the local choice: high deductible health plan (hdhp) info_d… · the local choice: high deductible...

1

of 8

The

Loca

l Cho

ice:

Hig

h D

educ

tible

Hea

lth P

lan

(HD

HP)

Cov

erag

e Pe

riod:

07/

01/2

014 –

06/3

0/20

15Su

mm

ary

of B

enef

its a

nd C

over

age:

Wha

t thi

s P

lan

Cov

ers

& W

hat i

t Cos

tsC

over

age

for:

Indi

vidu

al/F

amily

|Pl

an T

ype:

PP

O

Que

stio

ns:C

all 1

-888

-642

-441

4 or

visi

t us a

t ww

w.th

eloc

alch

oice

.vir

gini

a.go

v.If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.thel

ocal

choi

ce.v

irgi

nia.

gov

or c

all 1

-888

-642

-441

4 to

requ

est a

cop

y.

This

is o

nly

a su

mm

ary.

If y

ou w

ant m

ore

deta

il ab

out y

our c

over

age

and

cost

s, yo

u ca

n ge

t the

com

plet

e te

rms i

n th

e po

licy

or p

lan

docu

men

t at w

ww

.thel

ocal

choi

ce.v

irgi

nia.

gov

or b

y ca

lling

1-8

88-6

42-4

414.

Impo

rtan

t Que

stio

ns

Ans

wer

s W

hy th

is M

atte

rs:

Wha

t is

the

over

all

dedu

ctib

le?

For i

n-ne

twor

k pr

ovid

ers $

1,50

0pe

rson

/$3

,000

fam

ily

No

out-o

f-ne

twor

k be

nefit

s, ex

cept

in a

n em

erge

ncy

Doe

sn’t

appl

y to

pre

vent

ive

care

You

mus

t pay

all

the

cost

s up

to th

e de

duct

ible

am

ount

bef

ore

this

plan

beg

ins

to p

ay fo

r cov

ered

serv

ices

you

use

. Che

ck y

our p

olic

y or

pla

n do

cum

ent t

o se

e w

hen

the

dedu

ctib

le st

arts

ove

r (us

ually

, but

not

alw

ays,

Janu

ary

1st).

See

the

char

t sta

rting

on

page

2 fo

r how

muc

h yo

u pa

y fo

r cov

ered

serv

ices

afte

r you

m

eet t

he d

educ

tible

.

Are

ther

e ot

her

dedu

ctib

les

for s

peci

fic

serv

ices

? N

o.

You

don

’t ha

ve to

mee

t ded

uctib

les

for s

peci

fic se

rvic

es, b

ut se

e th

e ch

art

star

ting

on p

age

2 fo

r oth

er c

osts

for s

ervi

ces t

his p

lan

cove

rs.

Is th

ere

an o

ut–o

f–po

cket

lim

it on

my

expe

nses

?

Yes

. For

par

ticip

atin

g pr

ovid

ers $

5,00

0pe

rson

/$1

0,00

0fa

mily

The

out-

of-p

ocke

t lim

it is

the

mos

t you

cou

ld p

ay d

urin

g a

cove

rage

per

iod

(usu

ally

one

yea

r) fo

r you

r sha

re o

f the

cos

t of c

over

ed se

rvic

es. T

his l

imit

help

s yo

u pl

an fo

r hea

lth c

are

expe

nses

. The

re a

re n

o ou

t-of-

netw

ork

bene

fits e

xcep

t in

an

emer

genc

y.

Wha

t is

not i

nclu

ded

in

the

out–

of–p

ocke

t lim

it?

Ded

uctib

le a

nd c

oins

uran

ce fo

r rou

tine

dent

al se

rvic

es

Eve

n th

ough

you

pay

thes

e ex

pens

es, t

hey

don’

t cou

nt to

war

d th

e ou

t-of

-po

cket

lim

it.

Is th

ere

an o

vera

ll an

nual

lim

it on

wha

t th

e pl

an p

ays?

N

o.

The

char

t sta

rting

on

page

2 d

escr

ibes

any

lim

its o

n w

hat t

he p

lan

will

pay

for

specific

cov

ered

serv

ices

, suc

h as

off

ice

visit

s.

Doe

s th

is p

lan

use

a ne

twor

k of

pro

vide

rs?

Yes

. See

ww

w.a

nthe

m.c

om o

r cal

l 1-

800-

552-

2682

for a

list

of i

n-ne

twor

k pr

ovid

ers.

If y

ou u

se a

n in

-net

wor

k do

ctor

or o

ther

hea

lth c

are

prov

ider

, thi

s pla

n w

ill p

ay

som

e or

all

of th

e co

sts o

f cov

ered

serv

ices

. Be

awar

e, y

our i

n-ne

twor

k do

ctor

or

hos

pita

l may

use

an

out-o

f-ne

twor

k pr

ovid

er fo

r som

e se

rvic

es. P

lans

use

th

e te

rm in

-net

wor

k, p

refe

rred

, or p

artic

ipat

ing

for p

rovi

ders

in th

eir

netw

ork .

See

the

char

t sta

rting

on

page

2 fo

r how

this

plan

pay

s diff

eren

t kin

ds

of p

rovi

ders

.

Do

I ne

ed a

refe

rral

to

see

a sp

ecia

list?

N

o. Y

ou d

on’t

need

a re

ferr

al to

see

a sp

ecia

list.

You

can

see

the

spec

ialis

t you

cho

ose

with

out p

erm

issio

n fr

om th

is pl

an.

Page

22

2

of 8

Are

ther

e se

rvic

es th

is

plan

doe

sn’t

cove

r?

Yes

. So

me

of th

e se

rvic

es th

is pl

an d

oesn

’t co

ver a

re li

sted

on

page

5. S

ee y

our

polic

y or

plan

doc

umen

t for

add

ition

al in

form

atio

n ab

out e

xclu

ded

serv

ices

.

Cop

aym

ents

are

fixe

d do

llar a

mou

nts (

for e

xam

ple,

$25)

you

pay

for c

over

ed h

ealth

car

e, us

ually

whe

n yo

u re

ceiv

e th

e se

rvic

e. C

oins

uran

ce is

your

shar

e of

the

cost

s of a

cov

ered

serv

ice,

calcu

lated

as a

per

cent

of t

he a

llow

ed a

mou

nt fo

r the

serv

ice.

For e

xam

ple,

if th

e pl

an’s

allo

wed

am

ount

for a

n ov

erni

ght h

ospi

tal s

tay

is $1

,000

, you

r coi

nsur

ance

pay

men

t of 2

0% w

ould

be

$200

. Th

is m

ay c

hang

e if

you

have

n’t m

et y

our d

educ

tible

. Th

e am

ount

the

plan

pay

s for

cov

ered

serv

ices

is b

ased

on

the

allo

wed

am

ount

. If a

n ou

t-of-

netw

ork

prov

ider

cha

rges

mor

e th

an th

e al

low

ed a

mou

nt, y

ou m

ay h

ave

to p

ay th

e di

ffer

ence

. For

exa

mpl

e, if

an o

ut-o

f-net

wor

k ho

spita

l cha

rges

$1,

500

for a

n ov

erni

ght s

tay

and

the

allo

wed

am

ount

is $

1,00

0, y

ou m

ay h

ave

to p

ay th

e $5

00 d

iffer

ence

. (Th

is is

calle

d ba

lanc

e bi

lling

.) Th

is pl

an m

ay e

ncou

rage

you

to u

se in

-net

wor

k pr

ovid

ers

by c

harg

ing

you

low

er d

educ

tible

s, co

paym

ents

and

coi

nsur

ance

am

ount

s.

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay

Nee

dYo

ur C

ost I

f You

U

se a

n

In-N

etw

ork

Prov

ider

Your

Cos

t If Y

ou

Use

a

Non

-Net

wor

kPr

ovid

er

Lim

itatio

ns &

Exc

eptio

ns

If y

ou v

isit

a he

alth

ca

re p

rovi

der’s

offi

ce

or c

linic

Prim

ary

care

visi

t to

treat

an

inju

ry o

r illn

ess

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

Spec

ialist

visi

t 20

% c

oins

uran

ce a

fter

dedu

ctib

le

Not

Cov

ered

––

––––

––––

–non

e–––

––––

––––

Oth

er p

ract

ition

er o

ffice

vi

sit

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

Cove

rage

is li

mite

d to

30

visit

s ann

ual m

ax fo

r ch

iropr

actic

. Pr

even

tive c

are/

sc

reen

ing/

imm

uniza

tion

No

char

ge

Not

Cov

ered

––

––––

––––

–non

e–––

––––

––––

If y

ou h

ave

a te

st

Diag

nost

ic te

st (x

-ray

, bl

ood

wor

k)

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

Imag

ing

(CT/

PET

scan

s, M

RIs)

20

% c

oins

uran

ce a

fter

dedu

ctib

le

Not

Cov

ered

Pr

e-au

thor

izat

ion

may

be

requ

ired.

Page

23

3

of 8

C

omm

onM

edic

al E

vent

Serv

ices

You

May

N

eed

Your

Cos

t If Y

ou

Use

an

In

-Net

wor

k Pr

ovid

er

Your

Cos

t If Y

ou

Use

a

Non

-Net

wor

kPr

ovid

er

Lim

itatio

ns &

Exc

eptio

ns

If y

ou n

eed

drug

s to

tr

eat y

our i

llnes

s or

co

nditi

on

Mor

e in

form

atio

n ab

out p

resc

riptio

n dr

ug c

over

age

is av

ailab

le a

t w

ww

.anth

em.co

m.

Gen

eric

dru

gs

20%

coi

nsur

ance

afte

r de

duct

ible

20

% c

oins

uran

ce a

fter

dedu

ctib

le

Cove

rs u

p to

a 3

4-da

y su

pply

(ret

ail

pres

crip

tion)

; 90

day

supp

ly (h

ome

deliv

ery

pres

crip

tion)

. If y

ou u

se a

non

-net

wor

k ph

arm

acy,

you

pay

the

diffe

renc

e be

twee

n th

e ph

arm

acy

char

ge a

nd th

e pl

an a

llow

able

cha

rge.

Pref

erre

d br

and

drug

s 20

% c

oins

uran

ce a

fter

dedu

ctib

le

20%

coi

nsur

ance

afte

r de

duct

ible

Pl

ease

see

limita

tions

in G

ener

ic d

rugs

.

Non

-pre

ferr

ed b

rand

dr

ugs

20%

coi

nsur

ance

afte

r de

duct

ible

20

% c

oins

uran

ce a

fter

dedu

ctib

le

Plea

se se

e lim

itatio

ns in

Gen

eric

dru

gs.

Spec

ialty

dru

gs

20%

coi

nsur

ance

afte

r de

duct

ible

20

% c

oins

uran

ce a

fter

dedu

ctib

le

Plea

se se

e lim

itatio

ns in

Gen

eric

dru

gs.

If y

ou h

ave

outp

atie

nt s

urge

ry

Faci

lity

fee

(e.g

., am

bulat

ory

surg

ery

cent

er)

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

–––––––––––n

one–––––––––––

Phys

ician

/sur

geon

fees

20

% c

oins

uran

ce a

fter

dedu

ctib

le

Not

Cov

ered

–––––––––––n

one–––––––––––

If y

ou n

eed

imm

edia

te m

edic

al

atte

ntio

n

Em

erge

ncy

room

serv

ices

20

% c

oins

uran

ce a

fter

dedu

ctib

le

Not

Cov

ered

. E

mer

genc

y se

rvice

s w

ill b

e co

nsid

ered

at

the

In-N

etw

ork

bene

fit

leve

l; ho

wev

er, b

alanc

e bi

lling

may

still

occ

ur.

–––––––––––n

one–––––––––––

Em

erge

ncy

med

ical

trans

porta

tion

20%

coi

nsur

ance

afte

r de

duct

ible

Not

Cov

ered

. E

mer

genc

y se

rvice

s w

ill b

e co

nsid

ered

at

the

In-N

etw

ork

bene

fit

leve

l; ho

wev

er, b

alanc

e bi

lling

may

still

occ

ur.

–––––––––––n

one–––––––––––

Urg

ent c

are

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

–––––––––––n

one–––––––––––

Page

24

4

of 8

If

you

hav

e a

hosp

ital s

tay

Faci

lity

fee

(e.g

., ho

spita

l ro

om)

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

Phys

ician

/sur

geon

fee

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

If y

ou h

ave

men

tal

heal

th, b

ehav

iora

l he

alth

, or s

ubst

ance

ab

use

need

s

Men

tal/

Beha

vior

al he

alth

outp

atie

nt se

rvic

es

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

Men

tal/

Beha

vior

al he

alth

inpa

tient

serv

ices

20

% c

oins

uran

ce a

fter

dedu

ctib

le

Not

Cov

ered

––

––––

––––

–non

e–––

––––

––––

Subs

tanc

e us

e di

sord

er

outp

atie

nt se

rvic

es

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

Subs

tanc

e us

e di

sord

er

inpa

tient

serv

ices

20

% c

oins

uran

ce a

fter

dedu

ctib

le

Not

Cov

ered

––

––––

––––

–non

e–––

––––

––––

Em

ploy

ee A

ssist

ance

Pr

ogra

m (E

AP)

N

o Ch

arge

N

ot C

over

ed

Cove

rs u

p to

4 v

isits

per

inci

dent

with

in a

12

mon

th p

erio

d.

If y

ou a

re p

regn

ant

Pren

atal

and

post

nata

l ca

re

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

Del

iver

y an

d all

inpa

tient

se

rvic

es

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

If y

ou n

eed

help

re

cove

ring

or h

ave

othe

r spe

cial

hea

lth

need

s

Hom

e he

alth

care

20

% c

oins

uran

ce a

fter

dedu

ctib

le

Not

Cov

ered

Co

vera

ge is

lim

ited

to 9

0 vi

sits m

ax. p

er

cove

rage

per

iod.

Reha

bilit

atio

n se

rvic

es

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

Hab

ilita

tion

serv

ices

20

% c

oins

uran

ce a

fter

dedu

ctib

le

Not

Cov

ered

––

––––

––––

–non

e–––

––––

––––

Skill

ed n

ursin

g ca

re

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

Cove

rage

is li

mite

d to

180

day

s max

. per

co

vera

ge p

erio

d.

Dur

able

med

ical

equi

pmen

t 20

% c

oins

uran

ce a

fter

dedu

ctib

le

Not

Cov

ered

––

––––

––––

–non

e–––

––––

––––

Hos

pice

serv

ice

20%

coi

nsur

ance

afte

r de

duct

ible

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

If y

our c

hild

nee

ds

dent

al o

r eye

car

e

Eye

exa

m

Not

Cov

ered

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

Glas

ses

Not

Cov

ered

N

ot C

over

ed

––––

––––

–––n

one–

––––

––––

––

Den

tal c

heck

-up

No

Char

ge

Prov

ider

Cha

rge

in

exce

ss o

f pla

n’s

cont

ract

ual r

ate

Den

tal c

over

age

adm

inist

ered

by

Del

ta D

enta

l of

Virg

inia,

ww

w.d

elta

dent

alva

.com

or c

all

1-88

8-33

5-82

96.

Page

25

5

of 8

Excl

uded

Ser

vice

s &

Oth

er C

over

ed S

ervi

ces:

Serv

ices

You

r Pla

n D

oes

NO

T C

over

(Thi

s is

n’t a

com

plet

e lis

t. C

heck

you

r pol

icy

or p

lan

docu

men

t for

oth

er e

xclu

ded

serv

ices

.)

Acu

punc

ture

Cosm

etic

surg

ery

Hea

ring

aids

Infe

rtilit

y tre

atm

ent

Long

-term

car

e

Rout

ine

eye

care

Rout

ine

foot

car

e (e

xcep

t for

som

e di

abet

ic

treat

men

t – p

leas

e se

e yo

ur m

embe

r ha

ndbo

ok fo

r com

plet

e de

tails

)

Wei

ght l

oss p

rogr

ams

Oth

er C

over

ed S

ervi

ces

(Thi

s is

n’t a

com

plet

e lis

t. C

heck

you

r pol

icy

or p

lan

docu

men

t for

oth

er c

over

ed s

ervi

ces

and

your

cos

ts fo

r the

se

serv

ices

.)

Baria

tric

surg

ery

Chiro

prac

tic c

are

Den

tal c

are

Mos

t cov

erag

e pr

ovid

ed o

utsid

e th

e U

nite

d St

ates

. See

ww

w.an

them

.com

/tlc

Non

-em

erge

ncy

care

whe

n tra

velin

g ou

tsid

e th

e U

.S.

Priv

ate-

duty

nur

sing

Your

Rig

hts

to C

ontin

ue C

over

age:

If y

ou lo

se c

over

age

unde

r the

plan

, the

n, d

epen

ding

upo

n th

e ci

rcum

stan

ces,

Fede

ral a

nd S

tate

law

s may

pro

vide

pro

tect

ions

that

allo

w y

ou to

kee

p he

alth

cove

rage

. Any

such

righ

ts m

ay b

e lim

ited

in d

urat

ion

and

will

requ

ire y

ou to

pay

a p

rem

ium

, whi

ch m

ay b

e sig

nific

antly

hig

her t

han

the

prem

ium

you

pay

w

hile

cov

ered

und

er th

e pl

an. O

ther

lim

itatio

ns o

n yo

ur ri

ghts

to c

ontin

ue c

over

age

may

also

app

ly.

For m

ore

info

rmat

ion

on y

our r

ight

s to

cont

inue

cov

erag

e, co

ntac

t the

plan

at 1

-888

-642

-441

4 . Y

ou m

ay a

lso c

onta

ct y

our s

tate

insu

ranc

e de

partm

ent,

the

U.S

. Dep

artm

ent o

f Lab

or, E

mpl

oyee

Ben

efits

Sec

urity

Adm

inist

ratio

n at

1-8

66-4

44-3

272

or w

ww

.dol

.gov

/ebs

a, or

the

U.S

. Dep

artm

ent o

f Hea

lth a

nd

Hum

an S

ervi

ces a

t 1-8

77-2

67-2

323

x615

65 o

r ww

w.cc

iio.cm

s.gov

.

Your

Grie

vanc

e an

d A

ppea

ls R

ight

s:

If y

ou h

ave

a co

mpl

aint o

r are

diss

atisf

ied

with

a d

enial

of c

over

age

for c

laim

s und

er y

our p

lan, y

ou m

ay b

e ab

le to

app

eal o

r file

a g

rieva

nce.

For

qu

estio

ns a

bout

you

r rig

hts,

this

notic

e, or

ass

istan

ce, y

ou c

an c

onta

ct:

Dire

ctor

, Dep

artm

ent o

f Hum

an R

esou

rce

Man

agem

ent,

101

Nor

th 1

4th S

treet

–

12th F

loor

, Ric

hmon

d, V

irgin

ia 23

219-

3657

. Mar

k en

velo

pe C

onfid

entia

l-App

eal E

nclo

sed.

Tel

epho

ne: 1

-888

-642

-441

4.

Page

26

6

of 8

D

oes

this

Cov

erag

e Pr

ovid

e M

inim

um E

ssen

tial C

over

age?

The

Aff

orda

ble

Car

e A

ct re

quire

s m

ost p

eopl

e to

hav

e he

alth

car

e co

vera

ge th

at q

ualif

ies

as “

min

imum

ess

entia

l cov

erag

e.”

Thi

s pl

an o

r pol

icy

does

pr

ovid

e m

inim

um e

ssen

tial c

over

age.

Doe

s th

is C

over

age

Mee

t the

Min

imum

Val

ue S

tand

ard?

The

Aff

orda

ble

Car

e A

ct e

stab

lishe

s a m

inim

um v

alue

stan

dard

of b

enef

its o

f a h

ealth

pla

n. T

he m

inim

um v

alue

stan

dard

is 6

0% (a

ctua

rial v

alue

). T

his

heal

th c

over

age

does

mee

t the

min

imum

val

ue s

tand

ard

for

the

bene

fits

it pr

ovid

es.

Lang

uage

Acc

ess

Serv

ices

:

––––

––––

––––

––––

––––

––To

see e

xam

ples

of ho

w th

is pl

an m

ight c

over

costs

for a

sam

ple m

edica

l situ

ation

, see

the n

ext p

age.–––––––––––

––––

––––

–––

Page

27

7

of 8

Hav

ing

a ba

by

(nor

mal

deliv

ery)

Man

agin

g ty

pe 2

dia

bete

s (ro

utin

e m

ainte

nanc

e of

a w

ell-c

ontro

lled

cond

ition

)

Abou

t the

se C

over

age

Exam

ples

: Th

ese

exam

ples

show

how

this

plan

mig

ht c

over

m

edica

l car

e in

giv

en si

tuat

ions

. Use

thes

e ex

ampl

es to

see,

in g

ener

al, h

ow m

uch

finan

cial

prot

ectio

n a s

ampl

e pa

tient

mig

ht g

et if

they

are

cove

red

unde

r diff

eren

t plan

s.

Amou

nt o

wed

to p

rovi

ders

: $7,

540

Plan

pay

s $4

,730

Pa

tient

pay

s $2

,810

Sam

ple

care

cos

ts:

Hos

pita

l cha

rges

(mot

her)

$2,7

00

Rout

ine

obste

tric

care

$2

,100

H

ospi

tal c

harg

es (b

aby)

$9

00

Ane

sthes

ia $9

00

Labo

rato

ry te

sts

$500

Pr

escr

iptio

ns

$200

Ra

diol

ogy

$200

V

accin

es, o

ther

pre

vent

ive

$40

Tot

al

$7,5

40

Patie

nt p

ays:

D

educ

tibles

$1

,500

Co

pays

$0

Co

insu

ranc

e $1

,160

Li

mits

or e

xclu

sions

$1

50

Tot

al

$2,8

10

Amou

nt o

wed

to p

rovi

ders

: $5,

400

Plan

pay

s $3

,070

Pa

tient

pay

s $2

,330

Sam

ple

care

cos

ts:

Pres

crip

tions

$2

,900

M

edica

l Equ

ipm

ent a

nd S

uppl

ies

$1,3

00

Offi

ce V

isits

and

Proc

edur

es

$700

Ed

ucat

ion

$300

La

bora

tory

tests

$1

00

Vac

cines

, oth

er p

reve

ntiv

e $1

00

Tot

al

$5,4

00

Patie

nt p

ays:

D

educ

tibles

$1

,500

Co

pays

$0

Co

insu

ranc

e $7

50

Lim

its o

r exc

lusio

ns

$80

Tot

al

$2,3

30

This

is

not a

cos

t es

timat

or.

Don

’t us

e th

ese

exam

ples

to

estim

ate

your

actu

al co

sts

unde

r thi

s plan

. The

actu

al ca

re y

ou re

ceiv

e w

ill b

e di

ffere

nt fr

om th

ese

exam

ples

, and

the c

ost o

f th

at c

are

will

also

be

diffe

rent

.

See

the

next

pag

e fo

r im

porta

nt in

form

atio

n ab

out

thes

e ex

ampl

es.

Page

28

8

of 8

Que

stio

ns a

nd a

nsw

ers

abou

t the

Cov

erag

e Ex

ampl

es:

Wha

t are

som

e of

the

assu

mpt

ions

beh

ind

the

Cov

erag

e Ex

ampl

es?

Cos

ts d

on’t

incl

ude

prem

ium

s. Sa

mpl

e ca

re c

osts

are

bas

ed o

n na

tiona

l av

erag

es su

pplie

d by

the

U.S

. D

epar

tmen

t of H

ealth

and

Hum

an

Serv

ices

, and

are

n’t s

peci

fic to

a

parti

cular

geo

grap

hic

area

or h

ealth

plan

. Th

e pa

tient

’s co

nditi

on w

as n

ot a

n ex

clud

ed o

r pre

exist

ing

cond

ition

. A

ll se

rvic

es a

nd tr

eatm

ents

star

ted

and

ende

d in

the

sam

e co

vera

ge p

erio

d.

Ther

e ar

e no

oth

er m

edic

al ex

pens

es fo

r an

y m

embe

r cov

ered

und

er th

is pl

an.

Out

-of-p

ocke

t exp

ense

s are

bas

ed o

nly

on tr

eatin

g th

e co

nditi

on in

the

exam

ple.

The

patie

nt re

ceiv

ed a

ll ca

re fr

om in

-ne

twor

k pr

ovid

ers.

If t

he p

atie

nt h

ad

rece

ived

car

e fr

om o

ut-o

f-ne

twor

k pr

ovid

ers,

cos

ts w

ould

hav

e be

en h

ighe

r.

Wha

t doe

s a

Cov

erag

e Ex

ampl

e sh

ow?

For e

ach

treat

men

t situ

atio

n, th

e Co

vera

ge

Exa

mpl

e he

lps y

ou se

e ho

w d

educ

tible

s,

copa

ymen

ts, a

nd c

oins

uran

ce c

an a

dd u

p. It

als

o he

lps y

ou se

e w

hat e

xpen

ses m

ight

be

left

up to

you

to p

ay b

ecau

se th

e se

rvic

e or

tre

atm

ent i

sn’t

cove

red

or p

aym

ent i

s lim

ited.

Doe

s th

e C

over

age

Exam

ple

pred

ict m

y ow

n ca

re n

eeds

?

No.

Tre

atm

ents

show

n ar

e ju

st e

xam

ples

. Th

e ca

re y

ou w

ould

rece

ive

for t

his

cond

ition

cou

ld b

e di

ffer

ent b

ased

on

your

do

ctor

’s ad

vice

, you

r age

, how

serio

us y

our

cond

ition

is, a

nd m

any

othe

r fac

tors

. D

oes

the

Cov

erag

e Ex

ampl

e pr

edic

t my

futu

re e

xpen

ses?

No.

Cov

erag

e E

xam

ples

are

not

cos

t es

timat

ors.

You

can

’t us

e th

e ex

ampl

es to

es

timat

e co

sts f

or a

n ac

tual

cond

ition

. The

y ar

e fo

r com

para

tive

purp

oses

onl

y. Y

our

own

cost

s will

be

diff

eren

t dep

endi

ng o

n th

e ca

re y

ou re

ceiv

e, th

e pr

ices

you

r pr

ovid

ers

char

ge, a

nd th

e re

imbu

rsem

ent

your

hea

lth p

lan a

llow

s.

Can

I us

e C

over

age

Exam

ples

to

com

pare

pla

ns?

Yes

. Whe

n yo

u lo

ok a

t the

Sum

mar

y of

Be

nefit

s and

Cov

erag

e fo

r oth

er p

lans,

you’

ll fin

d th

e sa

me

Cove

rage

Exa

mpl

es.

Whe

n yo

u co

mpa

re p

lans,

chec

k th

e “P

atie

nt P

ays”

box

in e

ach

exam

ple.

The

sm

aller

that

num

ber,

the

mor

e co

vera

ge

the

plan

pro

vide

s.

Are

ther

e ot

her c

osts

I sh

ould

co

nsid

er w

hen

com

parin

g pl

ans?

Yes

. An

impo

rtant

cos

t is t

he p

rem

ium

yo

u pa

y. G

ener

ally,

the

low

er y

our

prem

ium

, the

mor

e yo

u’ll

pay

in o

ut-o

f-po

cket

cos

ts, s

uch

as c

opay

men

ts,

dedu

ctib

les,

and

coi

nsur

ance

. You

sh

ould

also

con

sider

con

tribu

tions

to

acco

unts

such

as h

ealth

savi

ngs a

ccou

nts

(HSA

s), f

lexi

ble

spen

ding

arr

ange

men

ts

(FSA

s) o

r hea

lth re

imbu

rsem

ent a

ccou

nts

(HRA

s) th

at h

elp

you

pay

out-o

f-poc

ket

expe

nses

.

Page

29

HD

HP

Mon

thly

Rat

es

Hig

h D

educ

tible

Hea

lth P

lan

Em

ploy

ee O

nly

$0.0

0

Em

ploy

ee +

One

$158

.00

Fam

ily$3

03.0

0

Page

30

Page

31

���������3DJH���

Medical GOOCHLAND COUNTY PUBLIC SCHOOLS will offer Anthem medical benefits through The Local Choice (TLC). Please see the table below for a brief summary of coverage effective October 1, 2014. As always, please refer to the benefit summaries provided to you by TLC for further details on all benefits.

Option 1

Key Advantage 500 PPO

Option 2 Key Advantage 250

PPO

Option 3 High Deductible

Health Plan HMO

Referrals Required? No No No

Plan Year Deductible (October to October)

$500 individual $1,000 family

$250 individual $500 family

$1,500 individual$3,000 family

Maximum Out-of Pocket (Plan Year)

$3,000 individual $6,000 family

$2,000 individual $4,000 family

$5,000 individual$10,000 family

Office Visits (for illness or injury)

$25 PCP $40 Specialist

$20 PCP $35 Specialist

20% coinsurance, after deductible

Wellness Services (Well Child & Adult Preventive Care) Covered at 100%; No Charge Covered at 100%; No Charge Covered at 100%; No Charge

Inpatient Hospitalization 20% coinsurance, after deductible $300 copay per stay 20% coinsurance,

after deductible

Outpatient Hospitalization 20% coinsurance, after deductible $150 copay per visit 20% coinsurance,

after deductible

Emergency Room 20% coinsurance, after deductible $150 copay per visit 20% coinsurance,

after deductible

Pharmacy Prescription Drugs Tier 1 - $10 Tier 2 - $20 Tier 3 - $35

Tier 1 - $10 Tier 2 - $20 Tier 3 - $35

20% coinsurance, after deductible

Mail Order Prescription Drugs Tier 1 - $20 Tier 2 - $40 Tier 3 - $70

Tier 1 - $20 Tier 2 - $40 Tier 3 - $70

20% coinsurance, after deductible

Out-of-Network Benefits Yes Yes Only in emergency situations

Monthly Deduction (includes Medical, Dental & Vision)

Option 1 Key Advantage 500

Option 2 Key Advantage 250

Option 3 High Deductible

Health Plan

Employee $30.00 $73.00 $0.00

Employee + One $309.61 $389.61 $158.00

Employee + Family $559.38 $675.38 $303.00