Summary of Benefits and Coverage What this PlanCovers What You Pay Fo - PDF document

1 Summary of Benefits and Coverage: What t
Summary of Benefits and Coverage: What this PlanCovers & What You Pay For Covered Services Coverage Peri1/01/202112/31/ SignatureValueAdvantageHMOPlati80/20% Coverage for: Individual + Family | PlanType: HMO /4JH Subject to Regulatory Approval Page 1 of 7 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan(called the premium ) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.welcometouhc.com/uhcwest by calling 18008822For general definitions of common terms, such as allowed amountbalance billingcoinsurancecopaymedeductibleprovider , or other underlined terms , see the Glossary. You can view the Glossary at www.healthcare.go v/sbc - glossary/ or call 1 - 800

2 - 624 - 8822 to request a copy. Import
- 624 - 8822 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible ? $0 See theCommon Medical Events chartbelowfor our costs Are there services covered before you meet your deductible Yes. Preventive care and primary care services are covered before you meetyourdeductible his plancoverssome items and services even if you haven’t yet met thedeductibleamount. But copaymentor coinsurancemay apply. For example, this plancovers certain preventive services withoutcostsharing and before you meet your deductible. See a list ofcovered preventive serviceshttps://www.healthcare.gov/coverage/preventivecarebenefits/ Are there other deductiblesfor specific services? No. Youdon’thave to meetdeductiblesfor specific services. What is the pocket limit forthis plan For participating providers4,500 individual / $9,000 family. The outpocket limit mily members in this plan, they have to meet their own outpocket limitsuntil the overall familypocket limithas been met. What is not included inthe pocket limit Copaymentsforcertain services, premiumsbalancebillingcharges, ptional addenda, and health care this plandoesn’t cover. Even though you pay these expenses, they don’t count toward the outpocket limit Will you pay less if you use a network provider ? Yes. See www.welcometouhc.com/uhcwestor 6248822 for a list of participating providers This plan uses a provider network . You will pay less if you use a provide r in the plan’s network . You will pay the most if you use a nonparticipating provider , and you might receive a bill from a providerfo

3 r the difference between the provider

r the difference between the provider’scharge and what your planpays balance services (such as lab work). Check with your providerbefore you get services. Do you need a referral to see a specialist ? Yes, written or oral approval is required, based upon medical policies. This planwill pay some or allof the costs to see a specialistfor covered services but only if you have referralbefore you see the specialist Page 2 of 7 Common Medical Event Services You May Need W hat You Will Pay LimitationsExceions, & Other Important Information Participating Provider (You will pay the least) Non - Participating Provider (You will pay the most) If you visit a health care provider’soffice or clinic Primary care visit to treat an injury or illness No chargeoffice visit and No charge/ Virtual visits by a designated virtual participating provider Not covered If you receive services in addition to office visit, additional copaymentsor oinsurancemay apply. Specialistvisit copay/ visit Not covered ember is required toobtain a referrato specialistor other licensed health care practitioner, except for OB/GYN Physician services , reproductive health care services within the Participating Medical Groupand Emergency / Urgently needed services.If you receive services in addition to office visit, additional copaymentsor coinsurancemay apply. Preventivecare screening / immunization No charge Not covered You may have to pay for services that aren’t preventive. Ask your providerif the services u need are preventive. Then check what your plan will pay for. If you

4 have a test Diagnostic test ray, blood
have a test Diagnostic test ray, blood work) Lab $2 5 copay / test Radiology (Standard) $ 2 5 copay / test Not coveredNone Imaging (CT/PET scans, MRIs) copay/ test Not covered Page 3 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, &Other Important Information Participating Provider (You will pay the least) Non - Participating Provider (You will pay the most) If you need drugs to treat your illness or ndition More information about prescription drug coverage is available at www.welcometouhc.com/ uhcwest. ier 1 $ 5 copay / prescri ption retail copay/ prescription mail order Not covered Participating Provider means pharmacy for purposes of this section.Retail: Up to a 31 day supply.MailOrder: Up to a 90 day supply.You may need to obtain certain drugs, including certain pecialty drugs , from a pharmacy designated by us. MailOrder Specialty drugsto a 31 day supply. All limits are unless adjusted based on the drug manufacturer's packaging size,or based on supply limits. CopaymenMaximum of $250 (“Cap”)for up to a 31day supply of an orally administered anticancer medication for a plandesign not defined as a High uctibleHealth Planregardless of any Deductible. You may be required to use a cost drug(s) prior to benefits under your policy being available for certain prescribed drugs. See the website listed for information on drugs covered by your plan . Tier 2 $40 copay / prescription retail copay/ prescription mail order Not covered Tier 3 $8 0 copay / p rescr iption retail

5 copay/ prescription mail order Not c
copay/ prescription mail order Not covered Tier 4 coinsurance prescription retailup to a $250 copaymax per prescription coinsurance prescription mail orderup to a $500 copaymax per prescription Not covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance Not coveredNone Physician/surgeon fees No char Not covered If you need immediate medical attention Emergency room care 0% coinsurance 0% coinsurance None Emergency medical transportation $100copayrip $100copayrip Urgent care No charge copay/ visit If you receive services in a ddition to urgent care, additional copaymentsor coinsurance may apply. If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance Not covered None Physician/surgeon feesNo chargeNot covered Page 4 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participati ng Provider (You will pay the least) Non - Participating Provider (You will pay the most) If you need mental health, behavioral health, or substance abuse servic es Outpatient services No charge Not covered None Inpatient services 0% coinsurance Not covered If you are pregnant Office visits No charge Not covered Cost sharing does not apply to certain preventive services. Routine prenatal care and first postnatal visit iscovered at No charge. Depending on the type of services, additional copaymentsor coinsurancemay apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/d

6 elivery professional servicesNo charget
elivery professional servicesNo charget covered Childbirth/delivery facility services 0% coinsurance Not covere If you need help recovering or have other special health needs Home health care No chargeNot covered Limited to 100 visits per year. Limit does not apply to home healthvisits for rehabilitation and habilitation purposes. Rehabilitation services No charge Not covered None Habilitative services No chargeNot covered Skilled nursing care 20% coinsurance Not covered Up to 100 days per benefit period. Durable medical equipment copay/ item Not coveredNone Hospice services No charge Not covered I f inpatient admission, subject to inpatient copayments or coinsurance . If your child needs dental or eye care Children’s eye examNo chargeNot covere1 exam per year. Children’s glasses 20% coinsurance Not covered One pair every 12 months. Children’s dental checkNo chargeot covered Cleanings covered 2 times per 12 months. Additional limitations may apply. Page 5 of 7 xcluded services & Other Covered Services: Services Y our Plan Generally Does NOT Cover (Check yo ur policy or plan document for more information and a list of any other excluded services .) Cosmetic surgery Dental care (Adult) Infertility treatment Long - term care Nonemergency care whentraveling outside theU.S. Private - duty nursing Routine foot care Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture Bariatric surgery Chiroprac tic c

7 are Hearing aids Routine eye care
are Hearing aids Routine eye care (Adult) Page 6 of 7 Your Rights to Continue Crage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies are: Department of Managed Health Care California Help Center, 980 9Street Suite #500, Sacramento, CA 958144275 a8884662219 or www.dmhc.ca.gov ., or epartment of Labor’s Employee Benefits Security Administration at 1866444EBSA (3272) or http://www.dol.gov/ebsa/healthre Other coverage options may be available to you too, including buying individual insurance coverage through the ealth insuranceMarketplace . For more information about theMarketplace, visit www.HealthCare.gov or call 12596. ur Grievanceand AppealsRights:There are agencies that can help if you have a complaint against your planfor a denial of a claim This complaint is called a grievanceor appeal . For more information about your rights, look at the explanation of benefitsyou will receive for that medical laim. Your plandocuments also provide complete information on how to submit a claimappealor a grievancefor any reason to your plan. For more information about your rights, this notice, or assistance, contact: yourhuman resource department, and the Department of Labor’s Employee Benefits Security Administration at 1866444EBSA (3272) or http://www.dol.gov/ebsa/healthreform Additionally, a consumer assistance program may help you file your appealContact Department of Managed Health Care California Help Center, 980 9Street Suite #500, Sacramento, CA 958144275 at 18884662219 o

8 r www.dmhc.ca.gov Does this planpr
r www.dmhc.ca.gov Does this planprovide Minimum Essential CoverageYes Minimum Essential verage generally includes planshealth insuranceavailable through the Marketplaceor other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverageyou may not be eligible for the premium tax credit Does this meet the Minimum Value StandardsYes. If your plandoesn’t meet the Minimum Value Standards , you may be eligible for a premium tax creditto help you pay for a planthrough the Marketplace Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 18006248822.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 18008822.Chinese (): 如果需要中文的帮助6248822.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 8006248822. To see examples of how this plan might cover costs for a sample medi ca l situation, see the next section. Page 7 of 7 The planwould be responsible for the other costs of these EXAMPLE covered services. Peg is Having a Baby (9 months of participating providerprenatal care and a hospital delivery) Mia’s Simple Fracture participating provideremergency roomvisit and follow up care) M anaging Joe’s T ype 2 Diabetes (a year of routine participating providercare of a well - controlled condition) The plan’soverall deductible Specialistcopayment Hospital (facility) coinsuranc Othercoinsurance This EXAMPLE ev

9 ent includes services like: Specialisto
ent includes services like: Specialistoffice visits (prenatal care) Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility Services Diagnostic tests(ultrasounds and blood work) Specialisvisit (anesthesia) Total Example Cost $12,7 00 In this example, Pegwould pay: Cost Sharing Deductible s $ 0 Copayments $ 90 Coinsurance $ 1, 7 00 What isn’t covered Limits or exclusions $60 The total Peg would pay is $ 1, 8 5 0 The plan’soverall deductible Specialistcopayment Hospital (facility) coinsurance Othecoinsurance This EXAMPLE event includes services like: Primary care physician office visit including disease education) Diagnostic tests(blood work) Prescription drugs Durable medical equipment(glucose meter) Total Example Cost $ 5,6 00 In this example, Joe would pay: Cost Sharing Deductible s $ 0 Copayments $ 1,0 00 Coinsurance $ 0 What isn’t covered Limits or exclusions $ 0 The total Joe would pay is $ 1,0 0 0 The plan’soverall deductible Specialistcopayment Hospital (facility) coinsurance Othercoinsurance This EXAMPLE event includes services like: Emergency room care(including medical supplies) Diagnostic teray Durable medical equipment(crutches) Rehabilitation services(physical therapy T otal Example Cost $ 2,8 00 In this example, a would pay: Cost Sharing Deductible s $0 Copayments $ 2 0 0 Coinsurance $ 20 0 What isn’t covered Limits or exclusions $0 The total M

10 ia would pay is $ 4 0 0 Note:
ia would pay is $ 4 0 0 Note: These numbers a ssume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce you r costs. For more information about the wellness program, please contact: 1 - 800 - 624 - 8822. About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this planight cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providerscharge, and many other factors. Focus on the cost sharing amounts (deductiblescopaymentsand coinsurance) and excluded servicunder the plan. Use this information to compare the portion of costs you might pay under different health plaPlease note these coverage examples are based on selfonlycoverage �� &#x/Att;¬he; [/;ott;&#xom ];&#x/BBo;&#xx [3;“.8; 1;.23; 40; 29;&#x.952;&#x ]/S;&#xubty;&#xpe /;oot;r /;&#xType;&#x /Pa;&#xgina;&#xtion;&#x 000;&#x/Att;¬he; [/;ott;&#xom ];&#x/BBo;&#xx [3;“.8; 1;.23; 40; 29;&#x.952;&#x ]/S;&#xubty;&#xpe /;oot;r /;&#xType;&#x /Pa;&#xgina;&#xtion;&#x 000; &#x/MCI; 0 ;&#x/MCI; 0 ;Nondiscrimination Notice and Access to Communication ServicesUnitedHealthcare does not exclude, deny Covered Health Care Benefits to, or otherwise discriminate against any Member on the ground of race, color, national origin, ancestry, religion, se

11 x, marital status, gender, gender identi
x, marital status, gender, gender identity, sexual orientation, age, or disability for participation in, or receipt of the Covered Health Care Services under, any of its Health Plans, whether carried out by UnitedHealthcare directly or through a Network Medical Group or any other entity with which UnitedHealthcare arranges to carry out Covered Health Care Services under any of its Health Plans.Free services are available to help you communicate with us such as letters in other languages, or in other formats like large print. Or, you can ask for an interpreter at no charge. To ask for help, please call the tollfree number listed on your health plan ID card.If you think you weren’t treated fairly because of your sex, age, race, color, national origin, or disability, you can send a complaint to: Online: UHC_Civil_Rights@uhc.com Mail: Civil Rights Coordinator UnitedHealthcare Civil RightsGrievance P.O. Box 30608 Salt Lake City, UTAH 84130 You must send the complaint within 60 days of when you found out about it.A decision will be sent to you within 30 days.If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the tollfree phone number listed on your health plan ID card, Monday through Friday, 8 a.m. to 8 p.m.You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: tps://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Phone:Tollfree 13687697 (TDD)Mail: U.S. Dept. of Health and Human Services200 Independence Avenue,SW Room 509F, HHH BuildingWashington,