Summary of Benefits

Major Medical Coverage Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for : 
All Coverage Types | Plan Type:HDHP/PPO        

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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 by calling 1-866-667-4580.

 

 

Important Questions	Answers	Why this Matters:
What is the overall deductible?	$6,500 individual In-network/ $13,000 family in-network  $13,000 individual out-of-network/ $26,000 family out-of-network  Doesn’t apply to in-network preventive care. Co-payments and coinsurance do  not count towards the overall deductible.	You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use.The deductible is applicable to out-patient prescription drugs. 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. The deductible applies to the out-of-pocket limit.
Are there other deductibles for specific services?	No.	You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
Is there an out–of–pocket limit on my expenses?	Yes. For Network Providers $6,500 individual / $13,000 family  For out-of-network Providers $13,000 individual / $26,000 family	The 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 in the out–of–pocket limit?	Premiums, balance-billed charges,and health care this plan doesn’t cover.	Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall annual limit on what the plan pays?	No	The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a network of providers?	Yes. See www.firstchoiceselect.comorcall 1-866-667-4580 for a list of participating  providers.	If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-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 specialist?	All services, other than preventive, require Pre-Authorization from CCM. For Pre-  Authoriztion contact(228) 223-4005 or  Member Services at (866) 677-4580.	•All services, other than preventive, require pre-authorization from CCM. •Pre-Authorization contact number is (228) 223-4005
Are there services this plan doesn’t cover?	Yes.	Some of the services this plan doesn’t cover are listed on page 9. 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 participating providers by charging you lower deductibles, co-payments and co-insurance                                         amounts.

Common  Medical Event	Services You May Need	Your cost if you use an		Limitations & Exceptions
		In-network Provider	Out-of-network  Provider
If you visit a  health care provider’s  office or clinic	Primary care visit to treat an injury or illness	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Specialist visit	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Other practitioner office visit	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Preventive care/screening/immunization	$0	$0 copayment after deductible	Visit www.healthcare.gov for info on  services that are considered preventive.
If you have a test	Diagnostic test (x-ray, blood work)	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Imaging (CT/PET scans, MRIs)
If you need drugs to treat your illness or  condition	Generic drugs (Tier 1)	$0 copayment after deductible	Not Covered	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Preferred brand drugs (Tier 2)	$0 copayment after deductible
	Non-preferred brand drugs (Tier 3)	$0 copayment after deductible
	Specialty drugs	$0 copayment after deductible	Not Covered	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	$0 copayment after deductible		This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Physician/surgeon fees	$0 copayment after deductible
If you need immediate medical  attention	Emergency room services	$0 copayment after deductible
	Emergency medical transportation	$0 copayment after deductible
	Urgent care	$0 copayment after deductible
If you have a hospital stay	Facility fee (e.g., hospital room)	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Physician/surgeon fee	$0 copayment after deductible	$0 copayment after deductible
If you have mental health, behavioral  health,  or substance abuse needs	Mental/Behavioral health outpatient services	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Mental/Behavioral health inpatient services	$0 copayment after deductible	$0 copayment after deductible
	Substance use disorder outpatient services	$0 copayment after deductible	$0 copayment after deductible
	Substance use disorder inpatient services	$0 copayment after deductible	$0 copayment after deductible
If you are pregnant	Prenatal and postnatal care	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Delivery and all inpatient services	$0 copayment after deductible	$0 copayment after deductible
If you need help recovering or have  other  special health needs	Home health care	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Rehabilitation services	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Habilitation services	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Skilled nursing care	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Durable medical equipment	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
	Hospice service	$0 copayment after deductible	$0 copayment after deductible	This service requires pre-authorization  from Cornerstone Care Management  (CCM) – Contact Member Services            (228) 223-4005
If your child needs dental or eye care	Eye exam	$0 after deductible	Not Covered	-Refractive eye exam, 1 every other year
	Glasses	Not Covered	Not Covered
	Dental check-up	Not Covered	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	Long-term care	Routine foot care except for members with  Diabetes.
Cosmetic Surgery	All care when traveling outside the U.S.	Services beyond any benefit or monetary limit  listed in this Summary of Benefits and Coverage.
Early Intervention services for children age 3      and older.	Private-duty nursing	Weight loss programs, except as described in the  Evidence of Coverage.
Hearing Aids

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

Your Rights to Continue Coverage: 

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.  
For more information on your rights to continue coverage, contact the plan at 1-866-677-4580. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.  

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: Cornerstone Care Management at 866-677-4580 or by mail at:  
CCM, LLC      
P.O. Box 2939
Gulfport, MS 39505 


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 it provides.  

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Examples of how this plan might cover costs for a sample medical situation.

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 financial protection a sample patient might get if they are covered under different plans.		Having a baby (normal delivery)		Managing type 2 diabetes (routine maintenance of   a well-controlled condition)
		• Amount owed to providers: $7,540		• Amount owed to providers: $5,800
		• Plan pays $4,180		• Plan pays $2,780
		• Patient pays $3,360		• Patient pays $3,020
		Sample care costs:		Sample care costs:
This is not a cost estimator. Don’t use these exam ples 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.		Hospital charges (mother)	$2,700	Prescriptions	$2,900
		Routine obstetric care	$2,100	Medical Equipment and Supplies	$1,300
		Hospital charges (baby)	$900	Office Visits and Procedures	$700
		Anesthesia	$900	Education	$300
		Laboratory tests	$500	Laboratory tests	$400
		Prescriptions	$200	Vaccines, other preventive	$100
		Radiology	$200
		Vaccines, other preventive	$40
		Total	$7,540	Total	$5,800
		Patient pays:		Patient pays:
		Deductibles	$6,500	Deductibles	$5,800
		Co-pays	$0	Co-pays	$0
		Co-insurance	$0	Co-insurance	$0
		Limits or exclusions	$0	Limits or exclusions	$0
		Total	$6,500	Total	$5,800

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.
• 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 in-network providers.  If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show? 

For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, and co-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 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.

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 co-payments, deductibles, and co-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 out-of-pocket expenses.



If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-866-667-4580.