Are there other
deductibles for specific services?
No.
What is not included in the out-of-pocket limit?
Premiums, co-pays, penalties for failure to obtain precertification for services, balance-billed charges, prescription drugs and health care this plan doesn’t cover.
Is there an out-of-pocket limit on my expenses?
Yes. In-network: Individual $6,500 / Family 2 Individual Maximum; Out-of-network: Individual $12,500 / Family 2 Individual Maximum
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.
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.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Coverage Period:To Be Determined Coverage for: Individual + Family Plan Type: POS
a
GA Open Access Managed Choice Value 2500
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
What is the overall
deductible?
In-network: Individual $2,500 / Family 2 Individual Maximum; Out-of-network: Individual $5,000 / Family 2 Individual Maximum. Does not apply in-network for primary care and specialist visit, preventive care, emergency care, urgent care and prescription drugs.
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.HealthReformPlanSBC.com or by calling 1-866-253-8885.
Important Questions Answers Why this Matters
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Does the plan use a
network of providers?
Yes. For a list of in-network
providers, see www.aetna.com or call 1-866-253-8885.
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. 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.
• •
•
• This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts.
30% co-insurance
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.
Services You May Need Common Medical
Event
40% co-insurance for chiropractic care
Coverage is limited to 24 visits up to an Aetna maximum payment of $25 per visit for chiropractic care.
30% co-insurance
40% co-insurance
––––––––––– None ––––––––––– Other practitioner office visit
Primary care visit to treat an injury or illness
Coverage is limited to 5 combined Primary care and Specialist visits.
$30 co-pay per visit, deductible waived
Age and frequency schedules may apply. Specialist visit
If you have a test
Diagnostic test (x-ray, blood work)
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
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.)
Your cost if you use an In Network
Provider
Limitations & Exceptions Your cost if you
use an Out Of Network Provider
Coverage is limited to 5 combined Primary care and Specialist visits.
$75 co-pay per visit, deductible waived
Preventive care/screening/immunization No charge, deductible waived
30% co-insurance 30% co-insurance for
chiropractic care If you visit a health
care provider’s office or clinic
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.HealthReformPlanSBC.com or by calling 1-866-253-8885.
Not covered
If you need
immediate medical attention
Emergency room services $500 co-pay per visit, deductible waived
Paid as in-network
Urgent care $75 co-pay per visit,
deductible waived
30% co-insurance No coverage for non-urgent care. $20 co-pay for up to a
30 day supply
30% co-insurance after $20 co-pay for up to a 30 day supply.
Common Medical
Event Services You May Need
Your cost if you use an In Network
Provider
Your cost if you use an Out Of Network Provider
Limitations & Exceptions
Formulary brand drugs
Facility fee (e.g., ambulatory surgery center)
a
GA Open Access Managed Choice Value 2500
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period:To Be Determined Coverage for: Individual + Family Plan Type: POS
Not covered
40% co-insurance
––––––––––– None ––––––––––– 40% co-insurance
––––––––––– None ––––––––––– Physician/surgeon fees 40% co-insurance 40% co-insurance
If you have outpatient surgery If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at
http://www.aetna.co
m/pharmacy-insurance/individual
s-families/index.html
Generic drugs
Copay is waived if admitted. No coverage for non-emergency care.
Emergency medical transportation 30% co-insurance Paid as in-network
––––––––––– None –––––––––––
Non-formulary brand drugs Not covered Not covered
Covers up to a 30-day supply (retail prescription or mail order prescription). Includes diabetic supplies, contraceptive drugs and devices obtainable from a pharmacy. Includes Mandatory Generics with Dispense as Written (DAW) override. No charge for formulary generic FDA-approved women's contraceptives in-network. No coverage for Formulary brand and Non-formulary brand drugs.
40% co-insurance 40% co-insurance Common Medical
Event Services You May Need
Your cost if you use an In Network
Provider
Your cost if you use an Out Of Network Provider
Limitations & Exceptions
40% co-insurance
Coverage is limited to 48 visits.
Coverage is limited to 30 days.
Precertification required for inpatient out-of-network care. Benefits will be reduced up to $400 per occurrence if
precertification is not obtained. Not covered
––––––––––– None –––––––––––
Mental/Behavioral health inpatient services 30% co-insurance
Not covered Mental/Behavioral health outpatient
services
30% co-insurance 40% co-insurance
Substance use disorder outpatient services
40% co-insurance Physician/surgeon fee 40% co-insurance
Delivery and all inpatient services Not covered If you are pregnant
Prenatal and postnatal care Prenatal: No charge, deductible waived
Not covered Not covered
No coverage for Postnatal care. If you have mental
health, behavioral health or substance abuse needs
Not covered Not covered
Substance use disorder inpatient services Not covered
Not covered Coverage is limited to Complications of Pregnancy.
Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained.
If you have a hospital stay
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.HealthReformPlanSBC.com or by calling 1-866-253-8885.
Coverage is limited to 30 visits. Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained.
Rehabilitation services 30% co-insurance 40% co-insurance Coverage is limited to 24 visits combined for PT/OT. Speech therapy covered only under home health or skilled nursing care.
Home health care 30% co-insurance 40% co-insurance
Not covered
Not Covered
Skilled nursing care 40% co-insurance 40% co-insurance Coverage is limited to 30 days. Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained.
Not covered Not covered Habilitation services
Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained.
Not covered Not covered Not covered
Dental check-up If you need help
recovering or have other special health needs
Hospice service
Durable medical equipment Coverage is limited to $2,000 annual
maximum.
Not covered Inpatient: 40%
co-insurance; Outpatient: 30% co-insurance
40% co-insurance 40% co-insurance 40% co-insurance
Not covered Not covered Not covered
Your cost if you use an In Network
Provider
Your cost if you use an Out Of Network Provider
Limitations & Exceptions
If your child needs dental or eye care
Eye exam Not covered
Glasses
a
GA Open Access Managed Choice Value 2500
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period:To Be Determined Coverage for: Individual + Family Plan Type: POS
Common Medical
• • • Brand drugs
• • •
• • •
• • •
• • •
• • •
Your Grievance and Appeals Rights:
••
Infertility treatment Private-duty nursing
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.) Hearing Aids (Adults) limited to 1 hearing aid per
ear every 36 months up to $200 per hearing aid; no coverage for first 12 months.
Substance use disorder services (IP/OP) services Weight loss programs
Routine eye care (Adult & Child) Dental (Adult & Child)
Long-term care
Glasses (Adult & Child)
Non-emergency care when traveling outside the U.S.
Chiropractic care limited to 24 visits up to an Aetna maximum payment of $25 per visit.
Acupuncture Bariatric surgery
Cosmetic Surgery
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.)
Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep health coverage as long as you pay your premium. There are exceptions, however, such as if: • You commit fraud • The insurer stops offering services in the State • You move outside the coverage area
For more information on your rights to continue coverage, contact the plan at 1-866-253-8885. You may also contact your state insurance department, Office of Insurance and Safety Fire Commissioner Two Martin Luther King, Jr. Dr.West Tower, Suite 704 Atlanta, Georgia 30334 404-656-2070 Toll Free 800-656-2298, www.gainsurance.org/
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appealor file a grievance. For questions about your rights, this notice, or assistance, you can contact: Aetna at 1-866-253-8885, you may also contact Office of Insurance and Safety Fire Commissioner Two Martin Luther King, Jr. Dr.West Tower, Suite 704 Atlanta, Georgia 30334 404-656-2070 Toll Free 800-656-2298
Additionally, a consumer assistance program can help you file your appeal. Contact Georgia Office of Insurance and Safety Fire Commissioner Consumer Services Division, (800) 656-2298, http://www.oci.ga.gov/ConsumerService/Home.aspx
Language Access Services:
Routine foot carePregnancy
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.HealthReformPlanSBC.com or by calling 1-866-253-8885.
Amount owed to providers: Amount owed to providers:
Plan pays: Plan pays:
Patient pays: Patient pays:
Sample care costs: Sample care costs:
Hospital charges (mother) Prescriptions
Routine obstetric care Medical Equipment and Supplies
Hospital charges (baby) Office Visits and Procedures
Anesthesia Education
Laboratory tests Laboratory tests
Prescriptions Vaccines, other preventive
Radiology Total
Vaccines, other preventive
Total Patient pays:
Deductibles
Patient pays: Co-pays
Deductibles Co-insurance
Co-pays Limits or exclusions
Co-insurance Total
Limits or exclusions
Total Note: Your plan may have both copayments and coinsurance for covered services, if so, these examples use copayments only. Your costs may be higher.
$ 80 $ 4,620
$ - $ 3,490
$ 5,350
Managing type 2 diabetes
(routine maintenance of a well-controlled condition)
100 $ 5,400 $ 7,540
Having a baby
(normal delivery)
$ 2,900 $ 1,910
$ -
$ 730 $ 310
40
$ 2,500 $ 600 900
▪
200
▪
200
$ 3,490 $ 5,350
900
300
$ 7,540 $ 2,190
1,300
About these Coverage
Examples:
500
100 2,100
$ 5,400 $ 2,700
a
GA Open Access Managed Choice Value 2500
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.
Coverage Period:To Be Determined Coverage for: Individual + Family Plan Type: POS
▪
▪
▪
▪
Questions and answers about Coverage Examples:
• •
• • • •
• 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.
There are no other medical expenses for any member covered under this plan.
Yes.
An important cost is the premiumyou pay. Generally, the lower your
premium, the more you’ll pay in out-of-pocket costs, such as copayments,
deductibles, and coinsurance. You also should 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.
No
. Coverage Examples are not cost estimators. Youcan’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
Does the Coverage Example predict my
future expenses?
No.
Treatments shown are just examples. The care you would receive for these conditions could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors. Out-of-pocket expenses are based only ontreating the condition in the example.
All services and treatments started and ended in
the same policy period.
Are there other costs I should
consider when comparing
plans?
The patient’s condition was not an excluded orpreexisting condition.
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 for each example. The smaller that number, the more coverage the plan provides.Does the Coverage Example predict my
own care needs?
What are some of the assumptions
behind the Coverage Examples?
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. Costs don’t include premiums.
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.
