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Home My Public Portal AboutH P Independence SBC 2018-2019cyHarvard Pilgrim Health Care he Harvard Pilgrim IndependenceSM POS Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Massachusetts Coverage Period: 07/01/2018 • - 06/30/2019 Coverage for: Individual + Family 1 Plan Type: POS A Important Questions The Summary of Benefits and Coverage (SBC) document will help and the plan would share the cost for covered health care services. you choose a health plan. The SBC shows you how you NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. of the complete terms of coverage, www.harvardpilgrim.org. For general balance billing, coinsurance, copayment, deductible, provider, or For more information about your coverage, or to get a copy definitions of common terms, such as allowed amount, other underlined terms see the Glossary. You can view the request a copy. r Why this matters Glossary at www.harvardpilgrim.org/fhcr or call 1-888-333-4742 to What is the deductible? overall In -Network: $500 member / $1,000 family Out -of -Network: $500 member / $1,000 family Generally you must pay all the costs up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. The following In -Network services: preventive This plan covers some items and services even if you haven't yet care, provider office visits, mental health, met the deductible amount. But, a copayment or coinsurance rehabilitation services, and habilitation services are may apply. covered before you meet your deductible. Are there other deductibles for specific Yes. Prescription Drug Deductible: $100 member / $200 family There are no other specific deductibles. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services? services. What is the out—of—pocket limit In -Network: $5,000 member / $10,000 family Out -of -Network: $5,000 member / $10,000 family The out-of-pocket limit is the most you could pay in a year of covered services. If you have other family members in this plan, for this plan? they have to meet their own out-of-pocket limit until family out-of-pocket limit has been met. MD0000004773, RX0000014666 Page 1 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Important Questions Answers mu& this matters What is not included in the out—of—pocket limit? Premiums, balance -billed charges, penalties for failure to obtain preauthorization 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. Will you pay less if you use a network provider? Yes. See wwa.providerlookuponline.com/ harvardpilgrim/po7/Search.aspx or call 1-888-333-4742 for a list of preferred providers. 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 (balance -billing). 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. Do you need a referral to Yes, some exceptions apply. see a specialist? This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. Copayments and coinsurance cost shown in this chart are both before and after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need Network Provider (You will pay the least) What You Will Pay Out -of -Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness Specialist visit Level 1: $10 copay/ visit; deductible does not apply Level 2: $20 copay/ visit; deductible does not apply Level 3: $40 copay/ visit; deductible does not apply Level 1: $30 copay/ visit; deductible does not apply Level 2: $60 copay/ visit; deductible does not apply Level 3: $75 copay/ visit; deductible does not apply 20% coinsurance None 20% coinsurance None Preventive care/ No charge; deductible screening/immunization does not apply 20% coinsurance None Page 2 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Common Medical Event Services You May Need What You Will Network Provider (You will pay the least) Pay Out -of -Network Provider (You will pay the most) Limitations, Exceptions, & Othe Important Information If you have a test Diagnostic test (x-ray, No charge 20% coinsurance None blood work) Imaging (CT/PET scans, MRIs) $100 copay/ scan 20% coinsurance Participating Providers limited to a maximum of one copay/ Member/ day. Out -of -Network preauthorization required. Penalty of $500 if approval not received before services obtained. If you need drugs to treat your illness or condition More information about prescription P P Generic drugs Retail: $10 copay after deductible Prescription drug coverage is administered by Express Scripts. For additional information, visit www.express-scripts.com/gicrx or call Customer Service at 1-855-283-7679 (TTY 711). Retail cost share is for up to a 30 -day supply; mail order cost share is for up to a 90 -day supply. Some drugs require prior authorization to be covered. Some drugs have quantity limitations. A 90 -day supply of maintenance medications may be obtained at a CVS Pharmacy for the applicable mail order copay. If a drug has a generic equivalent, and you buy the brand name (even if your physician indicates no substitutions), you will pay the generic -level copay plus the cost difference between the generic and the brand name drug. Maintenance 90/Mail Order: deductible $25 copay after Preferred brand drugs Retail: $30 copay after deductible Maintenance 90/Mail Order: deductible $75 copay after drug coverage is available at www express- scripts.com/gicrx. Non -preferred brand drugs Retail: $65 copay after deductible Maintenance 90/Mail Order: deductible $165 copay after Specialty drugs Limited to a 30 -day supply with appropriate tier copay (see above) when purchased at a designated specialty pharmacy Must be obtained at a designated specialty pharmacy. Some drugs require prior authorization to be covered. Some drugs have quantity limitations. Some specialty Page 3 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Common Medical Event mil Services You May Need What You Will Pay Out -of -Network Network Provider Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Othe Important Information drugs may also be covered under your medical benefit. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) $250 copay/ visit 20% coinsurance Up to four Surgical Day Care Copays/ member/ year. Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/ visit None Emergency medical No charge None transportation Urgent care Convenience care clinic: $10 copay/ visit; Convenience care clinic: 20% coinsurance None deductible does not apply Urgent care clinic (including hospital urgent care clinic): $20 copay/ visit; deductible Urgent care clinic (including hospital urgent care clinic): 20% coinsurance does not apply If you have a hospital stay Facility fee (e.g., hospital room) Tier 1: $275 copay/ admit 20% coinsurance Up to one Medical or Mental Health & Substance Abuse Hospital Inpatient Copay/ Member each Quarter. Tier 2: $500 copay/ admit Tier 3: $1,500 copay/ admit Physician/surgeon fee No charge 20% coinsurance None If you have mental health, behavioral health, or substance abuse needs Outpatient services $10 copay/ visit; 20% coinsurance None deductible does not apply Inpatient services $275 copay/ admit; 20% coinsurance Up to one Medical or Mental Health & Substance Abuse Hospital Inpatient Copay/ Member each Quarter. deductible does not apply Page 4 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Common Medical Event Services You May Need What You Will Network Provider (You will pay the least) Pay Out -of -Network Provider (You will pay the most) Limitations, Exceptions, & Othe Important Information If you are pregnant Office visits Level 1: $10 copay/ visit; 20% coinsurance Cost sharing does not apply for deductible does not apply preventive services. Maternity care Level 2: $20 copay/ visit; may include tests and services described elsewhere in the SBC (i.e. ultrasound.) deductible does not apply Level 3: $40 copay/ visit; deductible does not apply Childbirth/delivery professional services No charge 20% coinsurance Cost sharing does not apply for preventive services. Maternity care Childbirth/delivery facility services Tier 1: $275 copay/ admit 20% coinsurance may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Up to one Medical or Mental Health & Substance Abuse Hospital Inpatient Copay/ Member each Quarter. Tier 2: $500 copay/ admit Tier 3: $1,500 copay/ admit If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services Physical & Occupational Therapy: $20 copay/ p y/ 20% coinsurance Physical & Occupational Therapy — 90 consecutive days/ illness or injury y / � y visit; deductible does not apply Speech Therapy: No charge; deductible does not apply Habilitation services Physical & Occupational Therapy: $20 copay/ 20% coinsurance visit; deductible does not apply Speech Therapy: No charge; deductible does not apply Skilled nursing care 20% coinsurance 20% coinsurance — 45 days/ year Page 5 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Othe Important Information Network Provider (You will pay the least) Out -of -Network Provider (You will pay the most) Durable medical No charge 20% coinsurance None equipment Hospice services No charge 20% coinsurance For inpatient services, see "If you have a hospital stay". If your child needs dental or eye care Children's eye exam Optometrist: $20 copay/ 20% coinsurance — 1 exam every 24 months visit; deductible does not apply Ophthalmologists: Level 1: $30 copay/ visit; deductible does not apply Level 2: $60 copay/ visit; deductible does not apply Level 3: $75 copay/ visit; deductible does not apply Children's glasses Not covered None Children's dental check-up Not covered None 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.) • Acupuncture • Long -Term (Custodial) Care • Most Cosmetic Surgery • Most Dental Care (Adult) • Private -duty nursing • Routine foot care • Services that are not Medically Necessary • Weight Loss Programs Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) • Bariatric surgery • Chiropractic Care - 20 visits/ year • Hearing Aids - $2,000/ hearing aid every 24 months/ impaired ear up to age 22 • Hearing Aids - up to $1,700 every 2 years for age 22 or older • Infertility Treatment - 5 cycles advanced reproductive technology/ lifetime • Non -emergency care when traveling outside the U.S. • Routine eye care (Adult) - 1 exam every 24 months Page 6 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services 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: the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. 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: HPHC Member Appeals -Member Services Department Harvard Pilgrim Health Care, Inc. 1600 Crown Colony Drive Quincy, MA 02169 Telephone: 1-888-333-4742 Fax: 1-617-509-3085 Department of Labor's Employee Benefits Security Administration 1-866-444-3272 www.dol.gov/ebsa/healthreform Health Care for All 30 Winter Street, Suite 1004 Boston, MA 02108 1-800-272-4232 http://www.hcfama.org/helpline Does this plan provide Minimum Essential Coverage? Yes 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 Coverage Meet the Minimum Value Standard? Yes 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. Language Access Services: Para obtener asistencia en Espanol. llame al 1-888-333-4742. t0 N 3Z EOM @i1, i n- - 1-888-333-4742. De assistencia em Portugues, por favor ligue 1-888-333-4742. To see examples of how this plan might cover costs for a sample medical situation, see the next page. Page 7 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services 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 (deductible, copayment 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) • The plan's overall deductible • Specialist copayment • Hospital (facility) copayment • Other copayment Managing Joe's type 2 Diabetes (a year of routine in -network care of a well -controlled condition) $600 • The plan's overall deductible $30 • Specialist copayment $275 • Hospital (facility) copayment $0 • Other copayment 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 $12,731 In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance $600 $280 $0 What isn't covered Limits or exclusions Mia's Simple Fracture (in -network emergency room visit and follow up care) $600 • The plan's overall deductible $30 • Specialist copayment $275 • Hospital (facility) copayment $0 • Other copayment 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 $7,389 In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance $320 $1,540 $0 What isn't covered $0 Limits or exclusions The total Peg would pay $880 is $600 $30 $275 $0 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 $1,925 In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance $500 $120 $0 What isn't covered $30 Limits or exclusions The total Joe would pay is $1,890 $0 The total Mia would pay is $620 The plan would be responsible for the other costs of these EXAMPLE covered services. Page 8 of 8 Language Assistance Services Espanol (Spanish) ATENCI6N: Si usted habia espanol, servicios de asistencia Iinguistica, de forma gratuita, estan a su disposicion. Llame al 1-888-333-4742 (TTY: 711). Portugues (Portuguese) ATEKAO: Se voce fala portugues, encontram-se disponiveis serviryos Iinguisticos gratuitos. Ligue para 1-888-333-4742 (TTY: 711). Kreyol Ayisyen (French Creole) ATANSYON: Si nou pale Kreybl Ayisyen, gen asistans pou sevis ki disponib nan lang nou pou gratis. Rele 1-888-333-4742 (TTY: 711). 211111:11C(Traditional Chinese) 5cg, : to 1 itJTI IGp , 1 7L;(9 14,111 #-YORE . Mkt 1- 888-333-4742 ( TTY : 711 ) Tieng ViOt (Vietnamese) CH1 Y: Neuu qui vi not Ting Viet, dich Al thong dich cua chung toi san sang phuc Vita qui vi mien phi. Gqi s6 1-888-333-4742 (TTY: 711). PyCCKNN (Russian) BHNMAHNE: SCAN Bbl roBopNTe Ha pyCCKOM fi3blKe, TO BaM 4OCrynHbl 6ecnnaTHble ycnyrw nepeBo4a. 3BOHHTe 1-888-333-4742 (TeneraHn: 711). 4x.ii (Arabic) 1 888-333-4742 cSlc• cl.4.1! Ut .+11'oJ9yie: Ul is1•4•4: _tali iAli rLS� ,Iii :0146.4 (TTY: 71 1 ) I?-1(Cambodian) t fi75st:zdi = tux m§tznturTit,nier, ttuEnstrvttmvumr.pri w i; ivy 1 ur srcvc� 1-888-333-4742 (TTY: 711)1 N V V G Francais (French) ATTENTION: Si vous parlez frangais, des services d'aide linguistique vous sont proposes gratuitement. Appelez le 1-888-333-4742 (ATS: 711). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia I'italiano, sono disponibili servizi di assistenza Iinguistica gratuiti. Chiamare it numero 1-888-333-4742 (TTY: 711). (Continued) q'#I (orean)'g :Lq-al AfgtEAl� T, i XI hidl�z T 01 75Ez ÷L ! LIcF-1- 888-333-4742 (TTY: 711) i `1 E off T X 12. E]LTir1vLKcc (Greek) IIPO OXH: Av ehhrlvucct, unctpxouv nrr Sror6carj ocrc Scopcccv urrripEcifc yX corKr1c undo-njPL rl(. Kantor€ 1-888-333-4742 (TTY: 711). Polski (Polish) UWAGA: Jeieli mowisz po polsku, moiesz skorzystacz bezplatnej pomocy jgzykowej. 2adzwori pod numer 1-888-333-4742 (TTY: 711). iWet (Hindi) t ia-1 3 3 �7 t 3-T' -f E I?Icii I1f-d 1-888-333-4742 (TTY: 711) o,1° ?trO. (Gujarati) kUUat 41t i : Q (14 3raR1c{t k -toil �Z cif 11 311 (11.04.1 -51.4 J. 1 c -1 al l ci GtJC4 t . CaRti ut( -ft CITY. T'Y' ^ f 11 tar} '}e9O (Lao) kiog u. fj')OI tJi c8-itJYz`) Y)O, mUt 57)1u O)CU O.nit,J')z'), kmC. 05.361, ltns 1-888-333.4742 (TTY: 711). ATTENTION: if you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-333-4742 CITY: 711). Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care, Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health Care of New England and HPHC Insurance Company. (Continued) General Notice About Nondiscrimination and Accessibility Requirements Harvard Pilgrim Health Care and its affiliates as noted below ("HPHC") comply with applicable federal dvil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. HPHC does not exclude people or treat them differently because of race, color, national origin, age. disability or sex. HPHC: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, otter formats) • Provides free language services to people whose prinary language is not English, such as qualified interpreters. If you need these services, contact our Civil Rights Compliance Officer. If you believe that HPHC has failed to provide these services a discriminated in another way on the basis of race, color. national origin, age, disability or sex, you can file a grievance with: Civil Rights Compliance Officer, 93 Worcester St, Wellesley, MA 02481, (866) 750.2074, TTY service: 711, Fax: (617) 509.3085, Email: civil_rights@harvardpilgrim.org. You can file a grievance h person or by mail, fax or email. If you need help filing a grievance, the Civil Rights Compliance Officer 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 Rghts Complaint Portal, available at httpsiloaportal.hhs.gov/oa/portalAobby.jsf, or by mail or phone at U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH 8uildng Washington, D.C. 20201 (800) 368-1019, (800) 537-7697 (TTY) Complaint forms are available at httpJ/w wr.hhs.govlocrlofficelfilelindex.hhnl. Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care, Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health Care of New England and HPHC Insurance Company. cc6589_memb_sery (11/9)