Small Employer Plans

(1)

(2)

Neighborhood

Health Plan of Rhode Island

Health Insurance that’s Right for You and Your Employees

Choose from Neighborhood’s small employer plans:

Small employers are the backbone of Rhode Island, anchoring our communities

and economy.

We understand you want to offer high-quality health insurance at the best value for your employees.

Every business is unique and deserves the personal attention we provide.

“Neighborhood has

the

best prices

for the coverage

I get in return.

The enrollment

process went

smoothly

and

the Neighborhood

customer service

team is extremely

helpful

.

”

– Bernadette S.,

Neighborhood Small Business

Health Options Program Member

(3)

• Primary Care, including

Annual Check-Ups

and Sick Visits

• Preventive Care, including

Screenings, Vaccinations and

Health Needs Assessments

• Inpatient and Outpatient

Hospital Services

• Pharmacy Benefits

• Full Range of Specialist Services

• Pediatric and Adolescent Care

• Care Management Programs for

Chronic Conditions

• Maternity and Newborn Care,

including Well Baby Visits

• Laboratory and Imaging Services

• Wellness Programs

• Skilled Nursing Facility Care

• Home Health Care

• Patient Education and

Counseling Services

• Emergency and Urgent

Care Services

• Behavioral Health Services

• Substance Abuse Treatment

• Residential and Day

Treatment Programs

• Rehabilitative/Habilitative

Services

• Prosthetic and Orthotic Devices

• Medical Equipment

and Supplies

• Physical and Occupational

Therapy, including

Chiropractic Care

• Vision and Hearing Services

• Social Needs Care Coordination

• Hospice Care

Neighborhood provides

high-quality, affordable coverage

through HealthSource RI

All Neighborhood plans offer comprehensive

benefits and services, including:

_Neighborhood

is offering the

lowest-priced plans

for small employers

for the

third

consecutive year.

(4)

PLAN NAME

Plan Type Bronze Silver Silver Gold Platinum

HSA-Qualified* Yes Yes No No No

DEDUCTIBLES, CO-INSURANCE AND OUT-OF-POCKET MAXIMUMS (PER BENEFIT YEAR)

Individual Plan Deductible $4,900 $2,000 $2,250 $1,500 $500

Family Plan Deductible $9,800 $4,000 $4,500 $3,000 $1,000

Co-insurance 20% after deductible 15% after deductible 30% after deductible 0% after deductible 0% after deductible

Individual Out-of-Pocket

Maximum $6,550 $6,550 $6,550 $5,000 $1,500

Family Out-of-Pocket Maximum $13,100 $13,100 $13,100 $10,000 $3,000

MEDICAL SERVICES COST-SHARING

Preventive Care Visit No Charge No Charge No Charge No Charge No Charge

Primary Care Visit 20% co-insurance _{after deductible} 15% co-insurance _{after deductible} $30 co-payment $20 co-payment $10 co-payment

Specialty Care Visit 20% co-insurance _{after deductible} 15% co-insurance _{after deductible} $60 co-payment $40 co-payment $30 co-payment

Urgent Care 20% co-insurance _{after deductible} 15% co-insurance _{after deductible} $60 co-payment $40 co-payment $30 co-payment

Emergency Room 20% co-insurance _{after deductible} 15% co-insurance _{after deductible} $250 co-payment $200 co-payment $100 co-payment

Inpatient Hospital 20% co-insurance _{after deductible} 15% co-insurance _{after deductible} 30% co-insurance _{after deductible} 0% co-insurance _{after deductible} 0% co-insurance _{after deductible} Outpatient Hospital 20% co-insurance _{after deductible} 15% co-insurance _{after deductible} 30% co-insurance _{after deductible} 0% co-insurance _{after deductible} 0% co-insurance _{after deductible} Imaging Services 20% co-insurance _{after deductible} 15% co-insurance _{after deductible} 30% co-insurance _{after deductible} 0% co-insurance _{after deductible} 0% co-insurance _{after deductible} Laboratory Services 20% co-insurance _{after deductible} 15% co-insurance _{after deductible} 30% co-insurance _{after deductible} 0% co-insurance _{after deductible} 0% co-insurance _{after deductible} Behavioral Health Care -

Outpatient 20% co-insurance after deductible 15% co-insurance after deductible $30 co-payment $20 co-payment $10 co-payment

Behavioral Health Care - Inpatient 20% co-insurance _{after deductible} 15% co-insurance _{after deductible} 30% co-insurance _{after deductible} 0% co-insurance _{after deductible} 0% co-insurance _{after deductible} Rehabilitation Services 20% co-insurance _{after deductible} 15% co-insurance _{after deductible} $60 co-payment $40 co-payment $30 co-payment

PRESCRIPTION DRUG COVERAGE

Tier 1

(Generic Drugs) $10 co-payment after deductible $10 co-payment after deductible $15 co-payment $10 co-payment $10 co-payment

Tier 2 (Preferred Brand Drugs) $35 co-payment _{after deductible} $35 co-payment _{after deductible} $40 co-payment $35 co-payment $35 co-payment

Tier 3 (Non-preferred Brand Drugs) $60 co-payment _{after deductible} $60 co-payment _{after deductible} $90 co-payment $60 co-payment $60 co-payment

Tier 4

(Specialty Drugs)

$100 co-payment

after deductible $100 co-payment after deductible $200 co-payment $100 co-payment $100 co-payment

* Health Savings Account Qualified Plan: Pursuant to Internal Revenue Code § 223, this plan qualifies as a High Deductible Health Plan, which is suitable for use with a Health Savings Account

(HSA). This plan may be used in conjunction with an HSA but it is not an HSA itself.

(5)