otal1.42

3

Amo"n% owed %o providers: $5,4

P&an pa#s $#,

Pa%ien% pa#s $#,4"

!amp&e are os%s:

0rescriptions:(,9;

;)edical *+uipment and

'upplies

:%,>;

;13ice Gisits and 0rocedures :7;;

*ducation :>;;

Haboratory tests :%;;

Gaccines, other preventive :%;;

0otal5.43

3

Pa%ien% pa#s:

Deductibles:%,(

;"opays ;

"oinsurance :(;;

Himits or eclusions:(,9>

;

0otal4.9

3


'his isno% a os%es%ima%or(

Don’t use theseeamples to estimate

your actual costs underthis plan. he actualcare you receive will bedi3erent from theseeamples, and the costof that care will also bedi3erent.

'ee the net page forimportant information

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*"es%ions and answers a?o"% %he Coverage E7amp&es:

+ha% are some of %heass"mp%ions ?ehind %heCoverage E7amp&es=

• "osts don’t include pre"iu"s.

• 'ample care costs are based onnational averages supplied bythe .'. Department of ealthand uman 'ervices, andaren’t specic to a particulargeographic area or health plan.

• he patient’s condition was notan ecluded or preeisting

condition.• @ll services and treatments

started and ended in the samecoverage period.

• here are no other medicalepenses for any membercovered under this plan.

• 1ut-of-pocket epenses arebased only on treating thecondition in the eample.

• he patient received all carefrom in-network providers. Ifthe patient had received carefrom out-of-network providers,costs would have been higher.

+ha% does a Coverage E7amp&eshow=

For each treatment situation, the

"overage *ample helps you seehow deductibles, copa#"ents,and coinsurance can add up. Italso helps you see what epensesmight be left up to you to paybecause the service or treatmentisn’t covered or payment is limited.

9oes %he Coverage E7amp&e

predi% m# own are needs= o( reatments shown are =ust

eamples. he care you wouldreceive for this condition couldbe di3erent based on yourdoctor’s advice, your age, howserious your condition is, andmany other factors.

9oes %he Coverage E7amp&epredi% m# f"%"re e7penses=

o( "overage *amples are not

cost estimators. !ou can’t usethe eamples to estimate costsfor an actual condition. hey arefor comparative purposes only.

!our own costs will be di3erentdepending on the care youreceive, the prices yourproviders charge, and thereimbursement your health planallows.

Can ) "se Coverage E7amp&es

%o ompare p&ans=

6es( Khen you look at the

'ummary of enets and"overage for other plans, you’llnd the same "overage*amples. Khen you compareplans, check the M0atient 0aysNbo in each eample. hesmaller that number, the morecoverage the plan provides.

Are %here o%her os%s ) sho"&donsider when omparingp&ans=

6es( @n important cost is the

pre"iu" you pay. 4enerally,the lower your pre"iu", themore you’ll pay in out-of-pocket

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costs, such as copa#"ents,deductibles, and coinsurance.

!ou should also consider

contributions to accounts suchas health savings accounts#'@s&, Oeible spendingarrangements #F'@s& or health

reimbursement accounts #C@s&that help you pay out-of-pocketepenses.

Documents

2016 AWANE NH Comp