x0000x0000National Allied Workers Union Insurance Trust Fund Hea - PDF document

1 1 of 8 ��National All
1 of 8 ��National Allied Workers Union Insurance Trust Fund Health EssentialsPlanCoverage Period: 04/01/2017 03/31/2018Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: FamilyPlan Type: PPO Questions:Call 889or visit us at aegisadmin.comIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary This is only a summaryIf you want more detail about youcoverage and costsou can get the complete terms in the policy or plan document at ww.aegisadmin.comor by calling Important Questions Answers Why this Matters: What is the overall deductible ? per person (PPO)/per person (NonPPO)Doesn’t apply to charges with fixed copays unless stated otherwise. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1 ). See the chart starting n page 2 for how much you pay for covered services after you meet the . Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Is there an outpocket limit on my expenses? Yes.3,5per person (PPO)/$12,000 per person (NonPPO). 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 inthe outpocket limit ? Deductible,fixed copays, penalty reductions for failure to precertifypremiums, balancebilled charges, and costs for health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the outpocket limit Note: $13,700 (family). Your deductibles and fixed copays do count toward thisoverall costsharing limit, but failures to precertify, balancebilled charges, and costs for health care this plan doesn’t covernot count. Is there an overall annual limiton what the plan ays? No. The chart starting on page 2 describes specific coverage limits, such as limits on the number of office visits. Does this planuse network ? Yes. For a list of preferred providers , seewww.cignasharedadministration.com . If you use an innetwork doctor or other health care provider , this plan will pay some or all of the costs of covered services.

2 Be aware, your innetwork doctor or hosp
Be aware, your innetwork doctor or hospitalmay use an outnetwork provider for some services. Plans use the term in network, preferred, or participating for providersin 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 a specialist ? No. You can see the specialist you choose without permission from this plan. Are there services this plandoesn’t cover?Yes.Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan document for additional information about excluded services . 2 of 8 ��National Allied Workers Union Insurance Trust Fund Health EssentialsPlan Coverage Period: 04/01/2017 03/31/2018Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: FamilyPlan Type: PPO Questions:Call 889or visit us at aegisadmin.comIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdfor call 12307 to request a copy. Common Medical Event Services You May Need Your Cost IYou Preferred Provider Your Cost IYou se a Non PreferredProvider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $45copay/visit 40% co - insurance after deductible Not including labs and xrays. Specialist visit 0 copay/visit 40% co - insurance after deductible Other practitioner office visitNot coveredNot covered No coverage for chiropractic care or acupuncture . Preventive care/screening/immunization No charge No charge after deductible Service provided after diagnosis is not preventative care. Preventative care for baby/child (under age 18) includes reimbursement for office visits, physical examination, laboratory tests, xrays, and immunizations. Preventative care for adult includes reimbursement for office visits, pap smear, prostate screening, gynecological examination, physical examination, immunizations, xrays, laboratory tests, preventative colonoscopies if age 50 or older and once every ten years, and mammogram screenings if age 40 or older. Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsuranceis 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 allowed am

3 ountfor an overnight hospital stay is $1
ountfor 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 planpayfor covered services is based on the allowed amount. If an networkprovidercharges more than the allowed amount , you may have to pay the difference. For example, if an ounetwork 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 preferred providers by charging you lower deductibles , copayments and coinsurance amounts. 3 of 8 ��National Allied Workers Union Insurance Trust Fund Health EssentialsPlan Coverage Period: 04/01/2017 03/31/2018Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: FamilyPlan Type: PPO Questions:Call 889or visit us at aegisadmin.comIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdfor call 12307 to request a copy. Common Medical Event Services You May Need Your Cost IYou Preferred Provider Your Cost IYou se a Non PreferredProvider Limitations & Exceptions If you have a test Diagnostic test (xray, blood work)0% coinsuranceafter deductible40% coinsuranceafter deductible------------------------------------------------ Imaging (CT/PET scans, MRIs) 0% coinsurance after deductible 40% coinsuranceafter deductible Coverage limited to 6 MRIs per cale ndar year; coverage limited to CAT/CT scans per calendar year; precertification required; 50% reduction in expenses covered by the Plan for failure to precertify; PET scans subject to deductible. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.aegisadmin.com . Generic drugsNot coveredNot coveredPrescription drug benefits provided through a separate discount program. Preferred brand drugs Not covered Not covered Nonpreferred brand drugsNot coveredNot covered Specialty drugs Not covered Not covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center)$1,000copay40% coinsuranceafter deductible Pre - certification required; 50% reduction in expenses covered by the Plan for failure to pre - certify . Physician/surgeon fees 3 0% co - insurance after deductible 40% co - insurance after deductible --------------

4 ---------------------------------- If yo
---------------------------------- If you need immediate medical attention Emergency room services$500copay$500copay Non - network provider is subject to usual and customary benefit payments Emergency medical transportation $2 5 0 co - pay ; 3 0% co - insurance after deductible $25 0 co - pay; 3 0% co - insurance after deductible Coverage limited to local ground transportati Urgent care $2 5 0 co - pay Not covered 4 of 8 ��National Allied Workers Union Insurance Trust Fund Health EssentialsPlan Coverage Period: 04/01/2017 03/31/2018Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: FamilyPlan Type: PPO Questions:Call 889or visit us at aegisadmin.comIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdfor call 12307 to request a copy. Common Medical Event Services You May Need Your Cost IYou Preferred Provider Your Cost IYou se a Non PreferredProvider Limitations & Exceptions If you have a hospital stay Facility fee (e.g., hospital room) $1,5copay 40% coinsurance after deductible Pre - certification required; 50% reduction in expenses covered by the Plan for failure to pre - certify. Physician/surgeon fee 3 0% co - insurance after deductible 40% co - insurance after deductible Coverage limited to one visit per day per Physician, excluding the day of surgery. If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services 0.00 copay Not covered 15 visits per calendar year. Mental/Behavioral health inpatient services Not coveredNot covered Substance use disorder outpatient services 0.00 copay Not covered 15 visits per calendar year. Substance use disorder inpatient services Not covered Not covered If you are pregnant Prenatal and postnatal care $1,00 copay% coinsurance after deductibleCoverage does not include expenses incurred by a dependent child. Delivery and all inpatient services If you need help recovering or have other special health needs Home health care $6 0.00 co - pay; 3 0% coinsurance after deductible Not covered 20 visits per calendar year; no benefits are payable for services or supplies not specified in the home health care treatment plan. Rehabilitation services 0 copay/visit coinsurance after deductible Occupational therapy and speech therapy (combined)limited to 10 visits per calendar year; physical t

5 herapy limited to 20 visits per calenda
herapy limited to 20 visits per calendar year; coverage for all rehabilitation services limited to outpatient care. Habilitation services 0 copay/visit 40% coinsurance after deductible Skilled nursing care Not covered Not covered No coverage for skilled nursing care. Durable medical equipment 3 0% co - insurance after deductible 40% co - insurance after deductible Purchase or rental of durable medical equipment depends on cost effectiveness. Hospice service Not covered Not covered No coverage for hospice services. If your child needs dental or eye care Eye exam Not covered Not covered Vision care provided through a separate discount program. Glasses Not covered Not covered 5 of 8 ��National Allied Workers Union Insurance Trust Fund Health EssentialsPlan Coverage Period: 04/01/2017 03/31/2018Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: FamilyPlan Type: PPO Questions:Call 889or visit us at aegisadmin.comIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdfor call 12307 to request a copy. Common Medical Event Services You May Need Your Cost IYou Preferred Provider Your Cost IYou se a Non PreferredProvider Limitations & Exceptions Dental check Not covered Not covered Dental care provided through a separate discount program. 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 .) AcupunctureBariatric surgeryChiropractic careCosmetic surgeryDental care (Adult and Child)(discounts provided through a separate discount program)Hearing aids Hospice services Infertility treatmentLongterm carental/behavioral health care(inpatient)Nonemergency care when traveling outside the U.S.Prescription drugs(discounts provided through a separate discount program)Privateduty nursing Routine eye care (Adult and Child)Routine foot careSkilled nursing careSpeech therapy/testingSubstance abuseare(inpatient)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 Please s ee covered services listed on pages 2 - 5. Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide prote

6 ctions that allow you to keep health cov
ctions that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium , which maybe significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. 6 of 8 ��National Allied Workers Union Insurance Trust Fund Health EssentialsPlan Coverage Period: 04/01/2017 03/31/2018Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: FamilyPlan Type: PPO Questions:Call 889or visit us at aegisadmin.comIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdfor call 12307 to request a copy. For more information on your rights to continue coverage, contact Aegis Administrative ServicesYou may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 13272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 18772323 x61565 orwww.cciio.cms.govYour 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 toappealor file a grievance For questions about your rights, this notice, or assistance, you can contactAegis Administrative Services at 1. You may also contact the Department of Labor’s Employee Benefits Security Administration at 13272 or www.dol.gov/ebsa/healthreform Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at 19431 or visit www.insurance.illinois.govDoes this Coverage Provide Minimum Essential Coveragehe Affordable Care Actrequires 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 standardfor the benefits it provides Language Access Services:Spanish (Espaol):Para obtener asistencia en Español, llame al 2307. Tagalog(Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1Chinese): Navajo(Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 889To see exampleof how this plan might cover costsfor a samp

7 le medical situation, see the next page
le medical situation, see the next page 7 of 8 ��National Allied Workers Union Insurance Trust Fund Health EssentialsPlan Coverage Period: 04/01/2017 03/31/2018Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: FamilyPlan Type: PPO Questions:Call 889or visit us at aegisadmin.comIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdfor call 12307 to request a copy. Having a baby(normal delivery) Managing type 2 diabetesroutine maintenance of a well - controlled condition ) About thCoverage Exampleexampleshowhow this planmight cover medical care in given situationUse thexampleto see, in general, how much financial protection sample patient might getif they are covered under different plansAmount owed to providersPlan paysPatientpaySample care costs Hospital charges (mother) $ 2,7 00 Routine obstetric care $ 2,1 00 Hospital charges (baby) $ 9 00 Anesthesia $ 9 00 Laboratory tests $ 5 00 Prescriptions $ 2 00 Radiology $ 2 00 Vaccines, other preventive $ 40 Total $ 7 , 54 0 Patientpay Deductibles $ 0 Co pays $ 1,4 0 0 Coinsurance $ 0 L imits or exclusions $ 45 0 Total $ 1, 8 5 0 Note:Amount does not include any discounts provided through the separate prescription discount program. Amount owed to providers$5,400Plan paysPatientpaySample 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 Patientpay Deductibles $ 1 50 Co pays $ 20 0 Co insurance $ 0 Limits or exclusions $ 4,6 00 Total $ 4,95 0 Note:Amount does not include any discounts provided through the separate prescription discount program. This is a cost estimator. Don’t use theseexampleto estimate your actual costs under thisplan. The actual care you receive will be different from theseexample, and the cost of that care will also be differenSeethe next page for important information about these examples. 8 of 8 ��National Allied Workers Union Insurance Trust Fund Health EssentialsPlan Coverage Period: 04/01/2017 03/31/2018Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: FamilyPlan Type: PPO Questions:Call 889or visit us at aegisadmin.comIf you aren’t clear about any of the un

8 derlined terms used in this form, see th
derlined terms used in this form, see the Glossary. You can view the Glossaryat ww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdfor call 12307 to request a copy. Questions andanswersabout the Coverage Example What are some of the assumptions behind the Coverage Example Costs don’t include premiums . Sample care costs are based on national averages supplied the U.S. Department of Health and Human Services, and aren’tspecific to a particular geographic areaor healthplanThe patient’scondition was not an excludedor preexisting condition.All servicesand treatments started and ended in the same coverageperiod.There are other medical expensesfor any member covered under this planOutpocket expenses are based only on treating the conditionin the exampleThe patient received all care from innetwork providers . If the patient had received care from outnetwork providers , costs would have been higher. What does Coverage Example show? For each treatment situation, the Coverage Examplehelpyou see how deductiblescopayments , and insurance 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 overage xample predict my own care needs? No Treatments shown are just examples The care you would receive for thcondition could be different based on your doctor’s advice, your age, how serious your condition, and many other factors. Does the overage xample predict my future expenses? overage Exampleare not cost estimator. You can’tuse the exampleto estimate costs for an actual condition. Theyare 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 healthplanallows. Can I use Coverage Example to compare plans? Y敳 When you look at the Summarof Benefits and Coverage for other plansyoufind the same overage ExampleWhen you compare plans, check the PatientPay” boxin each example. The smaller that number, the more coverage the planprovides. Are there other costs I should consider when comparing plan Y敳An important cost is the premium you pay. Generally, the lower your premium , the more you’ll pay in out pocket costs, such as paymentsdeductibles , and insurance 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 outpocket expenses 24239964.