: The Traditional Plan (PPO) Coverage Period: 01/01/ /31/2015

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1 : The Traditional Plan (PPO) Coverage Period: 01/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee only Plan Type: PPO 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 on your Benefits website, from your HR benefits department, from or by calling Important Questions Answers Why this Matters: Tier 1 Network (FHHS providers) You must pay all the costs up to the deductible amount before this $300 person/$600 family plan begins to pay for covered services you use. Check your policy or What is the overall Tier 2 Network (Customized MultiPlan network) $1,000 person/$2,000 plan document to see when the deductible starts over (usually, but deductible? family not always, January 1st). See the chart starting on page 2 for how Tier 3 Network (Out-of-network) $2,000 person/$4,000 family much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? No. Yes. Tier 1 Network (FHHS providers) $2,500 person/$5,000 family Tier 2 Network (Customized MultiPlan network) $4,000 person/$8,000 family Tier 3 Network (Out-of-network) none Premiums and out-of-network (Tier 3) balance-billed charges, copays, deductibles, and. No. Yes. For a list of in-network providers, see or call No. Yes. 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. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they do not count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call 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 obtain a copy. FH PPO 1 of 8

2 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 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 encourages you to use Adventist Health System (FHHS) providers or MultiPlan network providers by charging lower deductibles, copayments, and amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Your Cost If You Use a Tier 1 Network (FHHS providers) Family Health Center East, Medicine Specialists of FH, Centre for Family Medicine Winter Park and Center for Pediatric and Adolescent Medicine: No charge Other participating primary care providers: $25 copayment/visit Your Cost If You Use a Tier 2 Provider (Customized MultiPlan network) $40 copayment/visit Specialist visit $50 copayment/visit $65 copayment/visit Other practitioner office visit Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) $50 copayment/visit $65 copayment/visit No charge AHS Facility No charge; All Others: Office Setting Office visit copay may apply; Facility 10% $40 copayment/visit Office Setting Office visit copay may apply; Facility 30% Your Cost If You Use a Tier 3 Provider (Out-of- Network) Office Setting - ; Facility Limitations & Exceptions Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before 2 of 8

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www. Myahsrx.com. If you have outpatient surgery Services You May Need Imaging (CT/PET scans, MRIs) Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Your Cost If You Use a Tier 1 Network (FHHS providers) Your Cost If You Use a Tier 2 Provider (Customized MultiPlan network) 10% 30% Retail (30 day): $10 copayment/prescription Mail order (90 day): $10 copayment/prescription Retail (30 day): 20% /prescription (minimum $25, maximum $150) Mail order (90 day): 20% /prescription (minimum $50, maximum $150) Retail (30 day): 20% /prescription (minimum $50, maximum $300) Mail order (90 day): 20% /prescription (minimum $100, maximum $300) 30 day: 20% (minimum $50, maximum $200) 90 day*: 20% (minimum $100, maximum $400) 10% 10% 30% 30% Your Cost If You Use a Tier 3 Provider (Out-of- Network) Not covered Not covered Not covered Not covered Limitations & Exceptions Plan deductible must be met before Only one 30 day dispense of a maintenance medication is allowed through a local retail pharmacy. All consequent dispenses must be done through Rx Plus Pharmacy. Please contact the Rx Plus Pharmacy call center at To ensure you receive the most appropriate and costeffective drug therapy, your specific prescription benefit plan design requires some medications to have Quantity Limits (QL), require a Prior Authorization (PA) or Step Therapy (ST) prior to dispensing. Only one 30 day dispense of a maintenance medication is allowed through a local retail pharmacy. All consequent dispenses must be done through Rx Plus Pharmacy. Please contact the Rx Plus Pharmacy call center at All Specialty drugs are required to be dispensed through Rx Plus Pharmacy and managed by a member of the Specialty team. If a medication cannot be dispensed by Rx Plus Pharmacy, the Specialty team will facilitate the care of that member with another network Specialty pharmacy. *Only certain medications are applicable to the 90 day dispense and the Specialty team will work with members on a case by case basis. Plan deductible must be met before Plan deductible must be met before 3 of 8

4 Common Medical Event If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need Emergency room services Emergency medical transportation Your Cost If You Use a Tier 1 Network (FHHS providers) $150 copayment/visit Your Cost If You Use a Tier 2 Provider (Customized MultiPlan network) $150 copayment/visit 10% 10% Urgent care $50 copayment/visit $65 copayment/visit Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services Home health care Rehabilitation services 10% 10% 30% 30% $25 copayment/visit $40 copayment/visit 10% 30% $25 copayment/visit $40 copayment/visit 10% Prenatal - No charge Postnatal - $25 copayment/visit 10% 10% Office Setting - $50 copayment/visit Facility 10% 30% Prenatal - $40 copayment/visit Postnatal - $40 copayment/visit 30% 30% Office Setting - $65 copayment/visit Facility 30% Your Cost If You Use a Tier 3 Provider (Out-of- Network) $150 copayment/visit 10% Prenatal - Postnatal - Office Setting - Facility - Limitations & Exceptions Copayment waived if admitted to inpatient status through the emergency room. Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Plan deductible must be met before Coverage is limited to 60 visits per year. Plan deductible must be met before Coverage is limited to 60 visits per year for Physical Therapy, 60 for Occupational Therapy, and 60 for Speech Therapy. 4 of 8

5 Common Medical Event If your child needs dental or eye care Services You May Need Habilitation services Your Cost If You Use a Tier 1 Network (FHHS providers) Office Setting - $50 copayment/visit Facility 10% Your Cost If You Use a Tier 2 Provider (Customized MultiPlan network) Office Setting - $65 copayment/visit Facility 30% Your Cost If You Use a Tier 3 Provider (Out-of- Network) Office Setting - Facility - Limitations & Exceptions Plan deductible must be met before Skilled nursing care 10% 30% Plan deductible must be met before Coverage is limited to 90 days per year. Durable medical 30% Plan deductible must be met before 10% equipment Hospice service 10% 30% Plan deductible must be met before Eye exam Not covered Not covered Not covered none Glasses Not covered Not covered Not covered none Dental check-up Not covered Not covered Not covered none 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.) Acupuncture Cosmetic surgery Dental care (adult) Dental care (child) Eye glasses (adult) Eye glasses (child) Hearing aids Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Routine eye care (adult) Routine eye care (child) Routine foot care (except for Diabetes foot care) Weight loss programs 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.) Bariatric surgery (Surgery only at Florida Hospital Celebration) Chiropractic care (coverage is limited to 20 visits per year) Private-duty nursing (home nursing) 5 of 8

6 Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or 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: FHCA at Additionally, a consumer assistance program can help you file your appeal. States with consumer assistance programs can be found at 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 Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

7 : The Traditional Plan (PPO) Coverage Period: 01/01/ /31/2015 Coverage Examples Coverage for: Employee Only Plan Type: PPO 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 estimator. 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: $ 6,510 Patient pays: $ 1,030 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 $ 300 Copays $ 70 Coinsurance $ 510 Limits or exclusions $ 150 Total (mother s cost) $ 1,030 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $ 5,400 Plan pays: $ 4,250 Patient pays: $ 1,150 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 $ 300 Copays $ 650 Coinsurance $ 120 Limits or exclusions $ 80 Total $ 1,150 It is important to note that costs shown reflect employee only coverage. In the Having a baby example, the baby s hospital charges would be subject to his or her own deductible requirements. Questions: Call 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. 7 of 8

8 : The Traditional Plan (PPO) Coverage Period: 01/01/ /31/2015 Coverage Examples Coverage for: Employee Only Plan Type: PPO 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 can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and. 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. Questions: Call 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. 8 of 8

9 Glossary of Health Coverage and Medical Terms This glossary has many commonly used terms, but isn t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.) Bold blue text indicates a term defined in this Glossary. See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation. Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called eligible expense, payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.) Appeal A request for your health insurer or plan to review a decision or a grievance again. Balance Billing When a provider bills you for the difference between the provider s charge and the allowed amount. For example, if the provider s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. Co-insurance Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. Jane pays Her plan pays You pay co-insurance 20% 80% plus any deductibles (See page 4 for a detailed example.) you owe. For example, if the health insurance or plan s allowed amount for an office visit is $100 and you ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. Co-payment A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins Jane pays Her plan pays to pay. For example, if 100% 0% your deductible is $1000, your plan won t pay (See page 4 for a detailed example.) anything until you ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics. Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. Emergency Medical Transportation Ambulance services for an emergency medical condition. Complications of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren t complications of pregnancy. Emergency Room Care Emergency services you get in an emergency room. Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. OMB Control Numbers , , and Glossary of Health Coverage and Medical Terms Page 1 of 4

10 Excluded Services Health care services that your health insurance or plan doesn t pay for or cover. Grievance A complaint that you communicate to your health insurer or plan. Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Health Insurance A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium. Home Health Care Health care services a person receives at home. Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families. Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care. Hospital Outpatient Care Care in a hospital that usually doesn t require an overnight stay. In-network Co-insurance The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance. In-network Co-payment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments. Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Non-Preferred Provider A provider who doesn t have a contract with your health insurer or plan to provide services to you. You ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Out-of-network Co-insurance The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Outof-network co-insurance usually costs you more than innetwork co-insurance. Out-of-network Co-payment A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments. Out-of-Pocket Limit The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, Jane pays Her plan pays 0% 100% balance-billed charges or (See page 4 for a detailed example.) health care your health insurance or plan doesn t cover. Some health insurance or plans don t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. Physician Services Health care services a licensed medical physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) provides or coordinates. Glossary of Health Coverage and Medical Terms Page 2 of 4

11 Plan A benefit your employer, union or other group sponsor provides to you to pay for your health care services. Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn t a promise your health insurance or plan will cover the cost. Preferred Provider A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also participating providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more. Premium The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. Prescription Drug Coverage Health insurance or plan that helps pay for prescription drugs and medications. Prescription Drugs Drugs and medications that by law require a prescription. Primary Care Physician A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient. Provider A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law. Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions. Rehabilitation Services Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home. Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care. UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount. Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Primary Care Provider A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services. Glossary of Health Coverage and Medical Terms Page 3 of 4

12 How You and Your Insurer Share Costs - Example Jane s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000 January 1 st Beginning of Coverage Period December 31 st End of Coverage Period Jane pays 100% Her plan pays 0% more costs Jane pays 20% Her plan pays 80% more costs Jane pays 0% Her plan pays 100% Jane hasn t reached her $1,500 deductible yet Her plan doesn t pay any of the costs. Office visit costs: $125 Jane pays: $125 Her plan pays: $0 Jane reaches her $1,500 deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit. Office visit costs: $75 Jane pays: 20% of $75 = $15 Her plan pays: 80% of $75 = $60 Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year. Office visit costs: $200 Jane pays: $0 Her plan pays: $200 Glossary of Health Coverage and Medical Terms Page 4 of 4

13 The Traditional Plan (PPO) Duración de la póliza: 01/01/ /31/2015 Resumen de beneficios y cobertura: Lo que cubre el plan y los precios Cobertura de: sólo empleados Tipo de plan: PPO Éste es solo 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? Nivel 1 (FHHS Providers) - $300 persona/$600 familia Nivel 2 (Customized MultiPlan network) - $1,000 por persona/$2,000 por familia Nivel 3 (Fuera de la red) - $2,000 por persona/$4,000 por familia Hay otros deducibles para servicios específicos? Hay un límite para los gastos de mi bolsillo? Cuáles son las expensas que no cuentan para el límite de gastos del bolsillo? Hay un límite anual general para lo que paga el plan? Tiene este plan una red de proveedores? Necesito un referido para ver un especialista? Hay algún servicio(s) que el plan no cubra? No. Sí. Nivel 1 (FHHS Providers) - $2,500 persona/$5,000 familia Nivel 2 (Customized MultiPlan network) - $4,000 por persona/$8,000 por familia Nivel 3 (Fuera de la red) Ninguno Primas, gastos de saldo facturados, y copagos, deducibles, y fuera de la red (Nivel 3) y gastos relacionados con cirugía bariátrica. No. Sí. Para obtener un listado de proveedores dentro de la red, visite o llame al No. Sí. Usted debe pagar todos los costos hasta llegar a la suma del deducible antes de que el plan comience a pagar por los servicios cubiertos que utiliza. Revise su póliza o la documentación del plan, para ver cuándo comienza de nuevo el deducible (generalmente, pero no siempre, el 1º de enero). Consulte la tabla que comienza en la página 2 para saber cuánto paga por los servicios cubiertos después de cumplir con el deducible. Usted no tiene que cumplir con deducibles por servicios específicos, pero consulte la tabla que comienza en la página 2 para conocer otros costos por servicios que cubre este plan. El límite de desembolso personal es lo máximo que podría pagar durante el período de cobertura (generalmente, de un año) por su participación en los costos de servicios cubiertos. Este Límite le ayuda a planear sus gastos de atención de la salud. Aunque pague estos gastos, los mismos no se contabilizan para alcanzar el límite de gastos de bolsillo. La tabla que comienza en la página 2 describe los límites sobre los que el plan pagará por servicios cubiertos específicos, tales como visitas al consultorio. Si utiliza cualquier médico u otro proveedor de atención de la salud dentro de la red, este plan pagará algunos o todos los costos de los servicios cubiertos. Tenga en cuenta que su médico u hospital dentro de la red puede utilizar un proveedor fuera de la red para algunos servicios. Los planes utilizan los términos proveedor dentro de la red, preferido o participante, para los proveedores en su red. Consulte la tabla que comienza en la página 2 para conocer cómo el plan paga a las distintas clases de proveedores. Puede consultar al especialista que elija sin permiso de este plan. Algunos de los servicios que este plan no cubre están detallados en la página 5. Consulte su póliza o la documentación del plan para obtener información adicional sobre servicios excluidos. 1 of 8 Preguntas: Llame al Si no entiende alguno de los términos en negritas, consulte el Glosario en o llame al y pida una copia.

14 Copago es una cantidad fija (por ejemplo $15) que usted paga por los servicios médicos cubiertos, generalmente al momento de recibirlos. Coseguro es la parte que le corresponde pagar a usted por un servicio cubierto, 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 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 cubiertos está basado en la cantidad aprobada. Si un proveedor 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 proveedores de Adventist Health System (FHHS) o MultiPlan network cobrándole deducibles, copagos o más bajos. Eventos médicos comunes Si se atiende en la clínica o consultorio del proveedor médico Si tiene que hacerse un examen Los servicios que podría necesitar Consulta con su médico principal para tratar una condición o herida Consulta con un especialista Consulta con otro proveedor de la salud Servicios preventivos/evaluaciones /vacunas Exámenes de diagnóstico (radiografías, análisis de sangre) Imágenes (CT/PET scan, MRI) Su costo si usa el nivel 1 de proveedores (FHHS) Family Health Center East, Medicine Specialists of FH, Centre for Family Medicine Winter Park y Center for Pediatric y Adolescent Medicine: - Sin costo Otros proveedores participantes: $25 $50 de copago/ visita $50 de copago/ visita Sin costo Centro de salud de AHS sin costo; Todos otros: Consultorio copago puede aplicar; Centro de salud 10% de 10% después del deducible Su costo si usa el nivel 2 de proveedores (Customized MultiPlan network) $40 de copago/ visita $65 de copago/ visita $65 de copago/ visita $40 de copago/ visita Consultorio copago puede aplicar; Centro de salud 30% de 30% después del deducible Sus costos si usted usa el Nivel 3 de proveedores no participantes (Fuera de la red) Consultorio copago puede aplicar; Centro de salud Limitaciones y excepciones antes de que se aplique el para proveedores de MultiPlan network (Nivel 2) y de fuera de la red (Nivel 3). 2 of 8

15 Eventos médicos comunes Si necesita un medicamento Para más información sobre la cobertura de medicamentos visite Los servicios que podría necesitar Medicamentos genéricos Medicamentos de marca preferidos Medicamentos de marca no preferidos Medicamentos especiales Su costo si usa el nivel 1 de proveedores (FHHS) Su costo si usa el nivel 2 de proveedores (Customized MultiPlan network) Minorista (suministro de 30 días): $10 de copago/receta Venta por correo (suministro de 90 días): $10 de copago/receta Minorista (suministro de 30 días): 20% de /receta (mínimo $25; máximo $150) Venta por correo (suministro de 90 días): 20% de /receta (mínimo $50; máximo $150) Minorista (suministro de 30 días): 20% de /receta (mínimo $50; máximo $300) Venta por correo (suministro de 90 días): 20% de /receta (mínimo $100; máximo $300) 30 días: 20% de /receta (mínimo $50; máximo $200) 90 días*: 20% de /receta (mínimo $100; máximo $400) Sus costos si usted usa el Nivel 3 de proveedores no participantes (Fuera de la red) No cubierto No cubierto No cubierto No cubierto Limitaciones y excepciones Sólo se permite la venta de un suministro para 30 días de un medicamento de mantenimiento, a través de una farmacia minorista local. Todas las compras posteriores deben realizarse a través de Rx Plus Pharmacy. Por favor, comuníquese con atención al cliente de Rx Plus Pharmacy, al Para garantizar que usted reciba la terapia de medicamentos más apropiada y económica, el diseño de su plan de beneficios de recetas específicos requiere que algunos medicamentos tengan un límite de cantidad (QL), requiere autorización previa (PA) o terapia escalonada (ST) antes de la venta. Sólo se permite la venta de un suministro para 30 días de un medicamento de mantenimiento, a través de una farmacia minorista local. Todas las compras posteriores deben realizarse a través de Rx Plus Pharmacy. Por favor, contacte al centro de llamadas de Rx Plus Pharmacy en Se exige que todos los medicamentos de especialidades sean vendidos por Rx Plus Pharmacy y administrados por un miembro del equipo de la especialidad. Si un medicamento no puede ser vendido por Rx Plus Pharmacy, el equipo de la especialidad facilitará la atención del miembro con otra farmacia de especialidad de la red. *Sólo ciertos medicamentos corresponden a la venta para 90 días y el equipo de la especialidad trabajará con los afiliados en forma individual. 3 of 8

16 Eventos médicos comunes Si le hacen una cirugía ambulatoria Si necesita atención inmediata Si lo admiten al hospital Si tiene problemas psiquiátricos, de conducta o de abuso de sustancias Si está embarazada Los servicios que podría necesitar Arancel del centro (clínica) Tarifa del médico/cirujano Servicios de la sala de emergencias Traslado médico de emergencia Cuidado urgente Arancel del hospital (habitación) Tarifa del médico/cirujano Servicios ambulatorios de salud mental y de la conducta Servicios de salud mental y de la conducta para pacientes internados Tratamiento ambulatorio para el abuso de sustancias Tratamiento para el abuso de sustancias para pacientes internados Cuidados prenatales y post parto Parto y todos los servicios de internación Su costo si usa el nivel 1 de proveedores (FHHS) 10% de 10% de $150 de copago/ visita 10% de $50 de copago/ visita 10% de 10% de $25 de copago/ visita 10% de $25 de copago/ visita 10% de Prenatal: Sin costo Post parto: $25 de 10% de Su costo si usa el nivel 2 de proveedores (Customized MultiPlan network) 30% de 30% de $150 de 10% de $65 de 30% de 30% de $40 de 30% de $40 de 30% de Prenatal: $40 de Post parto: $40 de 30% de Sus costos si usted usa el Nivel 3 de proveedores no participantes (Fuera de la red) $150 de 10% de Prenatal: de Post parto: de Limitaciones y excepciones Se anula el copago si es admitido con estado de paciente hospitalizado a través de la sala de emergencias. 4 of 8

17 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 Servicios de rehabilitación Servicios de recuperación de las habilidades Cuidado de enfermería especializado Equipo médico duradero Cuidado de hospicio Su costo si usa el nivel 1 de proveedores (FHHS) 10% de Consultorio: $50 de Centro de salud: 10% de Consultorio: $50 de Centro de salud: 10% de 10% de 10% de 10% de Su costo si usa el nivel 2 de proveedores (Customized MultiPlan network) 30% de Consultorio: $65 de Centro de salud: 30% de Consultorio: $65 de Centro de salud: 30% de 30% de 30% de 30% de Sus costos si usted usa el Nivel 3 de proveedores no participantes (Fuera de la red) Consultorio: de Centro de salud: Consultorio: de Centro de salud: Limitaciones y excepciones La cobertura se limita a 60 visitas por año. La cobertura se limita a 60 visitas por año por terapia física, 60 visitas por terapia ocupacional, y 60 visitas por terapia de lenguaje. La cobertura se limita a 90 días por año. Examen de la vista No cubierto No cubierto No cubierto Ninguno Anteojos No cubierto No cubierto No cubierto Ninguno Consulta dental No cubierto No cubierto No cubierto Ninguno 5 of 8

18 Servicios excluidos y otros servicios cubiertos: Los servicios que su plan NO cubre. (Esta es una lista parcial. Consulte los documentos del plan para más información.) Acupuntura Cirugía cosmética Atención dental (adultos) Atención dental (niños) Anteojos (adultos) Anteojos (niños) Audífonos Tratamiento por infertilidad Atención a largo plazo Atención no de emergencias cuando se viaje fuera de EE.UU. Atención ocular de rutina (adultos) Atención ocular de rutina (niños) Atención de los pies de rutina (a excepción de cuidado del pie por la diabetes) Programas para adelgazar Otros servicios cubiertos. (Esta es una lista parcial. Consulte los documentos del plan para otros servicios cubiertos y sus precios.) Cirugía bariátrica (Se ofrece cobertura exclusivamente en Florida Hospital Celebration y la misma se limita a una cirugía de por vida para personas cubiertas hasta la edad de 18 años) Su derecho para continuar con la cobertura: Atención quiropráctica (la cobertura se limita a 20 visitas al año) Enfermería privada Si pierde la cobertura conforme al plan, según las circunstancias, las leyes estatales y federales pueden brindar protecciones que le permitan mantener la cobertura de salud. Todos esos derechos pueden estar limitados en duración, y le exigirán el pago de una prima, que puede ser significativamente mayor que la prima que paga mientras está cubierto conforme al plan. También pueden aplicarse otras limitaciones sobre sus derechos. Para obtener más información sobre sus derechos para continuar la cobertura, comuníquese con el plan en FHCA al También puede contactar a su departamento de seguro estatal, al Departamento de Trabajo de EE.UU., Administración de Seguridad de Beneficios para el Empleado, al , o en o al Departamento de Salud y Servicios Humanos de EE.UU. al x61565 o en 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 con FHCA al Provee Cobertura Esencial Minima 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 cobertura esencial mínima. Este plan o esta póliza ofrecen 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 cumple el estándar de valor mínimo para los beneficios que provee. Para ejemplos sobre cómo este plan paga por los servicios en una situación médica específica consulte la página siguiente. 6 of 8

19 The Traditional Plan (PPO) Duración de la póliza: 01/01/ /31/2015 Ejemplos de cobertura Cobertura de: sólo empleados Tipo de plan: PPO Sobre los ejemplos de cobertura: Estos ejemplos le muestran cómo cubriría el plan los servicios en situaciones distintas. Úselos para tener una idea de cuánta cobertura económica podría obtener el paciente del ejemplo de los distintos planes. Ésta no es una herramienta de cálculo de costos No use estos ejemplos para calcular los costos reales de su plan. 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 Nacimiento (parto normal) El proveedor cobra: $7,540 El plan paga: $ 6,510 Usted paga: $ 1,030 Ejemplos de los costos: El costo del hospital (madre) $2,700 Atención de rutina del obstetra $2,100 El costo del hospital (bebe) $900 Anestesia $900 Análisis de laboratorio $500 Medicamentos $200 Radiografías $200 Vacunas y otros servicios preventivos $40 Total $7,540 El paciente paga: Deducibles $ 300 Copagos $ 70 Coseguro $ 510 Límites o exclusiones $ 150 Total $ 1,030 Control de la diabetes (control rutinario de la enfermedad) El proveedor cobra: $5,400 El plan paga: $ 4,250 Usted paga: $ 1,150 Ejemplo de los costos: Medicamentos $2,900 Equipo médico e insumos $1,300 Visitas al 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 $ 300 Copagos $ 650 Coseguro $ 120 Límites o exclusiones $ 80 Total $ 1,150 Es importante notar que los costos que se observan sólo la cobertura del empleado. En el ejemplo nacimiento, los cargos del hospital del bebé están sujetos a sus requisitos propios del deducible. Preguntas y respuestas sobre los ejemplos mencionados: 7 of 8 Preguntas: Llame al Si no entiende alguno de los términos en negritas, consulte el Glosario en o llame al y pida una copia.

20 : The Traditional Plan (PPO) Duración de la póliza: 01/01/ /31/2015 Ejemplos de cobertura Cobertura de: sólo empleados Tipo de plan: PPO 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 que no son específicos para una zona geográfica 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 cubierto 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 proveedores de la red del plan. Si el paciente hubiese recibido los servicios de proveedores 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. También le ayudan a ver cuáles son los gastos que tendrá que pagar usted porque no están cubiertos o porque el pago es limitado. Contempla el ejemplo mis propias necesidades? No. Los tratamientos que mencionamos son solo 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 proveedor y del reembolso que autorice el plan. 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 Usted 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. 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. 8 of 8 Preguntas: Llame al Si no entiende alguno de los términos en negritas, consulte el Glosario en o llame al y pida una copia.

21 Glosario de términos médicos y seguros de salud El glosario contiene muchos de los términos médicos usados comúnmente, pero no todos. Los términos se definen con propósito educativo y pueden diferir de los que usa su plan. Algunos incluso podrían no tener el mismo significado cuando se usan en su póliza o plan, en cuyo caso debe atenerse a la definición del plan. (Vea el Resumen de Beneficios y Cobertura para averiguar cómo obtener una copia de su póliza o documento del plan.) Las palabras en Negritas en azul son los términos definidos en el Glosario. Consulte la página 4 para un ejemplo de los deducibles, y límites de gastos del bolsillo aplicados a una situación real. Cantidad aprobada La cantidad máxima que se paga por un servicio cubierto. También se le conoce como gasto aprobado, pago autorizado o precio negociado. Si el proveedor le cobra más de esta cantidad, usted tendrá que pagar la diferencia. (Vea Saldo de Facturación.) Complicaciones del embarazo Problemas del embarazo o parto que requieren atención médica para prevenir daños graves a la salud de la madre o del feto. Las náuseas y las cesáreas que no sean de emergencia no se consideran como complicaciones del embarazo. Apelación Un pedido de revisión que le hace al plan o a la compañía de seguro, sobre una decisión o sobre una queja que usted haya presentado. Saldo de facturación Cuando un proveedor le cobra la diferencia entre lo que ha facturado el proveedor y la cantidad aprobada. Por ejemplo, si el proveedor facturó $100 y la cantidad aprobada es $70, el proveedor le puede cobrar los $30 diferencia. Un proveedor preferido tal vez no le cobre el saldo de facturación por los servicios cubiertos. Coseguro La parte que le corresponde pagar a usted por los servicios cubiertos. Es un porcentaje (por ejemplo 20%) de la cantidad aprobada para dicho servicio. Usted paga el más cualquier deducible que deba. Por ejemplo, si la cantidad aprobada por el seguro médico o el plan para la visita médica es $100 y usted ya ha pagado el deducible, el (20% ) será $20. El seguro médico pagará el resto de la cantidad aprobada. Juana paga Su plan paga 20% 80% (Para un ejemplo detallado, consulte la página 4) Copago Una cantidad fija (por ejemplo $15) que usted paga por los servicios médicos cubiertos, generalmente al momento de recibirlos. La cantidad puede variar según el tipo de servicio. Deducible La cantidad que usted debe pagar por los servicios cubiertos antes de que su seguro médico o su plan comience a pagar. Por ejemplo, si su deducible es $1000, el plan no pagará hasta que usted haya gastado $1000 en los servicios cubiertos a los que se aplica el deducible. No todos los servicios requieren el pago del deducible. Juana paga 100% Equipo Médico Duradero (DME) Equipo e insumos ordenados por su proveedor de servicios de la salud para su uso cotidiano o por un tiempo prolongado. La cobertura del DME puede incluir: el oxígeno, silla de ruedas, muletas o tiras de prueba para diabéticos. Su plan paga 0% (Para un ejemplo detallado, consulte la página 4) Emergencia médica Una enfermedad, herida, síntoma o afección tan grave, que la persona razonablemente buscará ayuda médica inmediata para evitar un daño grave. Glossary of Health Insurance and Medical Terms - Spanish Página 1 de 5