Kingsville Independent School District: Plan I coverage Period: 10/01/2015 – 09/30/2016 Summary of Benefits and Coverage

Kingsville Independent School District: Plan I Coverage Period: 10/01/2015 – 09/30/2016

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Eligible Dependents | Plan Type: PPO

80	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 www.hfbenefits.com or by calling 1-866-301-9428.

Important Questions	Answers	Why this Matters:
What is the overall deductible?	$1,000 person / (3) per family Spohn Network $1,250 person / (3) per family First Health Network $2,000 person /(3) per family Non-PPO Provider	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 on page 2 for how much you pay for covered services after you meet the deductible. Doesn’t apply to copays or services provided at no cost share. If First Health provider is seen inside the Spohn service area, Non-PPO benefits apply.
Are there other deductibles for specific services?	No. There are no other specific deductibles.	You don’t have to meet deductibles for specific services, but see the chart on page 2 for other cost for services the plan covers. Inpatient Services must be pre-certified with HMS at 1-800-625-6834 to avoid a $250 penalty.
Is there an out–of–pocket limit on my expenses?	$6,600 person / $13,200 family Spohn Network $6,600 person / $13,200 family First Health Network $25,000 person / $75,000 family Non-PPO Provider	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. PPO OOP includes the deductibles and Medical & Rx copays. The Out-of-Pocket Maximum is combined for Spohn, First Health and Out-of-Network Providers. If a Covered Person satisfies the Spohn or First Health out of pocket then later that same plan year uses an Out-of-Network provider, the out-of-Network must now be satisfied, however, the Spohn or First Health out of pocket that was already satisfied will apply towards satisfaction of the Out-of-Network.
What is not included in the out–of–pocket limit?	Premiums, balance-billed charges, benefits paid at no cost share, penalties, 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.	Sleep Studies limited to $5,000 Lifetime Maximum. Payment for Renal Dialysis will not exceed 200% of Medicare allowable The chart 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, For Spohn Network visit www.christusspohnhealthnetwork.org or call 1-800-419-3461. FirstHealth Network visit www.firsthealth.com or call 1-800-226-5116.	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 on page 2 for how this plan pays different kinds of providers.
Do I need a referral to see a specialist?	No. You don’t need a referral to see a specialist.	You can see the specialist you choose without permission from this plan.
Are there services this plan doesn’t cover?	Yes.	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.

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance 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 coinsurance 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, copayments and coinsurance amounts.

Common Medical Event	Services You May Need	Your Cost If You Use a Spohn Provider	Your Cost If You Use a First Health Provider	Your Cost If You Use a Non-PPO Provider	Limitations & Exceptions
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness	$30 copay	$30 copay	50% coinsurance	Charges (including associated lab and x-ray service performed in the physician’s office and billed by the physician’s office) are paid at 100%, after the copay (for Spohn and First Health Network only), up to $100 per visit. Charges exceeding $100 will be subject to the deductible and coinsurance. Non-PPO Providers are deductible and coinsurance only.
	Specialist visit	$30 copay	$30 copay	50% coinsurance
	Other practitioner office visit	20% coinsurance (Chiropractic care)	30% coinsurance (Chiropractic care)	50% coinsurance (Chiropractic care)	Chiropractic care limited to $300 per calendar year
	Preventive care/screening /immunization	No charge	No charge	50% coinsurance	Network Benefits for preventive care that are payable at 100% of Eligible Expenses (without application of any Copayment, Coinsurance, or deductible) and apply to the following: Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention
If you have a test	Diagnostic test (x-ray, blood work)	20% coinsurance	30% coinsurance	50% coinsurance	Freestanding lab services.
	Imaging (CT/PET scans, MRIs)	20% coinsurance	30% coinsurance	50% coinsurance	Freestanding lab services.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.hfbenefits.com	Generic drugs	$5 copay/prescription (retail ) $15 copay /maintenance generic prescription		N/A	The Plan will pay the cost of a generic equivalent to the prescribed medication when filled at HEB Rxtra Advantage. If a brand is dispensed, charges are paid under the Medical Plan at 80%, subject to the Plan Year Deductible. (member will have to pay for prescription up front, then submit a claim for reimbursement) Generic Oral Contraceptives paid at 100% (No Charge) Compound Drugs limited to $300 Maximum For Diabetic Supplies call MedWise at 1-800-596-4465 or visit www.medwise.us
	Preferred brand drugs	20% coinsurance		N/A
	Non-preferred brand drugs	20% coinsurance		N/A
	Specialty drugs	20% coinsurance		N/A
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	20% coinsurance	30% coinsurance	50% coinsurance	–––––––––––none–––––––––––
	Physician/surgeon fees	20% coinsurance	30% coinsurance	50% coinsurance	–––––––––––none–––––––––––
If you need immediate medical attention	Emergency room services	$100 copay, then deductible & 20% coinsurance			–––––––––––none–––––––––––
	Emergency medical transportation	20% coinsurance	30% coinsurance	50% coinsurance	–––––––––––none–––––––––––
	Urgent care	20% coinsurance	30% coinsurance	50% coinsurance	–––––––––––none–––––––––––
If you have a hospital stay	Facility fee (e.g., hospital room)	20% coinsurance	30% coinsurance	50% coinsurance	Inpatient Services must be pre-certified with HMS at 1-800-625-6834 to avoid a $250 penalty. Pre-admission testing paid at 100% (No Charge) Second or third Surgical opinions paid at 100% (No Charge)
	Physician/surgeon fee	20% coinsurance	30% coinsurance	50% coinsurance	–––––––––––none–––––––––––
If you have mental health, behavioral health, or substance abuse needs	Mental/Behavioral health outpatient services	$30 copay	$30 copay	50% coinsurance	Physician office visit for lab services.
	Mental/Behavioral health inpatient services	20% coinsurance	30% coinsurance	50% coinsurance	Services must be pre-certified with HMS at 1-800-625-6834 to avoid a $250 penalty.
	Substance use disorder outpatient services	$30 copay	$30 copay	50% coinsurance	See Physician office visit for lab services.
	Substance use disorder inpatient services	20% coinsurance	30% coinsurance	50% coinsurance	Services must be pre-certified with HMS at 1-800-625-6834 to avoid a $250 penalty.
If you are pregnant	Prenatal and postnatal care	20% coinsurance	30% coinsurance	50% coinsurance	Services must be pre-certified during the first trimester of pregnancy with HMS at 1-800-625-6834.
	Delivery and all inpatient services	20% coinsurance	30% coinsurance	50% coinsurance	Services must be pre-certified with HMS at 1-800-625-6834 for vaginal deliveries requiring more than a 48 hour stay and for cesarean section deliveries requiring more than a 96 hour stay.
If you need help recovering or have other special health needs	Home health care	20% coinsurance	30% coinsurance	50% coinsurance	–––––––––––none–––––––––––
	Rehabilitation services	20% coinsurance	30% coinsurance	50% coinsurance	Occupational and speech therapy require prior authorization for additional visits over the 18^th visit limit.
	Habilitation services	20% coinsurance	30% coinsurance	50% coinsurance	–––––––––––none–––––––––––
	Skilled nursing care	20% coinsurance	30% coinsurance	50% coinsurance	–––––––––––none–––––––––––
	Durable medical equipment	20% coinsurance	30% coinsurance	50% coinsurance	–––––––––––none–––––––––––
	Hospice service	20% coinsurance	30% coinsurance	50% coinsurance	–––––––––––none–––––––––––
If your child needs dental or eye care	Eye exam	No Charge	Not Covered	Not Covered	Up to age 5 and as defined under the preventive benefits.
	Glasses	Not Covered	Not Covered	Not Covered	Not Covered
	Dental check-up	No Charge	Not Covered	Not Covered	Oral exam as defined under the preventive benefits.

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 Bariatric surgery Cosmetic surgery (except for injury or birth defect & within 12 months	Dental care (Adult) Hearing aids Infertility treatment Long-term care	Non-emergency care when traveling outside the U.S. Routine eye care (Adult) Routine foot 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 ($300 CYM)	Private-duty nursing ($25,000 LTM)

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 1-361-592-3387. 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: HealthFirst in writing at P.O. Box 130187, Tyler, Texas 75713 or by calling 1-866-301-9428.

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.

Language Access Services:

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[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-301-9428.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

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)





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.

 Amount owed to providers: $7,540

 Plan pays $5,130

 Patient pays $2,410

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	$40
Total	$7,540

Patient pays:

Deductibles	$1,000
Copays	$10
Coinsurance	$1,250
Limits or exclusions	$150
Total	$2,410

Managing type 2 diabetes
(routine maintenance of

a well-controlled condition)

 Amount owed to providers: $5,400

 Plan pays $3,710

 Patient pays $1,690

Sample 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

Patient pays:

Deductibles	$1,000
Copays	$390
Coinsurance	$220
Limits or exclusions	$80
Total	$1,690

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, 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.

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.

Q
of
uestions: Call 1-866-301-9428 or visit us at www.hfbenefits.com
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary

at www.hfbenefits.com or call 1-866-301-9428 to request a copy.