Essential Health Benefits Covered Under Small Business Medical Plans Following is an overview of the Affordable Care Act’s (ACA) Essential Health Benefits mandate and the Health Care and Education Reconciliation Act. Health Insurance Premiums Based on New Community Member Rating Design. Premiums will be based on your employees’ and their dependents’ ages, resulting in your premiums going up or down due to new government rating requirements. Routine Care Associated with Clinical Trials. Coverage is limited to services and supplies provided when you are enrolled in a qualified clinical trial if such services would be paid for by HMAA as routine care. These services require pre-certification. Note: Coverage for certain benefits may not apply to the plan’s annual deductible. In addition, limitations and exceptions may apply, such as required pre-certification. Out-of-pocket costs will vary based on the type of service and choice of provider (participating in-network vs. out-of-network). Habilitative Therapy Services and Devices. Coverage for services that assist an individual in partially or fully acquiring skills and functions of daily living. Habilitation is the process of evaluation, treatment and education for the purpose of developing, improving and maintaining skills and functions which the individual has not previously possessed. Note: Coverage for certain benefits may not apply to the plan’s annual deductible, and have limitations and exceptions such as required precertification. Out-of-pocket costs will vary based on the type of service and choice of provider (participating in-network vs. out-of-network). Elimination of Annual Limits on Essential Health Benefits. Annual limits have been removed for certain services covered under the following Essential Health Benefits for:       Ambulatory Services Emergency Services Habilitative and Rehabilitative Therapy Hospital and Facility Services Laboratory Services Maternity and Newborn Care  Mental Health and Substance Abuse (including behavioral health treatment) Pediatric Dental and Vision Care Prescription Drugs Preventive and Wellness Services (including chronic disease management)    Note: Day, visit, and frequency limits rare not subject to the annual limit rules. Pediatric Dental Care. Pediatric dental care benefits are available to children through age 18 for the following services. Our participating dental provider network is HWMG.     Diagnostic & Preventive Services (cleaning, exams, x-rays) Restorative Services (fillings & crowns) Endodontic Services (tooth roots) Periodontics Services (gums & jaws)     Dentures (artificial teeth) Maxillofacial Prosthetics Surgical Services (mouth, face, neck) Anesthesia, Emergency, & After Hours Care Note: Dental cleaning, exams, and certain x-rays are covered in full with a participating dental provider. Coverage for certain benefits applies to the annual deductible, and is subject to limitations and exceptions such as a maximum number of services per calendar year or required precertification. Out-of-pocket costs will vary based on the type of service and choice of dental provider (participating in-network vs. out-of-network). Pediatric Vision Care. Pediatric vision care benefits are available to children through age 18 for the following services. Our participating vision provider network is VSP Choice.   Eye Exams (fitting & evaluation) Contact Lenses instead of glasses  Prescription Glasses instead of contact lenses (frames, lenses, and lens options) Note: Eye exams, contacts and glasses (excluding certain lens options) are covered in full with a participating vision provider. Coverage for these services does not apply to the plan’s annual deductible but may be subject to limitations and exceptions such as a maximum number of services per calendar year. Out-of-pocket costs will vary based on the type of service and choice of vision provider (participating in-network vs. out-of-network). Prescription Drugs and Supplies. Prescription drug and supply benefits are available for the following categories. Our participating pharmacy provider network is Restat.     Chemotherapy – Oral Drugs Contraceptives Diabetic Drugs, Supplies, and Insulin Spacers and Peak Flow Meters   Specialty Drugs U.S. Preventive Services Task Force (USPSTF) Recommended Drugs Note: Certain drugs and supplies in the categories listed above are covered in full with a participating pharmacy. Other prescription drugs will be covered based on a co-payment plan. Coverage for these prescription drugs and supplies will apply to the plan’s annual co-insurance maximum per calendar year ($3,850 per person/family) and may be subject to other limitations and exceptions such as required pre-certification. Once a member meets the co-insurance maximum, he/she is no longer responsible for the deductible, co-payments, or co-insurance amounts for prescription drugs and supplies unless otherwise noted. Out-of-pocket costs will vary based on the drug brand and choice of pharmacy (in-network vs. out-of-network). COMP E-44.EHB 010214