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2018-2019 SUMMARY OF PLAN Summary of Benefits and Coverage: What this Plan Covers &What You Pay For Covered Services Coverage Period: 07/01/2018—06/30/2019 Jefferson County Health Plan Coverage for: Employee & Dependent(s) I Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would Ali share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium)will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-866-753-1491 or visit www.ebms.com. For general definitions of common terms, such as allowed amount, balance billing., coinsurance, copavment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-866-487-2365 to request a copy. Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible What is the overall $400 per covered person amount before this plan begins to pay. If you have other family members on deductible? $800 per family unit the plan, each family member must meet their own individual deductible until Each JANUARY a new deductible amount is required. the total amount of deductible expenses paid by all family members meets the overall family deductible. Yes. WellVia, outpatient prescription drugs, dental Are there services covered services, vision services, the first$1,000 for CPAP before you meet your machine, the first five physician office visits or outpatient This plan covers some items and services even if you haven't yet met the deductible'? visits for mental disorders/substance abuse (combined), deductible amount. But a copavment or coinsurance may apply. and certain preventive care are covered before you meet your deductible. Are there other deductibles No. You don't have to meet deductibles for specific services. for specific services? Medical: $1,500 per covered person. Prescription What is the out-of-pocket Drug Coverage: $5,450 per covered person. The out-of-pocket limit is the most you could pay in a year for covered limit for this plan? Each JANUARY a new maximum out-of-pocket amount services. is required. Deductibles, copavments, outpatient prescription drug expenses (copayments, coinsurance, maximum out-of- What is not included in pocket, and discounts or coupons), dental services, Even though you pay these expenses, they don't count toward the out—of— the out-of-pocket limit? vision services, premiums, balance-billing charges pocket limit. (unless balanced billing is prohibited), and health care this plan doesn't cover. This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network Will you pay less if you use Yes. See www.ebms.com or call 1-866-753-1491 fora provider, and you might receive a bill from a provider for the difference a network provider? list of network providers. between the provider's charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 1 of 5 Summary of Benefits and Coverage: What this Plan Covers &What You Pay For Covered Services Coverage Period: 07/01/2018—06/30/2019 Jefferson County Health Plan Coverage for: Employee & Dependent(s) I Plan Type: PPO All copavment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Medical Event Services You May Need What You Will Pay Limitations, Exceptions, &Other Important Information Primary care visit to treat an ° No charge for the first 5 visits per calendar year(combined with injury or illness 20/° coinsurance outpatient visits for mental disorders and substance abuse). Specialist visit 20% coinsurance Spinal manipulation/chiropractic care subject to$25 If you visit a health copayment/visit and limited to 35 visits/calendar year. care provider's WeIIVia Telehealth $30 consultation fee per consult; Contact WellVia toll-free at 1-877-872-0370 or through their office or clinic Consultation deductible does not apply website www.wellviasolutions.com for more information regarding a tele-medicine consultation visit via phone. Preventive care/screening/ No charge up to$500/calendar year, No charge for routine well child care, ages birth through 7 years. immunization then 20% coinsurance Diagnostic test 20% coinsurance There is no charge up to first$1,500 for diagnostic If you have a test (x-ray, blood work) colonoscopy/sigmoidoscopy; thereafter 20% coinsurance. No Imaging 20% coinsurance charge for prostate screening, mammograms, and Pap smear (CT/PET scans, MRIs) (lab services only) If you need drugs to treat your illness or Generic drugs No charge condition More Retail and mail order drugs are available up to a 90-day supply information about Name brand drugs 40% copavment per prescription. prescription drug Name brand drugs without a ° coverage is available generic equivalent 20/o copavment at www.ebms.com or call Navitus Health Limited to a 30-day supply/prescription & requires purchase Solutions at 1-866- Specialty drugs Subject to the above copavment amounts through the specialty pharmacy program. Only first fill will be 333-2757 eligible through the retail pharmacy. Facility fee (e.g., ambulatory 20% coinsurance None If you have surgery center) outpatient surgery Physician/surgeon fees 20% coinsurance None Emergency room care 20% coinsurance None If you need immediate medical Emergency medical 20% coinsurance None attention transportation Urgent care 20% coinsurance None OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 2 of 5 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2018—06/30/2019 Jefferson County Health Plan Coverage for: Employee & Dependent(s) ; Plan Type: PPO Common Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Medical Event Pre-notification of inpatient admissions is strongly Facility fee (e.g., hospital ° recommended, but not required. When inpatient services are If you have a room) 20% coinsurance provided in Billings, MT, it is required that Billings Clinic be hospital stay utilized in order for benefits to be payable. Limited to semiprivate room rate. Physician/surgeon fees 20% coinsurance None Outpatient services 20% coinsurance No charge for the first 5 visits per calendar year(combined with If you need mental physician office visits). health, behavioral Pre-notification of inpatient admissions is strongly health, or substance Inpatient services 20% coinsurance recommended, but not required. When inpatient services are abuse services provided in Billings, MT, it is required that Billings Clinic be utilized in order for benefits to be payable. Office visits 20% coinsurance Childbirth/delivery 20% coinsurance When inpatient services are provided in Billings, MT, it is If you are pregnant professional services required that Billings Clinic be utilized in order for benefits to Childbirth/delivery facility 20% coinsurance be payable. Limited to semiprivate room rate. services Home health care 20% coinsurance Pre-notification of certain services is strongly recommended, but not required. If you need help Rehabilitation services 20% coinsurance Applied Behavioral Analysis (birth through age 18) limited to recovering or have 152 visits/calendar year. Pre-notification of inpatient admission other special health is strongly recommended, but not required. When inpatient needs Habilitation services 20% coinsurance services are provided in Billings, MT, it is required that Billings Clinic be utilized in order for benefits to be payable. Skilled nursing care 20% coinsurance Limited to semiprivate room rate and 60 days/calendar year. Pre-notification of DME over$2,000 is strongly recommended, Durable medical equipment 20% coinsurance but not required. Hospice services 20% coinsurance Pre-notification of certain services is strongly recommended, but not required. Children's eye exam No charge Limited to one exam/calendar year for covered persons age 18 and under. If your child needs Ages 18 and under: coverage limited to one pair lenses/ dental or eye care Children's glasses No charge calendar year, one set frames/2 calendar years, and 12-month supply of contact lenses for covered persons. Children's dental check-up No charge Coverage limited to two routine oral exams/calendar year. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 3 of 5 Summary of Benefits and Coverage: What this Plan Covers &What You Pay For Covered Services Coverage Period: 07/01/2018—06/30/2019 Jefferson County Health Plan Coverage for: Employee & Dependent(s) I Plan Type: PPO Excluded Services &Other Covered Services: Services Your Plan Generally Does NOT Cover(Check your policy or plan document for more information and a list of any other excluded services.) • Cosmetic Surgery • Non-emergency care when traveling outside the U.S. • Routine Foot Care • Hearing Aids • Private Duty Nursing • Weight Loss Programs • Long Term Care Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) • Acupuncture • Chiropractic Care • Infertility Treatment • Bariatric Surgery • Dental Care • Routine eye care (Adult) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. For more information, contact EBMS at 1-800-777-3575 or these agencies: Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA(3272) or www.dol.gov/agencies/ebsa/or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a arievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: EBMS at 1-800-777-3575 or the DOL's Employee Benefits Security Administration at 1-866-444-EBSA (3272). Additionally, a consumer assistance program can help you file your appeal. Contact your state's program if available at: http://www.cros.gov/CCI10/Resources/Consumer-Assistance-Grants/. Does this plan provide Minimum Essential Coverage? Yes. If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Espanol): Para obtener asistencia en Espanol, Ilame al 1-866-753-1491. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-753-1491. Chinese (L ): p 'rt E1=IxTJAult, ICA till/N—i 1-866-753-1491. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-753-1491. To see examples of how this plan might cover costs for a sample medical situation, see the next section. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 4 of 5 Summary of Benefits and Coverage: What this Plan Covers &What You Pay For Covered Services Coverage Period: 07/01/2018—06/30/2019 Jefferson County Health Plan Coverage for: Employee & Dependent(s) I Plan Type: PPO About these Coverage Examples: f This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be iiiiii different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copavments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby Managing Joe's type 2 Diabetes Mia's Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up hospital delivery) controlled condition) care) ■ The plan's overall deductible $400 ■ The plan's overall deductible $400 ■ The plan's overall deductible $400 ■ Specialist coinsurance 20% ■ Primary care physician coinsurance 20% ■ Specialist coinsurance 20% ■ Hospital (facility) coinsurance 20% ■ Hospital (facility) coinsurance 20% ■ Hospital (facility) coinsurance 20% ■ Other coinsurance 20% ■ Other coinsurance 20% ■ Other coinsurance 20% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including disease Emergency room care (including medical supplies) Childbirth/Delivery Professional Services education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $400 Deductibles $400 Deductibles $400 Copayments $40 Copayments $100 Copayments $0 Coinsurance $1,100 Coinsurance $1,089 Coinsurance $326 What isn't covered What isn't covered What isn't covered Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0 The total Peg would pay is $1,560 The total Joe would pay is $1,544 The total Mia would pay is $726 The plan would be responsible for the other costs of these EXAMPLE covered services. 5 of 5