Health First Silver AV94 HMO Coverage Period: On or after 01/01/ PDF Free Download

Health First Silver AV94 HMO Coverage Period: On or after 01/01/2019

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1 Health First Silver AV94 HMO Coverage Period: On or after 01/01/2019 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual Only Plan Type: HMO 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, For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment,, provider, or other underlined terms see the Glossary. You can view the Glossary at or call to request a copy. Important Questions Answers Why this Matters: What is the overall? Are there services covered before you meet your? Are there other s for specific services? What is the out-of- pocket limit for this plan? What is not included in the out of pocket limit? Will you pay less if you use a network provider? Do I need a referral to see a specialist? $250 person/ $500 family Preventive services, maternity office visits (1-15 per year) Yes, Prescription drugs_$0 $1,250 person/ $2,500 family; Premiums, balance billed charges, non-covered services. Yes. See or call for a list of network providers. No. Generally, you must pay all of the costs from providers up to the amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual until the total amount of expenses paid by all family members meets the overall family This plan covers some items and services even if you haven't yet met the annual amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventative services without cost sharing and before you meet your See a list of covered preventative services at Yes, You must pay all of the costs for these services up to the specific amount before this plan begins to pay for these services. 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 Even though you pay these expenses, they don't count toward the out-of-pocket limit 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 (a balance bill. 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. You can see the specialist you choose without a referral SBC_Health First Silver AV94 HMO (1_2019) 1 of 11

2 All copayments and coinsurance costs shown in this chart are after your has been met, if a applies. Common Medical Event If you visit a health care provider's office or clinic Services You May Need Primary care visit to treat an injury or illness Preferred Provider What You Will Pay Non-Preferred Provider $5 Not Covered None Limitations, Exceptions, & Other Important Information Specialist visit $10 copay Not Covered 26 visit maximum - Chiropractor Preventive care / screening /immunization $0 copay You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Not Covered See section IV and V of plan document Requires authorization, without which uncovered expenses might become member's responsibility SBC_Health First Silver AV94 HMO (1_2019) * For more information about limitations and exceptions, see the plan or policy document at 2 of 11

3 Common Medical Event Services You May Need Preferred Provider What You Will Pay Non-Preferred Provider Limitations, Exceptions, & Other Important Information If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Preferred Generic drugs Non-Preferred Generic drugs Preferred brand drugs Non-preferred brand drugs $2 copay, retail or mail order $3 copay, mail order or retail $5 copay, mail order or retail $10 copay, mail order or retail N/A N/A N/A N/A Copay is for 30 day supply. Copay is for 30 day supply. Copay is for 30 day supply Copay is for 30 day supply Specialty drugs 2 Rx N/A Available in 30 day supply only. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees 5% coinsurancae after Not Covered Not Covered Requires authorization, without which uncovered expenses might become member's responsibility Authorization may be required. If you need immediate medical attention Emergency room services Emergency medical transportation See section IV and V of plan document See section IV and V of plan document Urgent care $25 copay $25 copay See section III.E of plan document for details. If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fee Authorization required. Authorization may be required. SBC_Health First Silver AV94 HMO (1_2019) * For more information about limitations and exceptions, see the plan or policy document at 3 of 11

4 Common Medical Event If you need mental health, behavioral health, or substance abuse services If you are pregnant Services You May Need Preferred Provider What You Will Pay Outpatient services $5 copay Inpatient services Office visits Childbirth/delivery professional services $0 per visit 1-15; ultrasounds 5% coinsurance after Non-Preferred Provider Limitations, Exceptions, & Other Important Information Requires authorization, without which uncovered expenses might become member's responsibility Requires authorization, without which uncovered expenses might become member's responsibility In network visit 16+ subject to Specialist cost share. Perinatology not included. Authorization required. Delivery and all inpatient services Requires authorization, without which uncovered expenses might become member's responsibility Home health care Limit 60 visits per year. Rehabilitation services 35 visits per year, per condition. If you need help recovering or have other special health needs Habilitation services Skilled nursing care 5% coinsurancer after 35 visits per year, per condition. 60 days maximum per year. Durable medical equipment Authorization may be required. Hospice service See section IV and V of plan document Children's eye exam $0 copay. One routine eye exam per year. If your child needs dental or eye care Children's glasses $0 copay. One pair of eyeglasses (frame and basic lenses) per year. See sections IV and V of plan document. Children's dental check-up $0 copay. See sections IV, V, and X of plan document. SBC_Health First Silver AV94 HMO (1_2019) * For more information about limitations and exceptions, see the plan or policy document at 4 of 11

5 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Abortion, except in cases of rape, incest, or jeopardized health of the mother Acupuncture Bariatric surgery Cosmetic Surgery Dental care Dental care (adult) Hearing aids Infertility treatment Long-term care Non-emergency care when traveling outside the U.s. Private-duty nursing Routine eye care Routine foot care Weight loss programs Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) Chiropractic services (limited) SBC_Health First Silver AV94 HMO (1_2019) 5 of 11

6 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: state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Other options to continue coverage are available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call 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: Health First Health Plans Customer Service (weekdays 8am to 5pm) Phone Toll-Free: TDD services for the hearing or speech impaired: Fax Number: Health First Health Plans Attn: Member Advocate 6450 US Highway 1 Rockledge, FL Agency for Health Care Administration (AHCA) Call (fully-insured plans only) Florida's Office of Insurance Regulation (OIR) Call (fully-insured plans only) Employee Benefits Security Administration Call EBSA (3272). Does this plan provide Minimum Essential Coverage? This plan or policy Does provide minimum essential coverage. 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. Does this plan meet the Minimum Value Standards? This health coverage Does meet the minimum value standard for the benefits it provides. 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. To see examples of how this plan might cover costs for a sample medical situation, see the next page. SBC_Health First Silver AV94 HMO (1_2019) 6 of 11

7 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 ( s, 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 (9 months of in-network pre-natal care and a hospital delivery) Managing Joe's type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Mia's Simple Fracture (in-network emergency room visit and follow up care) The plan's overall $250 Specialist [cost sharing] copayment $5 Hospital (facility) [cost sharing] coinsurance 5% Other coinsurance coinsurance 5% This EXAMPLE event includes services like: Specialist office visits ( prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests ( ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $11,500 In this example, Peg would pay: Cost Sharing Deductibles $300 Copayments $20 Coinsurance $500 What isn't covered Limits or exclusions $60 The total Peg would pay is 900 The plan's overall $250 Specialist [cost sharing] copayment $5 Hospital (facility) [cost sharing] coinsurance 5% Other coinsurance coinsurance 5% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $300 Copayments $300 Coinsurance $20 What isn't covered Limits or exclusions $60 The total Joe would pay is $700 The plan's overall $250 Specialist [cost sharing] copayment $5 Hospital (facility) [cost sharing] coinsurance 5% Other coinsurance coinsurance 5% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $300 Copayments $30 Coinsurance $80 What isn't covered Limits or exclusions $0 The total Mia would pay is $400 SBC_Health First Silver AV94 HMO (1_2019) 7 of 11

8 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 participating providers. If the patient had received care from non-participating providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how s, 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-ofpocket costs, such as copayments, s, 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. SBC_Health First Silver AV94 HMO (1_2019) 8 of 11

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11 Nondiscrimination Notice Health First Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health First Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health First Health Plans: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, accessible electronic formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, please contact our Civil Rights Coordinator. If you believe that Health First Health Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, 6450 US Highway 1, Rockledge, FL 32955, , (TTY), Fax: , You can file a grievance in person or by mail, fax, or . If you need help filing a grievance our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at SBC_Health First Silver AV94 HMO (1_2019) 11 of 11

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