DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
Platinum
Coinsurance Plan
Platinum
Copay Plan
88.62%
88.41%
$0
$0
$0
$0
$0
$0
$0
$0
$4,000
$4,000
2/20/2014
Actuarial Value - AV Calculator
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
Member Cost
Share
Deductible Member Cost Deductible
Applies
Applies
Share
Primary care visit to treat an injury or illness
$20
$20
Specialist visit
$40
$40
No cost share
No cost share
$20
$40
10%
$5 or less
$15
$25
10%
10%
10%
$20
$40
$150
$5 or less
$15
$25
10%
Emergency room services (waived if admitted)
$150
$150
Emergency medical transportation
$150
$150
Urgent care
$40
$40
Facility fee (e.g., hospital room)
Physician/surgeon fee
10%
10%
$250 per day
up to 5 days
Mental/Behavioral health outpatient services
$20
$20
10%
$250 per day
up to 5 days
$20
$20
10%
$250 per day
up to 5 days
No cost share
No cost share
10%
10%
10%
$20
$20
10%
$250 per day
up to 5 days
$20
$20
$20
$150 per day
up to 5 days
10%
Hospice service
No cost share
No cost share
Eye exam (deductible waived )
Glasses
0%
1 pair per year
0%
1 pair per year
No cost share
No cost share
Service Type
Preventive care/ screening/ immunization
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
Tests
Need
immediate
attention
Hospital stay
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
Substance use disorder inpatient services
Prenatal care and preconception visits
Pregnancy
Delivery and all inpatient services
Hospital
Professional
Home health care
Rehabilitation services
Habilitation services
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
10%
Dental Major Services3
50%
Orthodontics (medically necessary)
50%
Notes:
1
2
3
20%
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs
$250
see fee
schedule
see fee
schedule
$300
DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
Individual
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
Gold
Coinsurance Plan
Gold
Copay Plan
79.60%
79.22%
$0
$0
$0
$0
$0
$0
$0
$0
$6,350
$6,350
2/20/2014
Actuarial Value - AV Calculator
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
Member Cost Deductible Member Cost Deductible
Applies
Applies
Share
Share
Service Type
Primary care visit to treat an injury or illness
$30
$30
Specialist visit
$50
$50
No cost share
No cost share
$30
$50
20%
$15 or less
$50
$70
20%
20%
20%
$30
$50
$250
$15 or less
$50
$70
20%
Emergency room services (waived if admitted)
$250
$250
Emergency medical transportation
$250
$250
Urgent care
$60
$60
Facility fee (e.g., hospital room)
Physician/surgeon fee
20%
20%
$600 per day
up to 5 days
Mental/Behavioral health outpatient services
$30
$30
20%
$600 per day
up to 5 days
$30
$30
20%
$600 per day
up to 5 days
No cost share
No cost share
20%
20%
20%
$30
$30
20%
$600 per day
up to 5 days
$30
$30
$30
$300 per day
up to 5 days
20%
Hospice service
No cost share
No cost share
Eye exam (deductible waived )
Glasses
0%
1 pair per year
0%
1 pair per year
No cost share
No cost share
Preventive care/ screening/ immunization
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
Tests
Need
immediate
attention
Hospital stay
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
Substance use disorder inpatient services
Prenatal care and preconception visits
Pregnancy
Delivery and all inpatient services
Hospital
Professional
Home health care
Rehabilitation services
Habilitation services
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
20%
Dental Major Services3
50%
Orthodontics (medically necessary)
50%
Notes:
1
2
3
20%
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs
$600
see fee
schedule
see fee
schedule
$300
DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
Individual
Individual
Silver
Coinsurance Plan
Silver
Copay Plan
68.74%
68.49%
N/A
N/A
$2,000
$250
$0
$2,000
$250
$0
$6,350
$6,350
2/20/2014
Actuarial Value - AV Calculator
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
Member Cost Deductible Member Cost Deductible
Applies
Applies
Share
Share
Service Type
Primary care visit to treat an injury or illness
$45
$45
Specialist visit
$65
$65
No cost share
No cost share
$45
$65
20%
$15 or less
$50
$70
20%
20%
20%
$45
$65
$250
$15 or less
$50
$70
20%
20%
20%
Preventive care/ screening/ immunization
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
Tests
Need
immediate
attention
Hospital stay
X
X
X
X
$250
X
Emergency medical transportation
$250
X
$250
X
Urgent care
$90
Facility fee (e.g., hospital room)
Physician/surgeon fee
20%
20%
Mental/Behavioral health outpatient services
$45
Prenatal care and preconception visits
Pregnancy
Delivery and all inpatient services
20%
$90
X
20%
X
20%
20%
20%
$45
$45
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
20%
20%
X
20%
X
20%
X
20%
Hospice service
No cost share
No cost share
Eye exam (deductible waived )
Glasses
0%
1 pair per year
0%
1 pair per year
No cost share
No cost share
Dental Major Services3
50%
Orthodontics (medically necessary)
50%
Notes:
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs
X
X
$45
$45
$45
20%
20%
X
No cost share
20%
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
X
$45
No cost share
Hospital
Professional
20%
$45
$45
Home health care
Rehabilitation services
Habilitation services
3
X
X
X
$250
Substance use disorder inpatient services
2
X
Emergency room services (waived if admitted)
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
1
SHOP
see fee
schedule
see fee
schedule
$300
X
DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
SHOP
SHOP
Silver
Coinsurance Plan
Silver
Copay Plan
69.36%
69.07%
N/A
N/A
$1,500
$500
$0
$1,500
$500
$0
$6,350
$6,350
2/20/2014
Actuarial Value - AV Calculator
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
Member Cost
Share
Service Type
$45
$45
Specialist visit
$65
$65
No cost share
No cost share
$45
$65
20%
$15 or less
$50
$70
20%
20%
20%
$45
$65
$250
$15 or less
$50
$70
20%
20%
20%
Preventive care/ screening/ immunization
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
Hospital stay
X
X
X
X
$250
X
Emergency medical transportation
$250
X
$250
X
Urgent care
$90
Facility fee (e.g., hospital room)
Physician/surgeon fee
20%
20%
Mental/Behavioral health outpatient services
$45
Prenatal care and preconception visits
Pregnancy
Delivery and all inpatient services
20%
$90
X
20%
X
20%
20%
20%
$45
$45
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
20%
20%
X
20%
X
20%
X
20%
Hospice service
No cost share
No cost share
Eye exam (deductible waived )
Glasses
0%
1 pair per year
0%
1 pair per year
No cost share
No cost share
20%
see fee schedule
Dental Major Services3
50%
see fee schedule
Orthodontics (medically necessary)
50%
$300
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs
X
X
$45
$45
$45
20%
Notes:
X
No cost share
20%
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
X
$45
No cost share
Hospital
Professional
20%
$45
$45
Home health care
Rehabilitation services
Habilitation services
3
X
X
X
$250
Substance use disorder inpatient services
2
X
Deductible Applies
Emergency room services (waived if admitted)
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
1
Member Cost
Share
Primary care visit to treat an injury or illness
Tests
Need
immediate
attention
Deductible
Applies
S
X
DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
SHOP
Silver
HSA Plan
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
2/20/2014
Actuarial Value - AV Calculator
71.48%
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
$1,500 integrated Med/Rx Ded
N/A
N/A
$0
$6,350
Member Cost
Share
Deductible
Applies
Primary care visit to treat an injury or illness
20%
X
Specialist visit
20%
X
Service Type
Preventive care/ screening/ immunization
No cost share
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
20%
20%
20%
20%
20%
20%
20%
20%
20%
X
X
X
X
X
X
X
X
X
Emergency room services (waived if admitted)
20%
X
Emergency medical transportation
20%
X
Urgent care
20%
X
Facility fee (e.g., hospital room)
Physician/surgeon fee
20%
20%
X
X
Mental/Behavioral health outpatient services
20%
X
20%
X
20%
X
20%
X
Tests
Need
immediate
attention
Hospital stay
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
Substance use disorder inpatient services
Prenatal care and preconception visits
Pregnancy
No cost share
20%
20%
20%
20%
20%
X
X
X
X
X
20%
X
20%
X
Hospice service
No cost share
X
Eye exam (deductible waived )
Glasses
0%
1 pair per year
Delivery and all inpatient services
Hospital
Professional
Home health care
Rehabilitation services
Habilitation services
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
No cost share
Dental Major Services3
50%
Orthodontics (medically necessary)
50%
Notes:
1
2
3
20%
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs
DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
Silver Coinsurance Plan
100%-150% FPL
Silver Coinsurance Plan
150%-200% FPL
94.38%
87.44%
$0
N/A
$0
$0
$0
$500
$50
$0
$2,250
$2,250
2/20/2014
Actuarial Value - AV Calculator
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
Member Cost Deductible
Applies
Share
Service Type
$3
$15
Specialist visit
$5
$20
No cost share
No cost share
$3
$5
10%
$3 or less
$5
$10
10%
10%
10%
$15
$20
15%
$5 or less
$15
$25
15%
15%
15%
Emergency room services (waived if admitted)
$25
$75
X
Emergency medical transportation
$25
$75
X
Urgent care
$6
$30
10%
10%
15%
15%
$3
$15
10%
15%
$3
$15
10%
15%
No cost share
No cost share
10%
10%
10%
$3
$3
15%
15%
15%
$15
$15
10%
15%
10%
15%
Hospice service
No cost share
No cost share
Eye exam (deductible waived )
Glasses
0%
1 pair per year
0%
1 pair per year
No cost share
No cost share
20%
20%
Dental Major Services3
50%
50%
Orthodontics (medically necessary)
50%
50%
Preventive care/ screening/ immunization
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
Hospital stay
Facility fee (e.g., hospital room)
Physician/surgeon fee
Mental/Behavioral health outpatient services
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
Substance use disorder inpatient services
Prenatal care and preconception visits
Pregnancy
Delivery and all inpatient services
Hospital
Professional
Home health care
Rehabilitation services
Habilitation services
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
Notes:
1
2
3
Deductible
Applies
Primary care visit to treat an injury or illness
Tests
Need
immediate
attention
Member Cost
Share
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs
X
X
X
X
X
X
X
X
X
DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
Silver Coinsurance Plan
200%-250% FPL
2/20/2014
Actuarial Value - AV Calculator
73.47%
N/A
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
Primary care visit to treat an injury or illness
$40
Specialist visit
$50
Preventive care/ screening/ immunization
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
Hospital stay
$5,200
Member Cost Deductible
Applies
Share
Service Type
No cost share
$40
$50
20%
$15 or less
$30
$50
20%
20%
20%
Tests
Need
immediate
attention
$1,500
$250
$0
$250
X
Emergency medical transportation
$250
X
Urgent care
$80
Facility fee (e.g., hospital room)
Physician/surgeon fee
20%
20%
Mental/Behavioral health outpatient services
$40
20%
Prenatal care and preconception visits
Pregnancy
Delivery and all inpatient services
20%
Hospital
Professional
20%
20%
20%
$40
$40
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
20%
20%
Hospice service
No cost share
Eye exam (deductible waived )
Glasses
0%
1 pair per
year
No cost share
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
20%
Dental Major Services3
50%
Orthodontics (medically necessary)
50%
Notes:
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs
X
X
No cost share
Home health care
Rehabilitation services
Habilitation services
3
X
$40
Substance use disorder inpatient services
2
X
X
X
Emergency room services (waived if admitted)
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
1
X
X
X
DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
Silver Copay Plan
100%-150% FPL
Silver Copay Plan
150%-200% FPL
94.42%
87.40%
$0
N/A
$0
$0
$0
$500
$50
$0
$2,250
$2,250
2/20/2014
Actuarial Value - AV Calculator
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
Member Cost Deductible Member Cost
Applies
Share
Share
Service Type
Primary care visit to treat an injury or illness
$3
$15
Specialist visit
$5
$20
No cost share
No cost share
$3
$5
$50
$3 or less
$5
$10
10%
10%
10%
$15
$20
$100
$5 or less
$15
$25
15%
15%
15%
Emergency room services (waived if admitted)
$25
$75
X
Emergency medical transportation
$25
$75
X
Urgent care
$6
$30
10%
15%
$3
$15
10%
15%
$3
$15
10%
15%
No cost share
No cost share
10%
15%
$3
$3
$3
$15
$15
$15
10%
15%
10%
15%
Hospice service
No cost share
No cost share
Eye exam (deductible waived )
Glasses
0%
1 pair per year
0%
1 pair per year
No cost share
No cost share
see fee
schedule
see fee
schedule
$300
see fee
schedule
see fee
schedule
$300
Preventive care/ screening/ immunization
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
Tests
Need
immediate
attention
Hospital stay
Facility fee (e.g., hospital room)
Physician/surgeon fee
Mental/Behavioral health outpatient services
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
Substance use disorder inpatient services
Prenatal care and preconception visits
Pregnancy
Delivery and all inpatient services
Hospital
Professional
Home health care
Rehabilitation services
Habilitation services
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
Dental Major Services3
Orthodontics (medically necessary)
Notes:
1
2
3
Deductible
Applies
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs
X
X
X
X
X
X
X
X
DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
Silver Copay Plan
200%-250% FPL
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
2/20/2014
Actuarial Value - AV Calculator
73.18%
N/A
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
$1,500
$250
$0
$5,200
Member Cost
Share
Service Type
Primary care visit to treat an injury or illness
$40
Specialist visit
$50
Preventive care/ screening/ immunization
No cost share
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
$40
$50
$250
$15 or less
$30
$50
20%
20%
20%
Tests
Need
immediate
attention
Hospital stay
$250
X
Emergency medical transportation
$250
X
Urgent care
$80
Facility fee (e.g., hospital room)
Physician/surgeon fee
20%
Mental/Behavioral health outpatient services
$40
20%
Prenatal care and preconception visits
Pregnancy
Delivery and all inpatient services
20%
Hospital
Professional
20%
X
20%
20%
Hospice service
No cost share
Eye exam (deductible waived )
Glasses
0%
1 pair per year
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
X
$40
$40
$40
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
No cost share
Dental Major Services3
Orthodontics (medically necessary)
Notes:
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs
X
No cost share
Home health care
Rehabilitation services
Habilitation services
3
X
$40
Substance use disorder inpatient services
2
X
X
X
Emergency room services (waived if admitted)
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
1
Deductible
Applies
see fee
schedule
see fee
schedule
$300
X
DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
Bronze Plan
Bronze
HSA Plan
60.87%
58.95%
2/20/2014
Actuarial Value - AV Calculator
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
Primary care visit to treat an injury or illness
$60
Specialist visit
$70
Preventive care/ screening/ immunization
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
Hospital stay
$6,350
Deductible
Applies
After 1st 3
nonpreventive
visits
X
Member Cost Deductible
Applies
Share
40%
X
40%
X
No cost share
X
X
X
X
X
X
X
X
X
40%
40%
40%
40%
40%
40%
40%
40%
40%
X
X
X
X
X
X
X
X
X
Emergency room services (waived if admitted)
$300
X
40%
X
Emergency medical transportation
$300
40%
X
Urgent care
$120
40%
X
Facility fee (e.g., hospital room)
Physician/surgeon fee
30%
30%
40%
40%
X
X
Mental/Behavioral health outpatient services
$60
X
After 1st 3
nonpreventive
visits
X
X
After 1st 3
nonpreventive
visits
40%
X
30%
X
40%
X
$60
After 1st 3
nonpreventive
visits
40%
X
30%
X
40%
X
Prenatal care and preconception visits
Pregnancy
No cost share
Hospital
Professional
No cost share
30%
30%
30%
30%
30%
X
X
X
X
X
40%
40%
40%
40%
40%
X
X
X
X
X
30%
X
40%
X
30%
X
40%
X
Hospice service
No cost share
X
No cost share
X
Eye exam (deductible waived )
Glasses
0%
1 pair per year
0%
1 pair per year
No cost share
No cost share
Delivery and all inpatient services
Home health care
Rehabilitation services
Habilitation services
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
Dental Major Services3
Orthodontics (medically necessary)
Notes:
3
$6,350
30%
30%
30%
$15 or less
$50
$75
30%
30%
30%
Substance use disorder inpatient services
2
N/A
N/A
$0
No cost share
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
1
N/A
N/A
$0
Member Cost
Share
Service Type
Tests
Need
immediate
attention
$5,000 integrated Med/Rx Ded $4,500 integrated Med/Rx
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs
see fee
schedule
see fee
schedule
$300
20%
50%
50%
DRAFT
2015 Standard Benefit Plan Designs - Sample 10.0 EHB
Changes in benefits from 2014 to 2015 are displayed in orange
Summary of Benefits and Coverage
COST SHARING AMOUNTS DESCRIBE THE ENROLLEE'S OUT OF
POCKET COSTS
Catastrophic Plan
2/20/2014
Actuarial Value - AV Calculator
60.56%
Overall deductible
Other deductibles for specific services
Medical
Brand Drugs
Dental
Out–of–pocket limit (includes $300 Pediatric Dental Out-of-pocket
limit)1
Common
Medical
Event
Visit to a
health care
provider’s
office or
clinic
$6,350 integrated Med/Rx
N/A
N/A
$0
$6,350
Member Cost
Share
Service Type
Primary care visit to treat an injury or illness
0%
Specialist visit
0%
Preventive care/ screening/ immunization
Laboratory Tests
X-rays and Diagnostic Imaging
Imaging (CT/PET scans, MRIs)
Generic drugs
Drugs to treat
Preferred brand drugs
illness or
Non-preferred brand drugs
condition
Specialty drugs2
Facility fee (e.g., ASC)
Outpatient
Physician/surgeon fees
surgery
Hospital stay
0%
0%
0%
0%
0%
0%
0%
0%
0%
X
X
X
X
X
X
X
X
X
Emergency room services (waived if admitted)
0%
X
Emergency medical transportation
0%
Urgent care
0%
Facility fee (e.g., hospital room)
Physician/surgeon fee
0%
0%
Mental/Behavioral health outpatient services
0%
X
After 1st 3
nonpreventive
visits
X
X
After 1st 3
nonpreventive
visits
Mental
health,
Mental/Behavioral health inpatient services
behavioral
health, or
substance
Substance use disorder outpatient services
abuse needs
Substance use disorder inpatient services
Prenatal care and preconception visits
Pregnancy
Hospital
Professional
0%
After 1st 3
nonpreventive
visits
0%
X
X
X
X
X
X
0%
X
0%
X
Hospice service
No cost share
X
Eye exam (deductible waived )
Glasses
0%
1 pair per year
Help
recovering or
Skilled nursing care
other special
health needs Durable medical equipment
Dental check-up - Preventive and Diagnostic Services
Child needs
dental or eye
Dental Basic Services3
care
No cost share
20%
Dental Major Services3
50%
Orthodontics (medically necessary)
50%
Notes:
3
X
No cost share
Home health care
Rehabilitation services
Habilitation services
2
0%
0%
0%
0%
0%
0%
Delivery and all inpatient services
1
After 1st 3
nonpreventive
visits
X
No cost share
Tests
Need
immediate
attention
Deductible
Applies
For members 19 years of age or older, the Pediatric Dental Out-of-pocket limit does not apply.
Oral anti-cancer drugs are capped at $200 monthly maximum.
See Dental Standard Benefit Plan Designs