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RCSB%20SBC%20June%201%202021

../RCSB%20SBC%20June%201%202021.pdf

Russell_County

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2021 – 12/31/2021 Russell County School Board Health Benefit Plan Coverage for: All Types | 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 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, contact Russell County School Board at 276-889-6500. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.mcoa.com or call 1-800-922-4966 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

Network providers:$7,350 individual / $14,700 family. Non-network providers $75,000 individual / $150,000 family.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Preventive care services are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

For network providers $7,350 individual / $14,700 family

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Cost containment penalties, Copayments for certain services, premiums, balance-billing 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.

Will you pay less if you use a network provider?

Yes. See www.mycigna.com for a list of network providers.

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 provider, and you might receive a bill from a provider for the difference 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 see a specialist? No. You can see the specialist you chose without a referral.

Russell County School Board Health Benefit Plan

Coverage Period: 01/01/2021 - 12/31/2021 Coverage for: All Types | Plan Type: PPO

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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

share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, contact Russell County School Board at }-889-6500. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined

terms see the Glossary. You can view the Glossary at www.mcoa.com or call 1-800-922-4966 to request a copy.

Important Questions | Answers | Why This Matters:

What is the overall deductible?

Are there services covered before you meet your deductible?

Network providers:$7,350 individual / $14,700 family.

Non-network providers $75,000 individual / $150,000 family.

Yes. Preventive care services are covered before you meet your deductible

This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible, See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

What is the out-of-pocket limit for this plan?

What is not included in the out-of-pocket limit?

Will you pay less if you

use a network provider?

Do you need a referral to see a specialist?

For network providers $7,350 individual / $14,700 family

Cost containment penalties, Copayments for certain services,

premiums, balance-billing charges, and health care this plan doesn't cover.

Yes. See www.mycigna.com for a lst of network providers,

No.

You don't have to meet deductibles for specific services.

Even though you pay these expenses, they don't count toward the out-of-pocket limit

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 provider, and you might receive a bill from a provider for the difference 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.

You can see the specialist you chose without a referral.

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common
Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness $10 copay/office visit 80% coinsurance In network deductible waived.

Specialist visit $20 copay/visit 80% coinsurance In network deductible waived.

Preventive care/screening/ immunization No charge Not Covered

You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work) 50% coinsurance 80% coinsurance Coinsurance waived on for all Labcard

participating providers. Imaging (CT/PET scans, MRIs) 50% coinsurance 80% coinsurance

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.magellanrx.com

Generic drugs (Tier 1) $5 copay/prescription (retail) $12.50 copay / prescription (mail order)

Not Covered

Tier 1, 2 and 3 covers up to a 30-day supply (retail subscription); 31-90 day supply (mail order prescription).

Preferred brand drugs (Tier 2) $30 copay/prescription (retail) $75 copay / prescription (mail order)

Not Covered

Non-preferred brand drugs (Tier 3)

The greater of $50 or 20% copay (up to $200) /prescription (retail) The greater of $125 or 20% copay (up to $400) /prescription (mail order)

Not Covered

Specialty drugs (Tier 4) The greater of $85 or 20% copay (up to $300) /prescription (retail). supply (mail order)

Not Covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 50% coinsurance 80% coinsurance None

Physician/surgeon fees 50% coinsurance 80% coinsurance Applies when performed in other than a physician’s office.

If you need immediate medical attention

Emergency room care 50% coinsurance 50% coinsurance None Emergency medical 50% coinsurance 80% coinsurance

Common Medical Event

Services You May Need

Network Provider

Out-of-Network Provider

Limitations, Exceptions, & Other Important

(You will pay the least) | (You will pay the most) [after Primary care vsitto treat a7 §19 copaylofice visit 80% coinsurance In network deductible waived. injury orilness ‘Ifyou visitahealth Specialist visit | $20 copayhisit 80% coinsurance | In network deductible waived. care provider's office You may have to pay for services that aren't or clinic Preventive care/screening/ preventive. Ask your provider if the services immunization hoeizE2 Rene) you need are preventive, Then check what your plan will pay for. iors) uggs test ray lead | 50% coinsurance 80% coinsurance Coinsuranoe waived on fr all Laboard Imaging (CTIPET scans, MRIs) _ 50% coinsurance 80% coinsurance | Parlcipating providers, $5 copay/prescription Generic drugs (Tier 1) (retail) $12.50 copay / Not Covered prescription (mail order) $30 copaylprescription Preferred brand drugs (Tier 2) (etal) $75 copay / Not Covered fied pee aes to prescription (mail order) GENT ber The greater of $50 or Tier 1, 2 and 3 covers up to a 30-day supply More information about 20% copay (up to $200) (retall subscription); 31-90 day supply (mail tie Non-preferred brand drugs prescription (retail) The order prescription). prescription drug P verre tos or nome | Not Covered coverages available at (Ter 3) poate CESS Ieee prescription (mail order) The greater of $85 or Specialty drugs (Tier 4) ee el Not Covered supply (mail order) Facilly fee (e.g. ambulatory en - TTT surno'y concn 50% coinsurance 80% coinsurance None surgery Physician/surgeon fees 50% coinsurance 80% coinsurance Applies when performed in other than a

physician's office,

If you need immediate medical attention

Emergency room care

50% coinsurance

Emergency medical

50% coinsurance

80% coinsurance

None

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Common
Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

transportation Urgent care $25 copay/visit 80% coinsurance

If you have a hospital stay

Facility fee (e.g., hospital room) 50% coinsurance 80% coinsurance Preauthorization is required. If you don't get preauthorization, benefits could be reduced on the total cost of the service.

Physician/surgeon fees 50% coinsurance 80% coinsurance None. If you need mental health, behavioral health, or substance abuse services

Outpatient services $20 copay/office visit 80% coinsurance Outpatient -In network deductible waived. Preauthorization is required for inpatient stays. If you don't get preauthorization, benefits could be reduced on the total cost of the service. Inpatient services 50% coinsurance 80% coinsurance

If you are pregnant

Office visits $20 copay/visit 80% coinsurance

Office visits – In network deductible waived Childbirth/delivery professional services 50% coinsurance 80% coinsurance

Childbirth/delivery facility services 50% coinsurance 80% coinsurance

If you need help recovering or have other special health needs

Home health care 50% coinsurance 80% coinsurance Limited to 30 visits per Calendar Year. In and out of network combined.

Rehabilitation services 50% coinsurance 80% coinsurance Limited to 60 visits per Calendar Year combined for occupational, speech, cardiac, pulmonary and physical therapies. In and out of network combined

Habilitation services 50% coinsurance 80% coinsurance

Skilled nursing care 50% coinsurance 80% coinsurance Limited to 60 days per Calendar Year. In and out of network combined.

Durable medical equipment 50% coinsurance 80% coinsurance None Hospice services 50% coinsurance 80% coinsurance None

If your child needs dental or eye care

Children’s eye exam $15 copay/visit Not covered None Children’s glasses Not Covered Not covered None Children’s dental check-up Not Covered Not covered None

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Importa Information

transportation

Urgent care $25 copay/visit 80% coinsurance Preauthorization is required. If you don't get Ifyou have ahospital Facility fee (e.g., hospital room) | 50% coinsurance 80% coinsurance reauthorization, benefits could be reduced on stay the total cost of the service. | Physician/surgeon fees | 50% coinsurance 80% coinsurance | None. Ifyou need mental a a A q Outpatient -In network deductible waived. health, behavioral | °u"Patient services $20 conayfofice visit | 80% coinsurance Preauthorization is required for inpatient stays. health, or substance 7 a Sy If you don't get preauthorization, benefits could abuse services Inpatient services 50's go sautenon BOM colnsurncse be reduced on the total cost of the service. Office visits $20 copaylisit 80% coinsurance Childbirth/delivery professional 1, Ifyou are pregnant —_ services 50% coinsurance 30% coinsurance Office visits - In network deductible waived Childbirth/delivery facility z - Pariceel 50% coinsurance 80% coinsurance . 10), rf Limited to 30 visits per Calendar Year. In and Home health care 50% coinsurance 80% coinsurance out of network combined. Rehabilitation services ‘50% coinsurance 80% coinsurance Limited to 60 visits per Calendar Year Ifyou need help ‘combined for occupational, speech, cardiac, recovering orhave Habilitation services 50% coinsurance 80% coinsurance pulmonary and physical therapies. In and out other special health of network combined needs F 2 e Limited to 60 days per Calendar Year. In and Skilled nursing care 50% coinsurance 80% coinsurance aiitcrnetncrtcombineds Durable medical equipment —_| 50% coinsurance 80% coinsurance None Hospice services ‘50% coinsurance 80% coinsurance None | , Children’s eye exam | $15 copayivisit Not covered | None Pectorayessee Chin's glasses | Not Covered Not covered | None I Children's dental check-up ___ Not Covered Not covered | None

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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.) • Acupuncture
• Cosmetic Surgery
• Dental Care • Infertility Treatment

• Long Term Care • Hearing Aids
• Non-emergency care when traveling outside the U.S.

• Routine Foot Care
• Weight Loss Programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Bariatric Surgery
• Chiropractic Care • Private Duty Nursing 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. The contact information for those agencies is Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA(3272) or www.dol.gov/ebsa/healthreform. 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 grievance 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 90 Degree Benefits Inc., at 1-800-922-4966 or contact the plan at 276-889-6500. You may also contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Additional help may also be found in your state by visiting: www.dol.gov/ebsa/healthreform and http://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants

Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. 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 (Español): Para obtener asistencia en Español, llame al 1-800-922-4966. [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-922-4966.
[Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-922-4966. [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-922-4966

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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 « Dental Care

Infertility Treatment

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA(3272) or www.dol.gov/ebsa/healthreform. 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.qov 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 ctievance 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 90 Degree Benefits Inc., at 1-800-922-4966 or contact the plan at 276-889-8500. You may also contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol,govlebsalhealthreform, Additional help may also be found in your state by visiting: www.dol.govlebsa/healthreform and http:/iwww.cms.gov/CClIO/Resources/Consumer-Assistance-Grants

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 (Espafiol): Para obtener asistencia en Espafiol, lame al 1-800-922-4966. [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-922-4966. [Chinese ("1 3¢): AU RARBEH SCHOMED), WARITIR- S73 1-800-922-4066.

[Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiligo holne' 1-800-922-4966 ——__—_—————10 see examples of how this plan might cover costs for a sample medical situation, see the next section.

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The plan would be responsible for the other costs of these EXAMPLE covered services.

Peg is Having a Baby (9 months of in-network pre-natal care and a

hospital delivery)

Mia’s Simple Fracture (in-network emergency room visit and follow up

care)

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-

controlled condition)

 The plan’s overall deductible $7,350  Specialist copayment $20  Hospital (facility) coinsurance 50%  Other coinsurance 50%

This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,700

In this example, Peg would pay:

Cost Sharing Deductibles $7,200 Copayments $0 Coinsurance $200

What isn’t covered Limits or exclusions $60 The total Peg would pay is $7,410

 The plan’s overall deductible $7,350  Specialist copayment $20  Hospital (facility) coinsurance 50%  Other coinsurance 50%

This EXAMPLE event includes services like:
Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs
Durable medical equipment (glucose meter)

Total Example Cost $5,600

In this example, Joe would pay:

Cost Sharing Deductibles* $0 Copayments $600 Coinsurance $0

What isn’t covered Limits or exclusions $800 The total Joe would pay is $1,400

 The plan’s overall deductible $7,350  Specialist copayment $20  Hospital (facility) coinsurance 50%  Other coinsurance 50%

This EXAMPLE event includes services like:
Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $2,800

In this example, Mia would pay:

Cost Sharing Deductibles* $2,430 Copayments $70 Coinsurance $60

What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,430

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments 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.

*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?” row above.

PE This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments 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

(9 months of in-network pre-natal care and a

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well

Mia’s Simple Fracture (in-network emergency room visit and follow up

hospital delivery)

™ The plan's overall deductible $7,350 specialist copayment $20

™ Hospital (facility) coinsurance 50%

™ Other coinsurance 50%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Chilabirth/Delivery Facility Services

Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing

Deductibles $7,200

Copayments $0

Coinsurance $200

What isn't covered Limits or exclusions $60 The total Peg would pay is $7,410

controlled condition)

™ The plan's overall deductible $7,350 Specialist copayment $20

Hospital (facility) coinsurance 50%

™ Other coinsurance 50%

This EXAMPLE event includes services like: Primary care physician office visits (including disease education)

Diagnostic tests (blood work)

Prescription drugs

Durable medical equipment (glucose meter)

Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing

Deductibles* $0

Copayments $600

Coinsurance $0

What isn’t covered Limits or exclusions $800 The total Joe would pay is $1,400

care) 1 The plan's overall deductible $7,350 '™ Specialist copayment $20

™ Hospital (facility) coinsurance 50% ™ Other coinsurance 50%

This EXAMPLE event includes services like: Emergency room care (including medical supplies)

Diagnostic test (x-ray)

Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles* $2,430 Copayments $70 Coinsurance $60 What isn't covered Limits or exclusions $0 The total Mia would pay is $2,430

*Note: This plan has other deductibles for specific services included in tis coverage example, See "Are there other deductibles for specific services?" row above.

The plan would be responsible for the other costs of these EXAMPLE covered services.

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