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Summary of Benefits and Coverage: What this Plan Covers & What it Costs HMO 25 C $7/30/50 Coverage for: Individual + Family I Plan Type: HMO Coverage Period: 07/01/2016 - 06/30/2017 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 or by calling (702) 242-7300 or 1-[PHONE REDACTED]. Important Questions Answers Why this Matters: What is the overall deductible? $0 See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific services? No. There are no other specific deductibles. 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, $2,500/Member and $5,000/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? Premium, balance-billed charges, penalties for failure to obtain prior authorization for services and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of pocket limit. Is there an overall annual limit on what the plan pays? 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. For a list of Plan Providers, see or call [PHONE REDACTED] or 1-[PHONE REDACTED]. 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 kind of providers. Do I need a referral to see a specialist? Yes. A written referral is required to see a specialist. This plan will pay some or all of the costs to see a specialist but only if you have the plan's permission before you see the specialist. 1 of 8 Questions: Call (702) 242-7300 or 1-[PHONE REDACTED] or visit us at If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at cms.gov/CCIIO/Resources/Files/Downloads/uniform-glossary-final.pdf or call the phone number above to request a copy. ---PAGE BREAK--- h Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. h 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. h 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.) h This plan may encourage you to use Plan Providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Limitations & Exceptions Your Cost If You Use a HMO Provider Your Cost If You Use a Non-Plan Provider If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness None Not Covered $25 copay/visit Specialist visit Member pays for cost of services if prior authorization is not obtained. Not Covered $50 copay/visit Other practitioner office visit Manual manipulation (Chiropractic) coverage is limited to 20 visits. Member pays for cost of services if prior authorization is not obtained. Not Covered $25 copay/visit Preventive care/ screening/ immunization None Not Covered $0 copay/visit If you have a test Diagnostic test (x-ray, blood work) Member pays for cost of services if prior authorization is not obtained. Not Covered X-ray: $25 copay/service Lab: $0 copay/service Imaging (CT/PET scans, MRIs) Not Covered $100 copay/service If you need drugs to treat your illness or condition Tier 1 You have a 3-Tier pharmacy plan. Covers up to a 30-day retail supply or up to a 90-day mail order supply. Member pays for cost of services if prior authorization or step therapy is not obtained. Not Covered $7 copay (retail) $17.50 copay (mail) 2 of 8 ---PAGE BREAK--- Common Medical Event Services You May Need Limitations & Exceptions Your Cost If You Use a HMO Provider Your Cost If You Use a Non-Plan Provider More information about prescription drug coverage is available at m. Tier 2 You have a 3-Tier pharmacy plan. Covers up to a 30-day retail supply or up to a 90-day mail order supply. Member pays for cost of services if prior authorization or step therapy is not obtained. Not Covered $30 copay (retail) $75 copay (mail) Tier 3 You have a 3-Tier pharmacy plan. Covers up to a 30-day retail supply. Member pays for cost of services if prior authorization or step therapy is not obtained. Not Covered $50 copay (retail) $125 copay (mail) Tier 4 Not Applicable. Not Covered Not Covered If you have outpatient surgery Facility fee ambulatory surgery center) Member pays for cost of services if prior authorization is not obtained. Not Covered $200 copay/admit Physician/surgeon fees Not Covered $0 copay/surgery If you need immediate medical attention Emergency room services You may be balance billed from Non-Plan Providers. ER Physician: $0 copay/visit ER Facility: $100 copay/visit ER Physician: $0 copay/visit ER Facility: $100 copay/visit Emergency medical transportation $0 copay/trip $0 copay/trip Urgent care You may be balance billed from Non-Plan Providers. $25 copay/visit $25 copay/visit If you have a hospital stay Facility fee hospital room) Member pays for cost of services if prior authorization is not obtained. Not Covered $400 copay/admit Physician/surgeon fee Not Covered $0 copay/surgery If you have mental health, behavioral health, or substance abuse needs Mental/behavioral health outpatient services Member pays for cost of services if prior authorization is not obtained. Not Covered $25 copay/visit Mental/behavioral health inpatient services Not Covered $400 copay/admit Substance abuse disorder outpatient services Member pays for cost of services if prior authorization is not obtained. Not Covered $25 copay/visit Substance abuse disorder inpatient services Not Covered $400 copay/admit 3 of 8 ---PAGE BREAK--- Common Medical Event Services You May Need Limitations & Exceptions Your Cost If You Use a HMO Provider Your Cost If You Use a Non-Plan Provider If you are pregnant Prenatal and postnatal care Routine prenatal care obtained from a Plan Provider is covered at no charge. Not Covered $0 copay/visit Delivery and all inpatient services Member pays for cost of services if prior authorization is not obtained. Not Covered Room: $400 copay/admit Surgical, Anesthesia: $0 copay/admit If you have a recovery or other special health need Home health care Does not include Specialty Prescription Drugs. Member pays for cost of services if prior authorization is not obtained. Not Covered $25 copay/visit Rehabilitation services Coverage is limited to a combined benefit of 120 days/visits. Member pays for cost of services if prior authorization is not obtained. Not Covered $25 copay/visit Habilitative services Not Covered $25 copay/visit Skilled nursing care Coverage is limited to 100 days. Member pays for cost of services if prior authorization is not obtained. Not Covered $400 copay/admit Durable medical equipment For purchase or rental at HPN's option. Purchases are limited to a single type of DME, including repair and replacement, every 3 years. Member pays for cost of services if prior authorization is not obtained. Not Covered $100 copay/device Hospice services Member pays for cost of services if prior authorization is not obtained. Not Covered $300 copay/admit If your child needs dental or eye care Eye exam Your Plan may include certain vision and/or dental services. Please refer to you Plan documents for more information. Not Covered Not Covered Glasses Not Covered Not Covered Dental check-up Not Covered Not Covered 4 of 8 ---PAGE BREAK--- 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.) Abortion (except for rape, incest, life at risk) Dental care (Adult) Routine eye care (Adult) Acupuncture Long-term care Routine foot care Cosmetic surgery Non-emergency care when traveling outside the U.S. Weight loss programs 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.) Bariatric surgery Hearing aids Private-duty nursing Chiropractic care Limited infertility treatment 5 of 8 ---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 (702) 242-7300 or 1-[PHONE REDACTED]. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-[PHONE REDACTED] or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-[PHONE REDACTED] 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 may contact your human resource department. If your employer determines that your plan is subject to ERISA, you may contact the Employee Benefits Security Administration at 1-[PHONE REDACTED] or http://www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Office of Consumer Health Assistance at 1-[PHONE REDACTED] or http://dhhs.nv.gov. A list of states with Consumer Assistance Programs is available at www.dol.gov/ebsa/healthreform and http://cciio.cms.gov/programs/consumer/capgrants/index.html. 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. see examples of how this plan might cover costs for a sample medical situation, see the next 6 of 8 ---PAGE BREAK--- 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. 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 (normal delivery) Amount owed to providers: $7,600 Plan pays $6,600 Patient pays $1,000 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: Plan pays Patient pays $5,400 $4,300 $1,100 Sample care costs: Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Total $2,700 $1,200 $900 $900 $500 $200 $200 $1,000 $7,600 Patient pays: Deductibles Copays Coinsurance Limits or Exclusions Total $0 $1,000 $0 $0 $1,000 Education Vaccines, other preventive Laboratory tests Office Visits and Procedures Medical Equipment and Supplies Prescriptions Total Total Limits or Exclusions Coinsurance Copays Deductibles Patient pays: $2,900 $1,300 $700 $300 $100 $100 $5,400 $0 $1,100 $0 $0 $1,100 This is not a cost estimator. 7 of 8 ---PAGE BREAK--- Does the Coverage Example predict my own care needs? û 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. 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. • If other than individual coverage, the Patient Pays amount may be more. Questions and answers about the Coverage Examples: 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. Can I use Coverage Examples to compare plans? üYes. 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. Does the Coverage Example predict my future expenses? ûNo. 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. Are there other costs I should consider when comparing plans? üYes. 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 Questions: Call (702) 242-7300 or 1-[PHONE REDACTED] or visit us at If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at cms.gov/CCIIO/Resources/Files/Downloads/uniform-glossary-final.pdf or call the phone number above to request a copy.