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Coventry Health & Life Insurance Company: Silver $15 Copay CSR 87
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period : 01/01/2015 - 12/31/2015
Coverage for: EE, EE/Sp., EE/1Ch.,
EE/Children, Fam.
| Plan Type: PPO
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 document at http://coventryone.com/individual-health-insurance/missouri/education-andresources/document-library/index.htm or by calling 1-855-449-2889.
Important Questions
What is the overall
deductible?
Answers
In Network: $1,250 person $2,500 family
Doesn't apply to: PCP visits,
Convenience/Urgent care, Generic drugs,
ER visits 1-2, Specialist visits, Preventive
care
Why This Matters:
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 deductible starts over (usually, but not always, January 1st). See the chart starting
on page 2 for how much you pay for covered services after you meet the deductible.
Out of Network: $7,500 person $15,000
family Doesn't apply to: Emergency room
visits 1-2
Are there other deductibles Yes, Out of Network: $1,000.
You must pay all of the costs for these services up to the specific deductible amount
for specific services?
before this plan begins to pay for these services.
Is there an out-of-pocket
In Network: Yes $2,050 person Yes
The out-of-pocket limit is the most you could pay during a coverage period (usually
limit on my expenses?
$4,100 family
one year) for your share of the cost of covered services. This limit helps you plan for
Out of Network: Yes $19,800 person Yes health care expenses.
$39,600 family
What is not included in the Premiums, balance-billed charges, health Even though you pay these expenses, they don't count toward the out-of-pocket
out-of-pocket limit?
care this plan does not cover, penalties
limit.
Is there an overall annual
No
The chart starting on page 2 describes any limits on what the plan will pay for specific
limit on what the plan pays?
covered services, such as office visits.
Does this plan use a
Yes
If you use an in-network doctor or other health care provider, this plan will pay some
network of providers?
Phone: 1-855-449-2889; Web:
or all of the costs of covered services. Be aware, your in-network doctor or hospital
http://moslcovoneppo.coventryproviders. may use an out-of-network provider for some services. Plans use the term incom
network, preferred, or participating for providers in 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 No
You can see the specialist you choose without permission from this plan.
specialist?
SNO: 1253710 SBC Name: 023_48118 023_17219
Questions: Call 1-855-449-2889 or visit us at http://coventryone.com/individual-health-insurance/missouri/education-and-resources/documentlibrary/index.htm. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at
http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
Page 1 of 8
Important Questions
Are there services this plan
doesn't cover?
Answers
Yes
Why This Matters:
Some of the services this plan doesn’t cover are listed on page 5. See your policy or
plan document for additional information about excluded services.
•
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
•
Co-insurance is 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's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you
haven't met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
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 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 In Network providers by charging you lower deductibles, copayments and coinsurance amounts.
•
•
Common Medical Event
Services You May Need
Primary care visit to treat an
injury or illness
Specialist visit
Other practitioner office visit
If you visit a health care
provider's office or clinic
If you have a test
Preventive care/
Screening/Immunization
Diagnostic test (x-ray, blood
work)
Imaging (CT/PET scans,
MRIs)
Your cost if you use a
In Network
Out of Network
Provider
Provider
$10 co-payment (co50% co-insurance (copay)/visit
ins)
$40 co-pay/visit
50% co-ins
Limitations & Exceptions
----------none-------------------none----------
Nurse practitioner,
50% co-ins
physician assistant: $10
copay/visit (PCP)/ $40
co-pay/visit (Specialist).
Chiropractor 10% coins/visit
No Charge
50% co-ins
Limited to 26 visits per calendar year.
No Charge x-ray
No Charge lab
10% co-ins
----------none----------
50% co-ins x-ray
50% co-ins lab
$250 co-pay/service +
50% co-ins
----------none----------
Pre-auth required. $400 per occurrence for
failure to precertify OON services.
SNO: 1253710 SBC Name: 023_48118 023_17219
Questions: Call 1-855-449-2889 or visit us at http://coventryone.com/individual-health-insurance/missouri/education-and-resources/documentlibrary/index.htm. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at
http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
Page 2 of 8
Common Medical Event
Services You May Need
Generic drugs
If you need drugs to treat
your illness or condition.
More information about
prescription drug coverage
is available at
http://coventryone.com/i Preferred brand drugs
ndividual-healthinsurance/missouri/educa
tion-andresources/documentNon-preferred brand drugs
library/index.htm.
Specialty drugs
If you have outpatient
surgery
Facility fee (e.g., ambulatory
surgery center)
Physician/surgeon fees
Emergency room services
If you need immediate
medical attention
If you have a hospital stay
Emergency medical
transportation
Urgent care
Facility fee (e.g., hospital
room)
Your cost if you use a
In Network
Out of Network
Provider
Provider
Tier One A: $3 co50% co-ins
pay/fill preferred retail,
$10 co-pay/fill nonpreferred retail, $6 copay/fill mail; Tier One:
$5 co-pay/fill preferred
retail, $10 co-pay/fill
non-preferred retail, $10
co-pay/fill mail
$30 co-pay/fill preferred
retail, $40 co-pay/fill
non-preferred retail, $75
co-pay/fill mail
$55 co-pay/fill preferred
retail, $65 co-pay/fill
non-preferred retail,
$165 co-pay/fill mail
30% co-ins preferred
retail, 40% co-ins nonpreferred retail
10% co-ins
Limitations & Exceptions
Limited to 31 day supply retail, 32-90 day
supply mail order. May require pre-auth.
50% co-ins
Limited to 31 day supply retail, 32-90 day
supply mail order. May require pre-auth.
50% co-ins
Limited to 31 day supply retail, 32-90 day
supply mail order. May require pre-auth.
Not covered
Limited: 31 day supply retail. May require
preauth for coverage.
10% co-ins
$250 co-pay/service +
50% co-ins
50% co-ins
First 2 visits: $100 copay/visit
10% co-ins
First 2 visits: $100 copay/visit
10% co-ins
May require prior auth. $400 per occurrence
for failure to precertify OON services.
May require prior auth. $400 per occurrence
for failure to precertify OON services.
Co-pay waived if patient is admitted. After 2
visits: Deductible + $100 co-pay/visit.
----------none----------
$75 co-pay/visit
50% co-ins
----------none----------
10% co-ins
$1000 co-pay/admit +
50% co-ins
Prior auth required. $400 per occurrence for
failure to precertify OON services.
SNO: 1253710 SBC Name: 023_48118 023_17219
Questions: Call 1-855-449-2889 or visit us at http://coventryone.com/individual-health-insurance/missouri/education-and-resources/documentlibrary/index.htm. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at
http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
Page 3 of 8
Common Medical Event
If you have a hospital stay
Services You May Need
Physician/surgeon fee
Mental/Behavioral health
outpatient services
Mental/Behavioral health
If you have mental health, inpatient services
behavioral health, or
substance abuse needs
Substance use disorder
outpatient services
Substance use disorder
inpatient services
Prenatal and postnatal care
If you are pregnant
If you need help
recovering or have other
special health needs
Delivery and all inpatient
services
Your cost if you use a
In Network
Out of Network
Provider
Provider
10% co-ins
50% co-ins
Limitations & Exceptions
Prior auth required. $400 per occurrence for
failure to precertify OON services.
----------none----------
$40 co-pay/visit
50% co-ins
10% co-ins
$1,000 co-pay/admit + Prior auth required. $400 per occurrence for
50% co-ins
failure to precertify OON services. Call
MHNet at 1-877-227-3520.
50% co-ins
----------none----------
$40 co-pay/visit
10% co-ins
Prenatal: No Charge,
Postnatal & Delivery:
$250 co-pay/pregnancy
10% co-ins
Home health care
10% co-ins
Rehabilitation services
Inpatient 10% co-ins
Outpatient 10% co-ins
Habilitation services
10% co-ins
$1,000 co-pay/admit + Prior auth required. $400 per occurrence for
50% co-ins
failure to precertify OON services. Call
MHNet at 1-877-227-3520.
50% co-ins
----------none----------
$1,000 co-pay/admit + Stays beyond 48/96 hours for vaginal
50% co-ins
delivery/cesarean section require prior auth.
$400 per occurrence for failure to precertify
OON services.
50% co-ins
Home health limited to 90 visits per calendar
year. Private duty nursing limited to 140 visits
per benefit period. Prior auth required. $400
per occurrence for failure to precertify OON
services.
Inpatient $1,000 coLimited to 60 days per calendar year for
pay/admit + 50% co-ins Inpatient Physical Medicine and Rehabilitation
Outpatient 50% co-ins Therapy Services.
50% co-ins
Non-autism therapies limited to 20 visits per
calendar year PT/OT combined. Limits are
shared between rehabilitation and non-autism
habilitation services. PT: $10 co-pay/visit.
SNO: 1253710 SBC Name: 023_48118 023_17219
Questions: Call 1-855-449-2889 or visit us at http://coventryone.com/individual-health-insurance/missouri/education-and-resources/documentlibrary/index.htm. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at
http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
Page 4 of 8
Common Medical Event
If you need help
recovering or have other
special health needs
If your child needs dental
or eye care
Skilled nursing care
Your cost if you use a
In Network
Out of Network
Provider
Provider
10% co-ins
50% co-ins
Durable medical equipment
10% co-ins
50% co-ins
Hospice Service
10% co-ins
50% co-ins
Eye exam
No Charge
50% co-ins
Glasses
No Charge
50% co-ins
Dental check-up
Not Covered
Not Covered
Services You May Need
Limitations & Exceptions
Limited to 90 days per calendar year. Prior
auth required. $400 per occurrence for failure
to precertify OON services.
Prior auth required for medical equipment
purchase over $500 and all rental equipment
(oxygen not included). $400 per occurrence for
failure to precertify OON services.
Prior auth required. $400 per occurrence for
failure to precertify OON services.
Limited to 1 exam per calendar year.
Limited to 1 set of frames and 1 set of contact
lenses or eyeglass lenses per calendar year.
Not Covered
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.)
• Acupuncture
• Dental Care (Adult)
• Non-Emergency Care when Traveling
Outside the U.S.
• Bariatric Surgery
• Hearing Aids
• Routine Eye Care (Adult)
• Child/Dental Check-up
• Infertility Treatment
• Routine Foot Care
• Cosmetic Surgery
• Long-Term Care
• 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.)
• Chiropractic Care
• Private-Duty Nursing
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 premium. There are exceptions,
however, such as if:
You commit fraud
The insurer stops offering services in the State
You move outside the coverage area
SNO: 1253710 SBC Name: 023_48118 023_17219
Questions: Call 1-855-449-2889 or visit us at http://coventryone.com/individual-health-insurance/missouri/education-and-resources/documentlibrary/index.htm. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at
http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
•
•
•
Page 5 of 8
For more information on your rights to continue coverage, contact the insurer at 1-855-449-2889. You may also contact your state insurance department at
Missouri Department of Insurance, Fin. Institutions & Prof. Registration; P.O. Box 690 Jefferson City, MO 76102-0690 573-751-4126 E-mail:
[email protected].
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 grievance. For questions
about your rights, this notice, or assistance, you can contact:
Missouri Department of Insurance, Fin. Institutions & Prof. Registration; P.O. Box 690 Jefferson City, MO 76102-0690 573-751-4126 E-mail:
[email protected]
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 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 standard for the benefits is provides.
Language Access Services:
Spanish (Espanol): Para obtener asistencia en Espanol, llame al 1-855-449-2889.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-449-2889.
Chinese ĩᷕ㔯ĪĻơġ⤪㝄暨天ᷕ㔯䘬ⷖ≑炻実㊐ㇻ征᷒⎟䞩ġ1-855-449-2889.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-449-2889.
––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––
SNO: 1253710 SBC Name: 023_48118 023_17219
Questions: Call 1-855-449-2889 or visit us at http://coventryone.com/individual-health-insurance/missouri/education-and-resources/documentlibrary/index.htm. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at
http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
Page 6 of 8
Having a baby
About these Coverage
Examples:
These examples show how this plan
might cover medical care in given
situations. Use these examples to see, in
general, how much insurance
protection you might get from different
plans.
This is not a cost
estimator.
Don’t use these examples to
estimate your actual costs under
this plan. The actual care you
receive will be different from these
examples, and the cost of that care
will also be different.
See the next page for important
information about these examples.
Managing type 2 diabetes
(normal delivery)
Amount owed to providers:
Plan pays:
You pay:
(routine maintenance of
a well-controlled condition)
$7,540
$5,440
$2,100
Sample care costs:
Hospital charges (mother)
$2,700
Routine Obstetric Care
$2,100
Hospital Charges (baby)
$900
Anesthesia
$900
Laboratory tests
$500
Prescriptions
$200
Radiology
$200
Vaccines, other preventive
Total
$40
$7,540
You pay:
Deductibles
$1,300
Co-pays
$300
Coinsurance
$300
Limits or exclusions
$200
Total
Amount owed to providers:
Plan pays:
$3,620
You pay:
$1,780
$5,400
Sample care costs:
Prescriptions
Medical equipment and supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccine, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
You pay:
Deductibles
Co-pays
Coinsurance
Limits or exclusions
Total
$300
$1,400
$0
$80
$1,780
$2,100
SNO: 1253710 SBC Name: 023_48118 023_17219
Questions: Call 1-855-449-2889 or visit us at http://coventryone.com/individual-health-insurance/missouri/education-and-resources/documentlibrary/index.htm. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at
http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
Page 7 of 8
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and aren’t
specific to a particular geographic area or
health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance 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 Coverage Example predict
my own care needs?
No. Treatments shown are just examples.
The care you would receive for this condition
could be different based on your doctor’s advice,
your age, how serious your condition is, and
many other factors.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only on
treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
Does the Coverage Example predict
my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They are
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 health plan allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary
of Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the
premium you pay. Generally, the lower
your premium , the more you’ll pay in
out-of-pocket costs, such as
copayments, deductibles, and
coinsurance . 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 out-of-pocket expenses.
SNO: 1253710 SBC Name: 023_48118 023_17219
Questions: Call 1-855-449-2889 or visit us at http://coventryone.com/individual-health-insurance/missouri/education-and-resources/documentlibrary/index.htm. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at
http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
Page 8 of 8