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CITY OF BURLEY Coverage Period: 10/01/2019 - 09/30/2020 Coverage for: Single/Family I Plan Type: POSID Why this Matters: Summary of Benefits and Coverage: What this Plan Covers & What it Costs The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit selecthealth.org or call 800-538- 5038. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at selecthealth.org/sbc or call [PHONE REDACTED] to request a copy. Important Questions Answers What is the overall deductible? $2,000 person/$4,000 family participating and $4,000 person/$8,000 family non-participating per calendar year. Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. What is the out-of-pocket limit for this plan? $3,500 person/$7,000 family participating and $7,000 person/$14,000 family non-participating. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of- pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out–of–pocket limit? Premiums, balance-billed charges, infertility services, healthcare this plan doesn't cover, and penalties for failure to obtain preauthorization for services. Even though you pay these expenses, they don't count toward the out-of-pocket limit. Are there services covered before you meet your deductible? Yes, for in-network providers: preventive care, office visits, prescription drugs, and chiropractic services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. Will you pay less if you use a network provider? Yes. To find an in-network provider visit selecthealth.org/findadoctor or call Member Services at [PHONE REDACTED]. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. * For more information about limitations and exceptions, see the plan or policy document at selecthealth.org/materials. 1 of 8 ---PAGE BREAK--- All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) No charge 50% co-insurance Frequency limitations apply. Deductible does not apply to in-network services. If you have a test Diagnostic test (x-ray, blood work) No charge 40% co-insurance Deductible does not apply to in-network services. Imaging (CT/PET scans, MRIs) 20% co-insurance If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness (PCP) $30/visit 40% co-insurance A different benefit may apply for major office surgery. Deductible does not apply to in-network services. Specialist visit (SCP) $30/visit 40% co-insurance Certain limitations apply to allergy testing, treatment and serum. A different benefit may apply for major office surgery. Deductible does not apply to in-network services. Preventive care / screening / immunization 40% co-insurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at selecthealth.org/prescrip tions/default.aspx?st=id &plan=select Standard Tier 1 (generic drugs) $15/prescription $15/prescription Certain limitations apply. Benefits may be denied or reduced by 50% for failure to obtain preauthorization for certain services. Maintenance Tier 2 (preferred brand drugs) $60/prescription $60/prescription Standard Tier 2 (preferred brand drugs) $30/prescription $30/prescription Standard Tier 3 (non- preferred brand drugs) $50/prescription $50/prescription Maintenance Tier 1 (generic drugs) $15/prescription $15/prescription Benefits may be denied or reduced by 50% for failure to obtain preauthorization for certain services. Maintenance Tier 3 (non- preferred brand drugs) $150/prescription $150/prescription Specialty drugs 20% co-insurance for medical, $100/prescription for pharmacy 40% co-insurance for medical, $100/prescription for pharmacy * For more information about limitations and exceptions, see the plan or policy document at selecthealth.org/materials. 2 of 8 ---PAGE BREAK--- Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you have outpatient surgery Facility fee ambulatory surgery center) 20% co-insurance 40% co-insurance Physician/surgeon fees 20% co-insurance 40% co-insurance $30/visit 40% co-insurance Applies to urgent care facilities only. Deductible does not apply to in-network services. If you have a hospital stay Facility fee hospital room) 20% co-insurance 40% co-insurance Benefits may be denied or reduced by 50% for failure to obtain preauthorization for certain services. If you need immediate medical attention Emergency room services $100/visit then 20% co- insurance $100/visit then 20% co- insurance Emergency room services apply to participating benefits. Emergency medical transportation 20% co-insurance 20% co-insurance Emergencies only. Emergency medical transportation applies to participating benefits. Urgent care Physician/surgeon fee 20% co-insurance 40% co-insurance If you need mental health, behavioral health, or substance abuse services Outpatient services $30 for office visits, 20% co-insurance for outpatient 40% co-insurance for office visits, 40% co- insurance for outpatient Benefits may be denied or reduced by 50% for failure to obtain preauthorization for certain services. Additional limitations and exclusions apply. Deductible does not apply to in-network office visits and outpatient services. Inpatient services Childbirth/delivery facility services 20% co-insurance 40% co-insurance 20% co-insurance 40% co-insurance If you are pregnant Office visits $30/visit 40% co-insurance A different benefit may apply for major office surgery. Deductible does not apply to in-network services. Childbirth/delivery professional services 20% co-insurance 40% co-insurance Benefits may be denied or reduced by 50% for failure to obtain preauthorization for certain services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. * For more information about limitations and exceptions, see the plan or policy document at selecthealth.org/materials. 3 of 8 ---PAGE BREAK--- Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care 20% co-insurance 40% co-insurance Benefits may be denied or reduced by 50% for failure to obtain preauthorization for certain services. Rehabilitation services $30/visit for outpatient, 20% co-insurance for inpatient 40% co-insurance Up to 40 days per calendar year for inpatient physical, speech, and occupational therapies combined. Benefits may be denied or reduced by 50% for failure to obtain preauthorization for certain services. Habilitation services Durable medical equipment (DME) 20% co-insurance 40% co-insurance Benefits may be denied or reduced by 50% for failure to obtain preauthorization for certain services. Hospice service 20% co-insurance 40% co-insurance Benefits may be denied or reduced by 50% for failure to obtain preauthorization for certain services. Not covered Not covered Habilitation is not covered. Skilled nursing care 20% co-insurance 40% co-insurance Up to 60 days per calendar year. Benefits may be denied or reduced by 50% for failure to obtain preauthorization for certain services. Not covered Not covered Dental check-ups are not covered. If your child needs dental or eye care Children's eye exam $30/visit 40% co-insurance Deductible does not apply to in-network services. Children's glasses Not covered Not covered Glasses are not covered. Children's dental check-up * For more information about limitations and exceptions, see the plan or policy document at selecthealth.org/materials. 4 of 8 ---PAGE BREAK--- Excluded Services & Other Covered Services: • Abortions/termination of pregnancy except in limited circumstances • Acupuncture • Administrative services/charges • Bariatric surgery • Cosmetic surgery and reconstructive and corrective services, except in limited circumstances • Dental care (adult/child), except in limited circumstances • Dental check-up • Experimental and/or investigational services • Glasses • Habilitation services • Hearing aids • Immunizations for Anthrax, BCG, Cholera, Plague, Typhoid and Yellow Fever • Infertility (select services) greater than $1,500 per year and $5,000 per lifetime • Infertility treatment • Long-term care • Orthotic and other corrective appliances for the foot • Services for which a third-party is or may be responsible • Services related to certain illegal activities • Services that are not medically necessary • Temporomandibular Joint (TMJ) services greater than $2,000 lifetime Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document. • Chiropractic care • Non-emergency care when traveling outside the U.S. • Private Duty Nursing, preauthorization required with limitations • Routine eye care (adult) • Routine foot care • Weight loss programs as part of a program approved by SelectHealth Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) * For more information about limitations and exceptions, see the plan or policy document at selecthealth.org/materials. 5 of 8 ---PAGE BREAK--- If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Para obtener asistencia en Español, llame al [PHONE REDACTED]. see examples of how this plan might cover costs for a sample medical situation, see the next Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-[PHONE REDACTED] x61565 or www.cciio.cms.gov; or contact the Plan. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-[PHONE REDACTED]. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Department of Labor's Employee Benefits Security Administration at 866-444-EBSA (3272) or dol.gov/ebsa/healthreform; or If your coverage is fully-insured, you may also contact the Idaho Department of Insurance, P.O. Box 83720, Boise, ID 83720-0043. To contact SelectHealth Member Services, please call [PHONE REDACTED] weekdays, TTY users should call 711, or visit us at selecthealth.org. Does this plan provide Minimum Essential Coverage? Yes Does this plan meet the Minimum Value Standards? Yes * For more information about limitations and exceptions, see the plan or policy document at selecthealth.org/materials. 6 of 8 ---PAGE BREAK--- The plan’s overall deductible $2,000 The plan’s overall deductible $2,000 The plan’s overall deductible $2,000 Specialist $30 Specialist $30 Specialist $30 Hospital (facility) 20% Hospital (facility) 20% Hospital (facility) 20% Other 20% Other 20% Other 20% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical Childbirth/Delivery Professional Services disease education) supplies) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray) Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy) $12,800 $7,400 $2,500 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: $2,000 $2,000 $1,100 $0 $1,200 $500 $1,500 $300 $200 $60 $60 $0 $3,560 $3,560 $1,800 CITY OF BURLEY OPTION 2 7/30/2019 C Total Example Cost Total Example Cost Total Example Cost Cost Sharing Cost Sharing Cost Sharing About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a hospital delivery) (a year of routine in-network care of a well-controlled condition) (in-network emergency room visit and follow up care) Coinsurance Coinsurance Coinsurance What isn’t covered What isn’t covered What isn’t covered Deductibles Deductibles Deductibles Copayments Copayments Copayments The plan would be responsible for the other costs of these EXAMPLE covered services. Limits or exclusions Limits or exclusions Limits or exclusions The total Peg would pay is The total Joe would pay is The total Mia would pay is * For more information about limitations and exceptions, see the plan or policy document at selecthealth.org/materials. 7 of 8 ---PAGE BREAK--- Non-Discrimination Notice Language Access Services SelectHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We provide free aid and services to people with disabilities to help them communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). We also provide free language services to people whose primary language is not English, such as qualified interpreters and member materials written in other languages. If you need these services, please call SelectHealth Member Services at [PHONE REDACTED] or SelectHealth Advantage Member Service at [PHONE REDACTED]. Any member or other person who believes he/she may have been subject to discrimination may file a complaint or grievance by calling the SelectHealth 504/Civil Rights Coordinator at [PHONE REDACTED] or the Compliance Hotline at [PHONE REDACTED] (TTY Users: 711). You may also call the Office for Civil Rights at 1-[PHONE REDACTED] (TTY Users: [PHONE REDACTED]). Spanish ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a SelectHealth: [PHONE REDACTED]. Chinese 注意：如果您使用繁體中文，您可以免費獲 得語言援助服務。請致電SelectHealth: [PHONE REDACTED]. 。 Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số SelectHealth: [PHONE REDACTED]. Korean 주의: 한국어를사용하시는경우, 언어 지원서비스를무료로이용하실수 있습니다. SelectHealth: [PHONE REDACTED]. 번으로전화해주십시오. Navajo Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dęʹęʹ’, t’áá jiik’eh, éí ná hólǫ′, kojį’ hódíílnih SelectHealth: [PHONE REDACTED]. Nepali Úयान िदनुहोस्: तपाइर्ंले नेपाली बोãनुहुÛछ भने तपाइर्ंको िनिàत भाषा सहायता सेवाहǾ िनःशुãक Ǿपमा उपलÞध छ । SelectHealth: [PHONE REDACTED] मा फोन गनुर्होस्। Tongan FAKATOKANGA’I: Kapau ‘oku ke lea fakatonga, ko e kau fakatonu lea te nau tokoni atu ta’etotongi, pea te ke lava ‘o ma’u ia. Telefoni ki he SelectHealth: [PHONE REDACTED]. Serb-Croatian ОБАВЕШТЕЊЕ: Ако говорите српски језик, услуге језичке помоћи доступне су вам бесплатно. Позовите SelectHealth: [PHONE REDACTED]. Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa SelectHealth: [PHONE REDACTED]. German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: SelectHealth: [PHONE REDACTED]. Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги переводчика. Позвоните SelectHealth: [PHONE REDACTED] Arabic ةدعاسمال تامدخ نإف ،ةيبرعال ثدحتت تنك اذإ : ةظوحلم ةكرشب لصتا . ناجمالب كل رفاوتت ةيوغلال SelectHealth: 800-538-5038s Mon-khmer, Cambodian សមាគល់៖ េបើសិនជាអនកនិយាយ ភាសាែខមរ េសវា ជំនួយែផនកភាសា េដាយមិនគិតៃថល គឺអាចមាន សំរាប់ អនក។ សូមទូរស័ពទមក SelectHealth: [PHONE REDACTED] ។ French ATTENTION : si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Contactez SelectHealth: [PHONE REDACTED]. Japanese 注意事項：日本語を話される場合、無料の 言語支援をご利用いただけます。 SelectHealth: [PHONE REDACTED]. まで、お電話にて ご連絡ください。 * For more information about limitations and exceptions, see the plan or policy document at selecthealth.org/materials. 8 of 8