This is only a summary If you want more detail about your coverage and - PDF document

1 This is only a summary. If you want more
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 documentat www .bcbsnm.com/co v erage or by calling 1-866-236-1702. Why this Matters:AnswersImportant QuestionsSee the chart starting on page 2 for your other costs for services this plan covers.$0What is the overalldeductible ?You don't have to meet deductibles for specific services, but see the chart starting on page 2for other costs for services this plan covers.No.Are there otherdeductibles for specificservices?There's no limit on how much you could pay during a policy period for your share of the costof covered services.No.Is there an out-of-pocket limit on my expenses?Not applicable because there's no out-of-pocket limit on your expense.This plan has no out-of-pocket limit .What is not included inthe out-of-pocket limit ?If you use an in-network doctor or other health care pr o vider , this plan will pay some or all ofthe costs of covered services. Be aware, your in-network doctor or hospital may use anYes. Please call 1-866-236-1702or see www .bcbsnm.com Does this plan use anetwor k of pr o viders ?out-of-network pr o vider for some services. Plans use the term in-network, pr eferr ed , orparticipating for pr o viders in their networ k . See the chart starting on page 2 for how thisplan pays different kinds of pr o viders .You can see the specialist you choose without permission from this plan.No. You don't need a referral tosee a specialist.Do I need a referral to seea specialist ?Some of the services this plan doesn't cover are listed on page 4. See your policy or plandocument for additional information about ex cluded ser vices .Yes.Are there services this plandoesn't cover? 1 of 7Questions: Call 1-866-236-1702 or visit us at www .bcbsnm.com/co v erage .If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww .dol.go v/ebsa/pdf/SBCU nifor mG lossar y .pdf or call 1-866-236-1702 to request a copy.Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Blue Advantage Gold HMO 002 Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: Individ

2 ual/FamilyPlan Type: HMO Copayments are
ual/FamilyPlan Type: HMO 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 allo w ed amount for the service. For example, if the healthplan's allo w ed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven'tmet your deductible . The amount the plan pays for covered services is based on the allo w ed amount . If an out-of-network pr o vider charges more than the allo w ed 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 allo w ed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing. ) The plan may encourage you to use HMO pr o viders by charging you lower deductibles , copayments , and coinsurance amounts. Limitations & ExceptionsYour cost if you use a BCBSNM HMOProviderServices You May NeedCommon Medical Event---none---No ChargePrimary care visit to treat an injury or illnessIf you visit a health careprovider�s office orclinicNo ChargeSpecialist visitAcupuncture treatment andchiropractic care each limited to 25visits/yearNo ChargeOther practitioner office visit---none---No ChargePreventive care/screening/immunization---none---No ChargeDiagnostic test (x-ray, blood work)If you have a testPreauthorization required for CT/PETscans.No ChargeImaging (CT / PET scans, MRIs)Retail-limited to a 30-day supply.Mail-order limited to a 90-day supply,No ChargePreferred Generic DrugsIf you need drugs totreat your illness orconditionNo ChargeNon-Preferred Generic Drugsin-network only. Specialty drugs arenot available through mail-order.No ChargePreferred Brand DrugsMore information aboutpr escription dr ug co v erage is available atwww .bcbsnm.com/ member/r x_dr ugs.html No ChargeNon-Preferred Brand DrugsNo ChargeSpecialty Drugs---none---No ChargeFacility fee (e.g., ambulatory surgery center)If you have outpatientsurgeryNo ChargePhysician/surgeon fees 2 of 7Questions: Call 1-866-236-1702 or visit us at www .bcbsnm.com/co v erage .If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww .dol.go v/ebsa/pdf/SBCU nifor mG lossar y .pdf or

3 call 1-866-236-1702 to request a copy. B
call 1-866-236-1702 to request a copy. Blue Advantage Gold HMO 002 Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: Individual/FamilyPlan Type: HMO Limitations & ExceptionsYour cost if you use a BCBSNM HMOProviderServices You May NeedCommon Medical Event---none---No ChargeEmergency room servicesIf you need immediatemedical attentionPreauthorization required fornon-emergency air ambulance.No ChargeEmergency medical transportation---none---No ChargeUrgent careRequires preauthorization.No ChargeFacility fee (e.g., hospital room)If you have a hospitalstay---none---No ChargePhysician/surgeon feeIncludes office, home, outpatient, andIOP services; inpatient and partialNo ChargeMental/Behavioral health outpatient servicesIf you have mentalhealth, behavioralhealth, or substanceabuse needsNo ChargeMental/Behavioral health inpatient serviceshospitalization (IOP, partialhospitalization, & inpatient requirepreauthorization).No ChargeSubstance use disorder outpatient servicesNo ChargeSubstance use disorder inpatient services---none---No ChargePrenatal and postnatal careIf you are pregnantNo ChargeDelivery and all inpatient servicesMax. 100 visits/year.No ChargeHome health careIf you need helprecovering or have otherspecial health needsIncludes physical, occupational, andspeech therapies in an office oroutpatient setting.No ChargeRehabilitation servicesNo ChargeHabilitation servicesMax. 60 days/year.No ChargeSkilled nursing care---none---No ChargeDurable medical equipmentMax. 45 visits/year.No ChargeHospice serviceOne visit per year.No ChargeEye examIf your child needsdental or eye careOne pair of glasses per year.No ChargeGlassesSee dental plan information for details.Not CoveredDental check-up 3 of 7Questions: Call 1-866-236-1702 or visit us at www .bcbsnm.com/co v erage .If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww .dol.go v/ebsa/pdf/SBCU nifor mG lossar y .pdf or call 1-866-236-1702 to request a copy. Blue Advantage Gold HMO 002 Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: Individual/FamilyPlan Type: HMO Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan d

4 ocument for other ex cluded ser vices .)
ocument for other ex cluded ser vices .) Routine eye care (Adult)Long-term careCosmetic surgery Dental Care (Routine dental for adults)Routine foot care (Unless you are diabetic)Non-emergency care when traveling outside theU.S. Infertility treatment (Unless for medical conditioncausing the infertility)Weight loss programs Private-duty nursing 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.) Hearing aids (For members age 21 and younger)Chiropractic care (Max. 25 visits/year)Acupuncture (Max. 25 visits/year) Bariatric surgery (Based on medical necessity)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 pr emium . There are exceptions,however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage areaFor more information on your rights to continue coverage, contact the insurer at 1-866-236-1702. You may also contact the Office of Superintendent of Insurancetoll-free at 1-855-427-5674.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 griev ance . For questions aboutyour rights, this notice, or assistance, you may also contact the Office of Superintendent of Insurance toll-free at 1-855-427-5674 or www .osi.state.nm.us .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 provideminimum essential coverage. 4 of 7Questions: Call 1-866-236-1702 or visit us at www .bcbsnm.com/co v erage .If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww .dol.go v/ebsa/pdf/SBCU nifor mG lossar y .pdf or call 1-866-236-1702 to request a copy. Blue Advantage Gold HMO 002 Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: Individual/FamilyPlan Type: HMO Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-866-236-1702.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tag

5 alog tumawag sa 1-866-236-1702.Chinese (
alog tumawag sa 1-866-236-1702.Chinese (m®): •àÁ Þm® 1 1-866-236-1702.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-236-1702. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 5 of 7Questions: Call 1-866-236-1702 or visit us at www .bcbsnm.com/co v erage .If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww .dol.go v/ebsa/pdf/SBCU nifor mG lossar y .pdf or call 1-866-236-1702 to request a copy. Blue Advantage Gold HMO 002 Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: Individual/FamilyPlan Type: HMO About These CoverageExamples:Managing type 2 diabetes(routine maintenance ofa well-controlled condition)Having a baby(normal delivery) �$�P�R�X�Q�W�R�Z�H�G�W�R�S�U�R�Y�L�G�H�U�V��������$�P�R�X�Q�W�R�Z�H�G�W�R�S�U�R�Y�L�G�H�U�V�������These examples show how this plan might covermedical care in given situations. Use these �3�O�D�Q�S�D�\�V�������3�O�D�Q�S�D�\�V������ �3�D�W�L�H�Q�W�S�D�\�V�����3�D�W�L�H�Q�W�S�D�\�V���examples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.�6�D�P�S�O�H�F�D�U�H�F�R�V�W�V��6�D�P�S�O�H�F�D�U�H�F�R�V�W�V�$2,900Prescriptions$2,700Hospital charges (mother)$1,300Medical Equipment and Supplies$2,100Routine obstetric care This is not acostestimator. $700Office Visits and Procedures$900Hospital charges (baby)$300Education$900Anesthesia$100Laboratory tests$500Laboratory tests$100Vaccines, other preventive$200Prescriptions$5,400Total$200RadiologyDon�t use these examples toestimate your actual

6 costs under$40Vaccines, other preventive
costs under$40Vaccines, other preventive$7,540Total�3�D�W�L�H�Q�W�S�D�\�V�the plan. The actual care youreceive will be different from these$0Deductibles$0Copays�3�D�W�L�H�Q�W�S�D�\�V�examples, and the cost of that carealso will be different.$0Deductibles$0Coinsurance$0Copays$80Limits or exclusionsSee the next page for importantinformation about these examples.$80Total$0Coinsurance$150Limits or exclusions$150Total 6 of 7Questions: Call 1-866-236-1702 or visit us at www .bcbsnm.com/co v erage .If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww .dol.go v/ebsa/pdf/SBCU nifor mG lossar y .pdf or call 1-866-236-1702 to request a copy. Blue Advantage Gold HMO 002 Coverage Period: 01/01/2014-12/31/2014 Coverage Examples:Coverage for: Individual/FamilyPlan Type: HMO Questions and answers about Coverage Examples: �:�K�D�W�D�U�H�V�R�P�H�R�I�W�K�H�D�V�V�X�P�S�W�L�R�Q�V�E�H�K�L�Q�G�W�K�H�&�R�Y�H�U�D�J�H�(�[�D�P�S�O�H�V�" Costs don�t include pr emiums . Sample care costs are based on nationalaverages supplied by the U.S. Department ofHealth and Human Services, and aren�tspecific to a particular geographic area orhealth plan. The patient�s condition was not an excludedor preexisting condition. All services and treatments started and endedin the same coverage period. There are no other medical expenses for anymember covered under this plan. Out-of-pocket expenses are based only ontreating the condition in the example. The patient received all care from in-networkpr o viders . If the patient had received carefrom out-of-network pr o viders , costs wouldhave been higher. �:�K�D�W�G�R�H�V�D�&�R�Y�H�U�D�J�H�(�[�D�P�S�O�H�V�K�R�Z�"For each treatment situation, the CoverageExample helps you see how deductibles ,copayments , and coinsurance can add up. It alsohelps you see what expenses might be left up toyou to pay because the service or treatment isn�tcovered or payment is limited. �'�R�H�V�W�K�H�&�R�Y�H�U�D�J�H�(�[&#

7 0;D�P�S�O�H�S�U�H&#
0;D�P�S�O�H�S�U�H�G�L�F�W�P�\�R�Z�Q�F�D�U�H�Q�H�H�G�V�" N o . Treatments shown are just examples. Thecare you would receive for this condition couldbe different based on your doctor�s advice,your age, how serious your condition is, andmany other factors. �'�R�H�V�W�K�H�&�R�Y�H�U�D�J�H�(�[�D�P�S�O�H�S�U�H�G�L�F�W�P�\�I�X�W�X�U�H�H�[�S�H�Q�V�H�V�" N o . Coverage Examples are not costestimators. You can�t use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Your owncosts will be different depending on the careyou receive, the prices your pr o viders charge,and the reimbursement your health planallows. �&�D�Q�,�X�V�H�&�R�Y�H�U�D�J�H�(�[�D�P�S�O�H�V�W�R�F�R�P�S�D�U�H�S�O�D�Q�V�" Y es . When you look at the Summary ofBenefits and Coverage for other plans, you�llfind the same Coverage Examples. When youcompare plans, check the
Patient Pays boxin each example. The smaller that number,the more coverage the plan provides. �$�U�H�W�K�H�U�H�R�W�K�H�U�F�R�V�W�V�,�V�K�R�X�O�G�F�R�Q�V�L�G�H�U�Z�K�H�Q�F�R�P�S�D�U�L�Q�J�S�O�D�Q�V�" Y es . An important cost is the pr emium youpay. Generally, the lower your pr emium , themore you�ll pay in out-of-pocket costs, suchas copayments , deductibles , and coinsurance .You should also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements (FSAs)or health reimbursement accounts (HRAs)that help you pay out-of-pocket expenses. 7 of 7Questions: Call 1-866-236-1702 or visit us at www .bcbsnm.com/co v erage .If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww .dol.go v/ebsa/pdf/SBCU nifor mG lossar y .pdf or call 1-866-236-1702 to request a copy. Blue Advantage Gold HMO 002 Coverage Period: 01/01/2014-12/31/2014 Coverage Examples:Coverage for: Individual/FamilyPlan Type: HM