Molina Marketplace Silver Plan. Molina Marketplace Silver Plan

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1 Summary of Benefits and Coverage Please select the deductible value that appears on your shopping screen to see details about the plan you are interested in. Resumen de beneficios y cobertura Por favor, seleccione el valor deducible que aparece en la pantalla de compras para ver detalles sobre el plan en el que está interesado. Molina Marketplace Silver Plan $1700 Deductible Molina Marketplace Silver Plan $1700 Deducible CLICK HERE to view this plan > $1400 Deductible HAGA CLIC AQUÍ para ver este plan > $1400 Deducible CLICK HERE to view this plan > HAGA CLIC AQUÍ para ver este plan > $100 $0 Deductible Deductible $100 $0 Deductible Deducible CLICK HERE to view this plan > $50 Deductible HAGA CLIC AQUÍ para ver este plan > $50 Deducible CLICK HERE to view this plan > For American Indian/Alaska Natives: $0 Deductible HAGA CLIC AQUÍ para ver este plan > For American Indian/Alaska Natives: $0 Deducible CLICK HERE to view this plan > HAGA CLIC AQUÍ para ver este plan >

2 Molina Healthcare of Washington, Inc.: Molina Silver 250 Plan Coverage Period: 01/01/ /31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HMO 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 or by calling Important Questions Answers Why this Matters: What is the overall Individual $1,700 See the chart starting on page 2 for your costs for services this plan covers. deductible? Family of 2 or more $3,400 Applies only to Outpatient Hospital/Facility and Inpatient Hospital/Facility Services Are there other Yes. Prescription Drug Deductible You must pay all of the costs for these services up to the deductible amount deductibles for specific Individual: $200 before this plan begins to pay for these services. services? Family of 2 or more: $400 Is there an out of pocket limit on my expenses? Yes $6,350 Individual, per Family, per year year $12,700 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 What is not included in Premium, balance-billed charges, and Even though you pay these expenses, they don t count toward the out of pocket the out of pocket limit? non-covered care limit Is there an overall annual No The chart starting on page 2 describes any limits on what the plan will pay for limit on what the plan specific covered services, such as office visits. pays? Does this plan use a Yes. For a list of participating If you use an in-network doctor or other health care provider, this plan will pay network of providers? providers, see some or all of the costs of covered services. Be aware, your in-network doctor or or call 1- 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 Do I need a referral to No. You can see the specialist you choose without permission from this plan. see a specialist? Are there services this plan doesn t cover? Yes. Some of the services this plan doesn t cover are listed on pages 5. See your policy or plan document for additional information about excluded services Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy.

3 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. 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. 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.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic Services You May Need Your Cost If You Use an Participating Provider Your Cost If You Use an Non- Participating Provider Primary care visit to treat an injury or illness Specialist visit $60 Copay/visit Not Covered Other practitioner office visit $60 Copay/visit Not Covered Limitations & Exceptions $30 Copay/visit Not Covered none Prior authorization may be required, or services not covered If you have a test If you need drugs to treat your illness or condition Preventive care/screening/immunization Diagnostic test x-ray, blood work No Charge Not Covered none $60 Copay/x-ray $30 Copay/blood work Not Covered none Imaging (CT/PET scans, MRIs) 30% Coinsurance Not Covered Prior authorization is required, or services not covered. Generic drugs $20 Copay Not Covered Preferred brand drugs $55 Copay Not Covered none More information about prescription drug Non-preferred brand drugs 30% Coinsurance Not Covered coverage is available at Specialty drugs 30% Coinsurance Not Covered Prior authorization is required, or services not covered. MSW-250 (8-13) Page 2

4 Common Medical Event If you have outpatient surgery If you need immediate medical attention Services You May Need Your Cost If You Use an Participating Provider Your Cost If You Use an Non- Participating Provider Facility fee (e.g., ambulatory surgery 30% Coinsurance Not Covered center) Physician/surgeon fees 30% Coinsurance Not Covered Emergency room services $250 Copay/visit $250 Copay/visit Limitations & Exceptions Prior authorization is required, or services not covered. Does not apply, if admitted to the hospital Emergency medical transportation $250 Copay/visit $250 Copay/visit Urgent care $75 Copay/ visit $75 Copay/visit If you have a hospital Facility fee (e.g., hospital room) 30% Coinsurance Not Covered stay Physician/surgeon fee 30% Coinsurance Not Covered none none Prior authorization is required, or services not covered. You have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $60 Copay/visit Not Covered Prior authorization is required, or services not covered. Mental/Behavioral health inpatient services Substance use disorder outpatient services 30% Coinsurance Not Covered Prior authorization is required, or services not covered. $60 Copay/visit Not Covered Prior authorization is required, or services not covered. Substance use disorder inpatient services 30% Coinsurance Not Covered Prior authorization is required or services not covered. If you are pregnant Prenatal and postnatal care No Charge Not Covered none Delivery and all inpatient services 30% Coinsurance Not Covered Notification only, Prior Authorization is not required. MSW-250 (8-13) Page 3

5 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use an Participating Provider Your Cost If You Use an Non- Participating Provider Limitations & Exceptions Home health care $60 Copay/ visit Not Covered Limited to: Up to two (2) hours nursing per visit Up to four (4) hours home health aide per visit Up to three (3) visits per day Limit is 130 visits per calendar year, Prior authorization is required, or no services. Rehabilitation services 30% Coinsurance Not Covered 25 visits/year - Speech, Physical, Occupational Therapy combined 10 visits/year Spinal Manipulations 12 visit/year Acupuncture services Prior authorization is required, or services not covered Habilitation services 30% Coinsurance Not Covered Prior authorization is required, or services not covered. Skilled nursing care 30% Coinsurance Not Covered Limited to 100 days per calendar year. Prior authorization is required, or services not covered Durable medical equipment 30% Coinsurance Not Covered Prior authorization is required for all durable medical equipment over $500, or services not covered. Hospice service No Charge Not Covered Notification only for inpatient care. Prior authorization is not required Eye exam No Charge Not Covered One screening/exam per calendar year Glasses No Charge Not Covered Limited to: One pair of frames and prescription lenses every 12 months One pair of contact lenses every 12 months, in lieu of prescription glasses Low vision optical devices, every 5 years, subject to coinsurance cost share Prior Auth Laser corrective surgery is not covered Dental check-up Not Covered Not Covered Not Applicable MSW-250 (8-13) Page 4

6 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.) Bariatric Surgery Cosmetic surgery Hearing aids Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care Dental care (Adult) Dental Check-up (Child) 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.) Acupuncture Chiropractic care Infertility treatment Long-term care Weight Loss programs Routine eye care (Adult) Pregnancy termination services Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance 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 insurer at You may also contact your state insurance department at the Washington State Office of the Insurance Commissioner Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page. MSW-250 (8-13) Page 5

7 About these 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. This is not a cost e stimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $3,980 Patient pays $3,560 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $1,700 Copays $370 Coinsurance $1,340 Limits or exclusions $150 Total $3,560 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $2,580 Patient pays $2,820 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $1,700 Copays $860 Coinsurance $180 Limits or exclusions $80 Total $2,820 MSW-250 (8-13) Page 6

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 innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? 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. 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. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. MSW-250 (8-13) 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, deductibles, 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. Page 7

9 Molina Healthcare of Washington, Inc.: Plan de Categoría Plata 250 de Molina Duración de la póliza: 01/01/ /12/2014 Resumen de beneficios y cobertura: Lo que cubre el plan y los precios Cobertura de: Individuo + familia Tipo de plan: HMO Éste es sólo un resumen. Si desea más información sobre la cobertura y los precios, puede obtener los documentos del plan o términos de la póliza en o llamando al Preguntas importantes Respuestas Por qué es importante? Qué es el deducible general? Individuo $1,700 Familia de 2 o más $3,400 Se aplicable sólo a los servicios de atención médica ambulatoria en hospital/centro y servicios de internación en un hospital/centro Vea la gráfica que empieza en la página 2 para los costos de los servicios que este plan cubre. Hay otros deducibles para Sí. Deducible de medicamentos Debe de pagar todos los costos para estos servicios hasta cumplir con la suma servicios específicos? recetados específica del deducible antes de que este plan pague por los servicios s que Individuo: $200 usted reciba. Hay un límite para los gastos de mi bolsillo? Familia de 2 o más: $400 Sí $6,350 Individuo, cada año $12,700 Familia, cada año El límite de gastos de su bolsillo es lo más que puede pagar durante un período de cobertura (comúnmente un año) para su costo compartido de los servicios s. Este límite le ayuda planificar para los gastos para atención médica Cuáles son las expensas Prima, cobros facturados del A pesar de pagar por estos gastos, no cuentan hacia su límite de gastos de su que no cuentan para el saldo y cuidado no bolsillo límite de gastos del bolsillo? Hay un límite anual No La gráfica que empieza en la página 2 describe cualquier límite sobre lo que el plan general para lo que paga el pagará para específicos servicios s, tales como las s a consultorios. plan? Tiene este plan una red Sí. Para una lista de los Si usted usa un u otro médico, este plan pagará de es? es s, visite parte o todos los costos de los servicios s. Esté consciente, su médico u o hospital puede usar un no para algunos servicios. llame al Los planes utilizan el término "en la red", preferido, o para es dentro de la red. Vea la gráfica en la página 2 para conocer cómo este plan le paga a diferentes tipos es Preguntas: Llame al o visite Si no entiende alguno de los términos subrayados, consulte el Glosario. Puede ver el Glosario en o llame al y pida una copia.

10 Necesito un referido para No. Puede consultar con el especialista que elija sin el permiso de este plan. ver un especialista? Hay algún servicio(s) que el plan no cubra? Sí. Algunos de los servicios que este plan no cubre aparecen en la página 6. Vea su póliza o su documento del plan para información adicional sobre los servicios excluidos Copago es una cantidad fija (por ejemplo $15) que usted paga por los servicios médicos s, generalmente al momento de recibirlos. Coseguro es la parte que le corresponde pagar a usted por un servicio, que es un porcentaje de la cantidad aprobada para dicho servicio. Por ejemplo, si la cantidad aprobada por el plan para pasar la noche en el hospital es $1,000, su coseguro será el 20% de esa cantidad o sea $200. Esta cantidad puede cambiar si usted aún no ha pagado el deducible. El pago del plan por los servicios s está basado en la cantidad aprobada. Si un fuera de la red (que no pertenece a la red del plan) le cobra más de la cantidad aprobada, usted tendrá que pagar la diferencia. Por ejemplo, en un hospital que no pertenece a la red le cobran por pasar la noche internado $1,500 la cantidad aprobada es $1,000, usted tendrá que pagar la diferencia de $500. (conocida como saldo de facturación.) El plan puede animarlo a que use es s cobrándole deducibles, copagos, y coseguro más bajos. Eventos médicos comunes Si se atiende en la clínica o consultorio del médico Los servicios que podría necesitar Consulta con su médico principal para tratar una condición o herida Consulta con un especialista Consulta con otro de la salud Su costo si usa un $30 de copago por $60 de copago por $60 de copago por Su costo si usa un no Limitaciones y excepciones ninguno Se puede requerir una autorización previa, o los servicios no se cubrirán Servicios preventivos/evaluaciones/vacunas Ningún cobro ninguno Si tiene que hacerse un examen Exámenes de diagnóstico radiografías, análisis de sangre Imagenología (TC/tomografía PET, RMf) $60 de copago/ radiografías $30 de copago/ análisis de sangre 30% de coseguro ninguno se cubrirán. MSW-250 (8-13) Página 2

11 Eventos médicos comunes Si necesita un medicamento Para más información sobre la cobertura de medicamentos visite Los servicios que podría necesitar Su costo si usa un Su costo si usa un no Medicamentos genéricos $20 de copago Medicamentos de marca preferidos $55 de copago Medicamentos de marca no preferidos 30% de coseguro Medicamentos especiales 30% de coseguro Limitaciones y excepciones ninguno se cubrirán. Si recibe una cirugía ambulatoria Arancel del centro (clínica) 30% de coseguro Tarifa del médico/cirujano 30% de coseguro se cubrirán. Si necesita atención médica inmediata Servicios de la sala de emergencias $250 de copago por $250 de copago por No es aplicable si es internado en el hospital Traslado médico de emergencia $250 de copago por $250 de copago por ninguno Cuidado urgente $75 de copago por $75 de copago por ninguno Si lo admiten al hospital Arancel del hospital (por ej., habitación) 30% de coseguro se cubrirán. MSW-250 (8-13) Página 3

12 Eventos médicos comunes Si tiene problemas psiquiátricos, de conducta o de abuso de sustancias Los servicios que podría necesitar Su costo si usa un Su costo si usa un no Tarifa del médico/cirujano 30% de coseguro Servicios ambulatorios de salud mental y de la conducta $60 de copago por Limitaciones y excepciones se cubrirán. Servicios de salud mental y de la conducta para pacientes internados 30% de coseguro se cubrirán. Tratamiento ambulatorio para trastornos de abuso de sustancias $60 de copago por se cubrirán. Tratamiento para el abuso de sustancias para pacientes internados 30% de coseguro Autorización previa requerida o los servicios no se cubrirán. Si está embarazada Cuidados prenatales y posparto Ningún cobro Parto y todos los servicios de 30% de coseguro internación ninguno Sólo notificación, autorización previa no requerida. MSW-250 (8-13) Página 4

13 Eventos médicos comunes Si necesita servicios de recuperación u otras necesidades especiales Si su hijo necesita servicios dentales o de la vista Los servicios que podría necesitar Cuidado de la salud en el hogar Su costo si usa un $60 de copago por Su costo si usa un no Servicios de rehabilitación 30% de coseguro Servicios de recuperación de las habilidades Cuidado de enfermería especializado 30% de coseguro 30% de coseguro Equipo médico duradero 30% de coseguro Cuidado de hospicio Ningún cobro Examen de la vista Ningún cobro Limitaciones y excepciones Limitado a: Máximo de dos (2) horas de enfermería por Máximo de cuatro (4) horas de auxiliar de salud en el hogar por Máximo de tres (3) s por día Límite de 130 s cada año natural, autorización previa requerida o no servicios. 25 s combinadas cada año - Terapia física, ocupacional y del habla 10 s cada año - Manipulación de la espina dorsal 12 s cada año - Servicios de acupuntura se cubrirán se cubrirán. Limitado a 100 días por cada año natural. se cubrirán Autorización previa requerida para todo el equipo médico duradero más de $500, o los servicios no se cubrirán. Sólo notificación para atención de internación. Autorización previa no es requerida. Un examen/evaluación de detección cada año natural MSW-250 (8-13) Página 5

14 Eventos médicos comunes Los servicios que podría necesitar Su costo si usa un Su costo si usa un no Anteojos Ningún cobro Consulta dental Limitaciones y excepciones Limitado a: Un par de marcos y lentes recetados cada 12 meses Un par de lentes de contacto cada 12 meses, en lugar de anteojos recetados Dispositivos ópticos de visión baja, cada 5 años, sujeto al costo compartido del coseguro - Autorización previa La cirugía correctiva de láser no está cubierta No aplicable Servicios excluidos y otros servicios s: Los servicios que su plan NO cubre (Esta es una lista parcial. Consulte su póliza o el documento del plan para los otros servicios excluidos.) Cirugía bariátrica Cirugía cosmética Aparatos auditivos Atención médica no urgente cuando viaja fuera de los EE.UU. Enfermera de atención privada Cuidado de los pies de rutina Atención dental (adultos) Atención dental (niños) Otros servicios s (Esta es una lista parcial. Consulte su póliza o el documento del plan para los otros servicios s y sus costos para estos servicios.) Acupuntura Cuidado quiropráctico Tratamiento de infertilidad Cuidado a largo plazo Programas para perder peso Atención de la vista rutinaria (adultos) Servicios de terminación de embarazo Su derecho para continuar con la cobertura: Las leyes federales y estatales pueden proveer protección que le permite mantener esta cobertura médica siempre y cuando usted pague su prima. Sin embargo, existen excepciones, por ejemplo, si: Comete fraude La compañía de seguros deja de ofrecer servicios en el estado MSW-250 (8-13) Página 6

15 Se muda fuera del área de servicio Para más información sobre sus derechos a continuar la cobertura, comuníquese con la compañía de seguros al También puede comunicarse con el departamento estatal de seguros en la Secretaría de Washington del Comisionado de Seguros al Su derecho a presentar una queja o una apelación: Si tiene una queja o no está conforme con una denegación de cobertura de su plan, puede apelar la decisión o presentar una queja. Si tiene preguntas sobre sus derechos, este aviso, o necesita ayuda comuníquese al: Provee cobertura esencial mínima esta cobertura? La Ley de Cuidado de Salud a Bajo Precio requiere que la mayoría de las personas tengan cobertura de atención médica que cumpla los requisitos de ser una cobertura esencial mínima. Este plan o póliza sí ofrece cobertura esencial mínima. Satisface esta cobertura el estándar de valor mínimo? La Ley de Cuidado de Salud a Bajo Precio establece un estándar de valor mínimo para los beneficios de un plan médico. El estándar de valor mínimo es 60% (valor actuario). Esta cobertura médica sí cumple el estándar de valor mínimo para los beneficios que provee. Servicios de acceso de idiomas: Spanish (Español): Para obtener asistencia en español, llame al Para ejemplos sobre cómo este plan paga por los servicios en una situación médica específica consulte la página siguiente. MSW-250 (8-13) Página 7

16 Sobre los ejemplos de cobertura: Estos ejemplos le muestran cómo cubriría el plan los servicios en situaciones distintas. Úselos para tener una idea, en general, de cuánta cobertura económica podría obtener el paciente del ejemplo cuando reciben cobertura bajo los distintos planes. Ésta no es una h erramienta de cálculo de costos. No use estos ejemplos para calcular los costos reales de suplan. Los servicios médicos que usted reciba y los precios pueden ser distintos a los mencionados en los ejemplos. Para información importante sobre estos ejemplos, consulte la página siguiente. Nacimiento (parto normal) El cobra: $7,540 El plan paga$3,980 El paciente paga $3,560 Ejemplos de los costos: El costo del hospital (madre) $2,700 Atención de rutina del obstetra $2,100 El costo del hospital (bebé) $900 Anestesia $900 Análisis de laboratorio $500 Medicamentos $200 Radiografías $200 Vacunas y otros servicios preventivos $40 Total $7,540 El paciente paga: Deducibles $1,700 Copagos $370 Coseguro $1,340 Límites o exclusiones $150 Total $3,560 Control de la diabetes tipo 2 (control rutinario de una enfermedad bien controlada) El cobra: $5,400 El plan paga$2,580 El paciente paga $2,820 Ejemplos de los costos: Medicamentos $2,900 Equipo médico e insumos $1,300 Visitas a consultorios y procedimientos médicos $700 Educación sobre el cuidado $300 Análisis de laboratorio $100 Vacunas y otros servicios preventivos $100 Total $5,400 El paciente paga: Deducibles $1,700 Copagos $860 Coseguro $180 Límites o exclusiones $80 Total $2,820 MSW-250 (8-13) Página 8

17 Preguntas y respuestas sobre los ejemplos mencionados: Qué conceptos se presuponen de estos ejemplos? Los costos no incluyen las primas. Los ejemplos de costos están basados en los promedios nacionales provenientes del Departamento de Salud y Servicios Humanos de los EE.UU. y no son específicos para una zona geográfica en particular o un plan. La afección del paciente no es una condición excluida ni preexistente. Todos los servicios y tratamientos empezaron y terminaron en el mismo período de cobertura. No hay otros gastos médicos para ningún miembro por este plan. Los gastos del bolsillo están basados solamente en el tratamiento del problema mencionado en el ejemplo. El paciente recibió todos los servicios de es de la red del plan. Si el paciente hubiese recibido los servicios de es fuera de la red, los costos hubieran sido más altos. Qué muestra el ejemplo? En cada ejemplo usted verá cómo suman los deducibles, copagos, y coseguro. También le ayudan a ver cuáles son los gastos que tendrá que pagar usted porque no están s o porque el pago es limitado. Contempla el ejemplo mis propias necesidades? No. Los tratamientos que mencionamos son sólo ejemplos. El tratamiento que usted podría recibir para esta condición tal vez sea distinto, según cuál sea el consejo de su médico, su edad, la gravedad de su caso y otros factores. Puede el ejemplo predecir mis gastos futuros? No. Los ejemplos de cobertura no son herramientas de cálculo de costos. Usted no puede usar el ejemplo para estimar el costo del cuidado de su condición. El ejemplo es únicamente para fines comparativos. Sus costos reales dependerán de los servicios que reciba, del precio del y del reembolso que autorice el plan. Preguntas: Llame al o visite Si no entiende alguno de los términos subrayados, consulte el Glosario. Puede ver el Glosario en o llame al y pida una copia. MSW-250 (8-13) Puedo usar los ejemplos para comparar los planes? Sí.. Cuando usted se fija en el Resumen de Beneficios y Cobertura de otros planes, encontrará los mismos ejemplos de cobertura. Cuando compare los planes, fíjese en el casillero titulado El paciente paga de cada ejemplo. Cuanto más bajo el número, mayor será la cobertura ofrecida por el plan. Debo tener en cuenta otros costos al comparar los planes? Sí. Un gasto importante es lo que paga de prima. Por lo general, cuanto más baja sea la prima mayores serán los gastos de su bolsillo, como los copagos, deducibles y coseguro. También debe tener en cuenta las contribuciones a cuentas tales como las Cuentas de Ahorros Médicos (HSA), Acuerdos de Gastos Flexibles (FSA) o las Cuentas de Reembolsos Médicos (HRA) que le ayudan con los gastos del bolsillo. Página 9

18 Molina Healthcare of Washington, Inc.: Molina Silver 200 Plan Coverage Period: 01/01/ /31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HMO 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 or by calling Important Questions Answers Why this Matters: What is the overall Individual $1,400 See the chart starting on page 2 for your costs for services this plan covers. deductible? Family of 2 or more $2,800 Applies only to Outpatient Hospital/Facility and Inpatient Hospital/Facility Services Are there other Yes. Prescription Drug Deductible You must pay all of the costs for these services up to the deductible amount deductibles for specific Individual: $30 before this plan begins to pay for these services. services? Family of 2 or more: $60 Is there an out of pocket limit on my expenses? Yes $5,200 Individual, per Family, per year year $10,400 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 What is not included in Premium, balance-billed charges, and Even though you pay these expenses, they don t count toward the out of pocket the out of pocket limit? non-covered care limit Is there an overall annual No The chart starting on page 2 describes any limits on what the plan will pay for limit on what the plan specific covered services, such as office visits. pays? Does this plan use a Yes. For a list of participating If you use an in-network doctor or other health care provider, this plan will pay network of providers? providers, see some or all of the costs of covered services. Be aware, your in-network doctor or or call 1- 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 Do I need a referral to see No. You can see the specialist you choose without permission from this plan. a specialist? Are there services this plan doesn t cover? Yes. Some of the services this plan doesn t cover are listed on pages 5. See your policy or plan document for additional information about excluded services Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy.

19 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. 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. 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.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic Services You May Need Your Cost If You Use an Participating Provider Your Cost If You Use an Non- Participating Provider Primary care visit to treat an injury or illness Specialist visit $50 Copay/visit Not Covered Other practitioner office visit $50 Copay/visit Not Covered Limitations & Exceptions $20 Copay/visit Not Covered none Prior authorization may be required, or services not covered If you have a test If you need drugs to treat your illness or condition Preventive care/screening/immunization Diagnostic test x-ray, blood work No Charge Not Covered none $50 Copay/x-ray $20 Copay/blood work Not Covered none Imaging (CT/PET scans, MRIs) 30% Coinsurance Not Covered Prior authorization is required, or services not covered. Generic drugs $10 Copay Not Covered Preferred brand drugs $40 Copay Not Covered none More information about prescription drug Non-preferred brand drugs 30% Coinsurance Not Covered coverage is available at Specialty drugs 30% Coinsurance Not Covered Prior authorization is required, or services not covered. MSW-200 (8-13) Page 2

20 Common Medical Event If you have outpatient surgery If you need immediate medical attention Services You May Need Your Cost If You Use an Participating Provider Your Cost If You Use an Non- Participating Provider Facility fee (e.g., ambulatory surgery 30% Coinsurance Not Covered center) Physician/surgeon fees 30% Coinsurance Not Covered Emergency room services $250 Copay/visit $250 Copay/visit Limitations & Exceptions Prior authorization is required, or services not covered. Does not apply, if admitted to the hospital Emergency medical transportation $250 Copay/visit $250 Copay/visit Urgent care $60 Copay/ visit $60 Copay/visit If you have a hospital Facility fee (e.g., hospital room) 30% Coinsurance Not Covered stay Physician/surgeon fee 30% Coinsurance Not Covered none none Prior authorization is required, or services not covered. You have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $50 Copay/visit Not Covered Prior authorization is required, or services not covered. Mental/Behavioral health inpatient services Substance use disorder outpatient services 30% Coinsurance Not Covered Prior authorization is required, or services not covered. $50 Copay/visit Not Covered Prior authorization is required, or services not covered. Substance use disorder inpatient services 30% Coinsurance Not Covered Prior authorization is required or services not covered. If you are pregnant Prenatal and postnatal care No Charge Not Covered none Delivery and all inpatient services 30% Coinsurance Not Covered Notification only, Prior Authorization is not required. MSW-200 (8-13) Page 3

21 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use an Participating Provider Your Cost If You Use an Non- Participating Provider Limitations & Exceptions Home health care $50 Copay/ visit Not Covered Limited to: Up to two (2) hours nursing per visit Up to four (4) hours home health aide per visit Up to three (3) visits per day Limit is 130 visits per calendar year, Prior authorization is required, or no services. Rehabilitation services 30% Coinsurance Not Covered 25 visits/year - Speech, Physical, Occupational Therapy combined 10 visits/year Spinal Manipulations 12 visit/year Acupuncture services Prior authorization is required, or services not covered Habilitation services 30% Coinsurance Not Covered Prior authorization is required, or services not covered. Skilled nursing care 30% Coinsurance Not Covered Limited to 100 days per calendar year. Prior authorization is required, or services not covered Durable medical equipment 30% Coinsurance Not Covered Prior authorization is required for all durable medical equipment over $500, or services not covered. Hospice service No Charge Not Covered Notification only for inpatient care. Prior authorization is not required Eye exam No Charge Not Covered One screening/exam per calendar year Glasses No Charge Not Covered Limited to: One pair of frames and prescription lenses every 12 months One pair of contact lenses every 12 months, in lieu of prescription glasses Low vision optical devices, every 5 years, subject to coinsurance cost share Prior Auth Laser corrective surgery is not covered Dental check-up Not Covered Not Covered Not Applicable MSW-200 (8-13) Page 4

22 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.) Bariatric Surgery Cosmetic surgery Hearing aids Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care Dental care (Adult) Dental Check-up (Child) 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.) Acupuncture Chiropractic care Infertility treatment Long-term care Weight Loss programs Routine eye care (Adult) Pregnancy termination services Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance 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 insurer at You may also contact your state insurance department at the Washington State Office of the Insurance Commissioner Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page. MSW-200 (8-13) Page 5

23 About these 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. This is not a cost e stimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $4,350 Patient pays $3,190 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $1,400 Copays $300 Coinsurance $1,340 Limits or exclusions $150 Total $3,190 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,210 Patient pays $2,190 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $1,400 Copays $520 Coinsurance $190 Limits or exclusions $80 Total $2,190 MSW-200 (8-13) Page 6

24 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 innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? 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. 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. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. MSW-200 (8-13) 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, deductibles, 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. Page 7

25 Molina Healthcare of Washington, Inc.: Plan de Categoría Plata 200 de Molina Duración de la póliza:01/01/ /12/2014 Resumen de beneficios y cobertura: Lo que cubre el plan y los precios Cobertura de: Individuo + familia Tipo de plan: HMO Éste es sólo un resumen. Si desea más información sobre la cobertura y los precios, puede obtener los documentos del plan o términos de la póliza en o llamando al Preguntas importantes Respuestas Por qué es importante? Qué es el deducible general? Individuo $1,400 Familia de 2 o más $2,800 Se aplicable sólo a los servicios de atención médica ambulatoria en hospital/centro y servicios de internación en un hospital/centro Vea la gráfica que empieza en la página 2 para los costos de los servicios que este plan cubre. Hay otros deducibles para Sí. Deducible de medicamentos Debe de pagar todos los costos para estos servicios hasta cumplir con la suma servicios específicos? recetados específica del deducible antes de que este plan pague por los servicios s que Individuo: $30 usted reciba. Hay un límite para los gastos de mi bolsillo? Familia de 2 o más $60 Sí $5,200 Individuo, cada año $10,400 Familia, cada año El límite de gastos de su bolsillo es lo más que puede pagar durante un período de cobertura (comúnmente un año) para su costo compartido de los servicios s. Este límite le ayuda planificar para los gastos para atención médica Cuáles son las expensas Prima, cobros facturados del A pesar de pagar por estos gastos, no cuentan hacia su límite de gastos de su que no cuentan para el saldo y cuidado no bolsillo límite de gastos del bolsillo? Hay un límite anual No La gráfica que empieza en la página 2 describe cualquier límite sobre lo que el plan general para lo que paga el pagará para específicos servicios s, tales como las s a consultorios. plan? Tiene este plan una red Sí. Para una lista de los Si usted usa un u otro médico, este plan pagará de es? es s, visite parte o todos los costos de los servicios s. Esté consciente, su médico u o hospital puede usar un no para algunos servicios. llame al Los planes utilizan el término "en la red", preferido, o para es dentro de la red. Vea la gráfica en la página 2 para conocer cómo este plan le paga a diferentes tipos es Preguntas: Llame al o visite Si no entiende alguno de los términos subrayados, consulte el Glosario. Puede ver el Glosario en o llame al y pida una copia.

26 Necesito un referido para No. Puede consultar con el especialista que elija sin el permiso de este plan. ver un especialista? Hay algún servicio(s) que el plan no cubra? Sí. Algunos de los servicios que este plan no cubre aparecen en la página 6. Vea su póliza o su documento del plan para información adicional sobre los servicios excluidos Copago es una cantidad fija (por ejemplo $15) que usted paga por los servicios médicos s, generalmente al momento de recibirlos. Coseguro es la parte que le corresponde pagar a usted por un servicio, que es un porcentaje de la cantidad aprobada para dicho servicio. Por ejemplo, si la cantidad aprobada por el plan para pasar la noche en el hospital es $1,000, su coseguro será el 20% de esa cantidad o sea $200. Esta cantidad puede cambiar si usted aún no ha pagado el deducible. El pago del plan por los servicios s está basado en la cantidad aprobada. Si un fuera de la red (que no pertenece a la red del plan) le cobra más de la cantidad aprobada, usted tendrá que pagar la diferencia. Por ejemplo, en un hospital que no pertenece a la red le cobran por pasar la noche internado $1,500 la cantidad aprobada es $1,000, usted tendrá que pagar la diferencia de $500. (conocida como saldo de facturación.) El plan puede animarlo a que use es s cobrándole deducibles, copagos, y coseguro más bajos. Eventos médicos comunes Si se atiende en la clínica o consultorio del médico Los servicios que podría necesitar Consulta con su médico principal para tratar una condición o herida Consulta con un especialista Consulta con otro de la salud Su costo si usa un $20 de copago por $50 de copago por $50 de copago por Su costo si usa un no Limitaciones y excepciones ninguno Se puede requerir una autorización previa, o los servicios no se cubrirán Servicios preventivos/evaluaciones/vacunas Ningún cobro ninguno Si tiene que hacerse un examen Exámenes de diagnóstico radiografías, análisis de sangre Imagenología (TC/tomografía PET, RMf) $50 de copago/ radiografías $20 de copago/ análisis de sangre 30% de coseguro ninguno se cubrirán. MSW-200 (8-13) Página 2