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Association of Washington Cities HealthFirst® Medical Plan Coverage Period: 01/01/2014 – 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family I Plan Type: 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.myRegence.com or by calling 1 (866) 240-9580. Important Questions Answers Why this Matters: What is the overall deductible? $0 claimant / $0 family per calendar year. See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific services? No. 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. Is there an out-of- pocket limit on my expenses? Yes. $1,100 claimant / $2,200 family per calendar year. 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. What is not included in the out-of-pocket limit? Coinsurance for outpatient rehabilitation services, neurodevelopmental therapy, premiums, balance-billed charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of- pocket limit. Does this plan use a network of providers? Yes. See www.myRegence.com or call 1 (866) 240-9580 for lists of preferred or participating 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. 1 of 8 Claims Administrator: Regence BlueShield 100000032SBC1 Questions: Call 1 (866) 240-9580 or visit us at www.myRegence.com. 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.cciio.cms.gov or call 1 (866) 240-9580 to request a copy. ---PAGE BREAK--- • 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 preferred and participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your Cost If You Use a Preferred Provider Your Cost If You Use a Participating Provider Your Cost If You Use a Non- Participating Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay / visit $10 copay / visit, and 30% coinsurance $10 copay / visit, and 30% coinsurance Copayment applies to each office visit only. All other services are covered at the coinsurance specified. Specialist visit $10 copay / visit $10 copay / visit, and 30% coinsurance $10 copay / visit, and 30% coinsurance Other practitioner office visit No charge for acupuncture and spinal manipulations 30% coinsurance for acupuncture and spinal manipulations 30% coinsurance for acupuncture and spinal manipulations Coverage is limited to 12 acupuncture visits / year. Coverage is limited to 15 spinal manipulations / year. Preventive care/ screening/immunization No charge No charge 30% coinsurance No charge for childhood immunizations from non–participating providers. If you have a test Diagnostic test (x-ray, blood work) No charge 30% coinsurance 30% coinsurance Imaging (CT/PET scans, MRIs) No charge 30% coinsurance 30% coinsurance 2 of 8 Claims Administrator: Regence BlueShield 100000032SBC1 ---PAGE BREAK--- Common Medical Event Services You May Need Your Cost If You Use a Preferred Provider Your Cost If You Use a Participating Provider Your Cost If You Use a Non- Participating Provider Limitations & Exceptions If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.RegenceRx.com. Generic drugs $4 copay / retail prescription $8 copay / mail order prescription No charge for self-administrable cancer chemotherapy drugs Coverage is limited to a 34-day supply retail or 90-day supply mail order. No charge for generic tobacco use cessation medication coverage provided when obtained with a prescription order at a participating pharmacy. Preferred brand drugs $15 copay / retail prescription $30 copay / mail order prescription No charge for self-administrable cancer chemotherapy drugs Non-preferred brand drugs $35 copay / retail prescription $70 copay / mail order prescription No charge for self-administrable cancer chemotherapy drugs Specialty drugs Refer to generic, preferred brand and non-preferred brand drugs above. If you have outpatient surgery Facility fee ambulatory surgery center) 10% coinsurance 30% coinsurance 30% coinsurance Physician/surgeon fees No charge 30% coinsurance 30% coinsurance If you need immediate medical attention Emergency room services Facility: 10% coinsurance after $75 copay Professional: No charge Facility: 10% coinsurance after $75 copay Professional: No charge Facility: 10% coinsurance after $75 copay Professional: No charge Copayment applies to the facility charge for each visit (waived if admitted). Emergency medical transportation 20% coinsurance 20% coinsurance 20% coinsurance Urgent care Covered the same as the If you visit a health care provider’s office or clinic or If you have a test Common Medical Events. If you have a hospital stay Facility fee hospital room) 10% coinsurance after $150 copay 30% coinsurance after $150 copay 30% coinsurance after $150 copay Copayment applies to each inpatient admission. Physician/surgeon fee No charge 30% coinsurance 30% coinsurance 3 of 8 Claims Administrator: Regence BlueShield 100000032SBC1 ---PAGE BREAK--- Common Medical Event Services You May Need Your Cost If You Use a Preferred Provider Your Cost If You Use a Participating Provider Your Cost If You Use a Non- Participating Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services No charge No charge 30% coinsurance Copayment applies to each inpatient admission. Mental/Behavioral health inpatient services 10% coinsurance after $150 copay 10% coinsurance after $150 copay 30% coinsurance after $150 copay Substance use disorder outpatient services No charge No charge 30% coinsurance Substance use disorder inpatient services 10% coinsurance after $150 copay 10% coinsurance after $150 copay 30% coinsurance after $150 copay If you are pregnant Prenatal and postnatal care No charge 30% coinsurance 30% coinsurance Maternity services for children are not covered. Copayment applies to each inpatient admission. Delivery and all inpatient services 10% coinsurance after $150 copay 30% coinsurance after $150 copay 30% coinsurance after $150 copay If you need help recovering or have other special health needs Home health care 10% coinsurance 10% coinsurance 10% coinsurance Coverage is limited to 130 visits / year. Rehabilitation services 10% coinsurance after $150 copay for inpatient services 30% coinsurance after $150 copay for inpatient services 30% coinsurance after $150 copay for inpatient services Coverage is limited to 15 inpatient days / year. Coverage is limited to 99 outpatient visits / year; does not apply to the out-of-pocket limit. Copayment applies to each inpatient admission. Habilitation services 10% coinsurance after $150 copay for inpatient services 30% coinsurance after $150 copay for inpatient services 30% coinsurance after $150 copay for inpatient services Coverage for neurodevelopmental therapy is limited to 60 outpatient visits / year; does not apply to the out-of-pocket limit. Copayment applies to each inpatient admission. Skilled nursing care 10% coinsurance after $150 copay 10% coinsurance after $150 copay 10% coinsurance after $150 copay Coverage is limited to 90 inpatient days / year. Copayment applies to each inpatient admission. Durable medical equipment 10% coinsurance 30% coinsurance 30% coinsurance 4 of 8 Claims Administrator: Regence BlueShield 100000032SBC1 ---PAGE BREAK--- Common Medical Event Services You May Need Your Cost If You Use a Preferred Provider Your Cost If You Use a Participating Provider Your Cost If You Use a Non- Participating Provider Limitations & Exceptions Hospice service 10% coinsurance after $150 copay for inpatient services 10% coinsurance after $150 copay for inpatient services 10% coinsurance after $150 copay for inpatient services Coverage is limited to 14 respite days / lifetime. Copayment applies to each inpatient admission. If your child needs dental or eye care Eye exam No charge No charge No charge Coverage is limited to 1 routine eye exam per claimant per calendar year. Glasses Not covered Not covered Not covered Dental check-up Not covered Not covered Not covered 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.) • Bariatric surgery • Cosmetic surgery, except congenital anomalies • Dental care (Adult) • Hearing aids • Infertility treatment • Long-term care • Private-duty nursing • Routine foot care • Vision hardware • Weight loss programs except for nutritional counseling 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.) • Acupuncture • Chiropractic care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult) 5 of 8 Claims Administrator: Regence BlueShield 100000032SBC1 ---PAGE BREAK--- 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 (866) 240-9580. 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 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 the plan at 1 (866) 240-9580 or visit www.myRegence.com. You may also contact your state insurance department at 1 (800) 562-6900 or www.insurance.wa.gov or the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) 444-3272 or www.dol.gov/ebsa/healthreform. 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? In order for certain types of health coverage (for example, individually purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed charges for covered services. This is called the “minimum value standard.” 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 (866) 240-9580. see examples of how this plan might cover costs for a sample medical situation, see the next 6 of 8 Claims Administrator: Regence BlueShield 100000032SBC1 ---PAGE BREAK--- Having a baby (normal delivery) Managing type 2 diabetes (routine maintenance of a well-controlled condition) 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. Amount owed to providers: $7,540 Plan pays $7,230 Patient pays $310 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $160 Coinsurance $0 Limits or exclusions $150 Total $310 Amount owed to providers: $5,400 Plan pays $4,220[] Patient pays $1,180 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $200 Coinsurance $900 Limits or exclusions $80 Total $1,180 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. 7 of 8 Claims Administrator: Regence BlueShield 100000032SBC1 ---PAGE BREAK--- 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 in- network 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 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. 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. 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. 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 copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8 Claims Administrator: Regence BlueShield 100000032SBC1 Questions: Call 1 (866) 240-9580 or visit us at www.myRegence.com. 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.cciio.cms.gov or call 1 (866) 240-9580 to request a copy.