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---
type: document
title: RCSB%20SBC%20June%201%202021
file: ../RCSB%20SBC%20June%201%202021.pdf
tags:
- Russell_County
- Documents
docDate: null
contentType: application/pdf
contentLength: 239839
sha256sum: 6b2278ac837dc54448f7a36dc2b8201e86747877f12ae2e22fe9702d470a1efa
sha1sum: a3047def502d36b32fd7dae708035432a33b44b4
---
1 of 5
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.
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#premium
https://www.healthcare.gov/sbc-glossary/#allowed-amount
https://www.healthcare.gov/sbc-glossary/#balance-billing
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#provider
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#network-provider
https://www.healthcare.gov/sbc-glossary/#out-of-network-provider
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#preventive-care
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#preventive-care
https://www.healthcare.gov/sbc-glossary/#cost-sharing
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#preventive-care
https://www.healthcare.gov/sbc-glossary/#preventive-care
https://www.healthcare.gov/coverage/preventive-care-benefits/
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit
https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#network-provider
https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit
https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit
https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#premium
https://www.healthcare.gov/sbc-glossary/#balance-billing
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit
https://www.healthcare.gov/sbc-glossary/#network-provider
https://www.healthcare.gov/sbc-glossary/#network-provider
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#network
https://www.healthcare.gov/sbc-glossary/#provider
https://www.healthcare.gov/sbc-glossary/#network
https://www.healthcare.gov/sbc-glossary/#out-of-network-provider
https://www.healthcare.gov/sbc-glossary/#provider
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#balance-billing
https://www.healthcare.gov/sbc-glossary/#balance-billing
https://www.healthcare.gov/sbc-glossary/#network-provider
https://www.healthcare.gov/sbc-glossary/#out-of-network-provider
https://www.healthcare.gov/sbc-glossary/#provider
https://www.healthcare.gov/sbc-glossary/#referral
https://www.healthcare.gov/sbc-glossary/#specialist
https://www.healthcare.gov/sbc-glossary/#specialist
https://www.healthcare.gov/sbc-glossary/#referral
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Russell County School Board Health Benefit Plan
Coverage Period: 01/01/2021 - 12/31/2021
Coverage for: All Types | Plan Type: PPO
a
Tl
27
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
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.
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?
No
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.
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.
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.
10f5
2 of 5
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
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#provider
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#specialist
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#preventive-care
https://www.healthcare.gov/sbc-glossary/#screening
https://www.healthcare.gov/sbc-glossary/#preventive-care
https://www.healthcare.gov/sbc-glossary/#provider
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#diagnostic-test
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage
https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#specialty-drug
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
Ad Alcopayment and coinsurance costs shown in this chart are after your deductible has been met, fa deductible apples.
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
50% coinsurance
Emergency medical
50% coinsurance
80% coinsurance
None
20f5
3 of 5
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
https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation
https://www.healthcare.gov/sbc-glossary/#urgent-care
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#preauthorization
https://www.healthcare.gov/sbc-glossary/#preauthorization
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#preauthorization
https://www.healthcare.gov/sbc-glossary/#preauthorization
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#home-health-care
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#rehabilitation-services
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#habilitation-services
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#skilled-nursing-care
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#hospice-services
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#copayment
Common
Medical Event
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
30f5
4 of 5
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.––––––––––––––––––––––
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#excluded-services
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#marketplace
https://www.healthcare.gov/sbc-glossary/#marketplace
http://www.healthcare.gov/
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#claim
https://www.healthcare.gov/sbc-glossary/#grievance
https://www.healthcare.gov/sbc-glossary/#appeal
https://www.healthcare.gov/sbc-glossary/#claim
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#claim
https://www.healthcare.gov/sbc-glossary/#appeal
https://www.healthcare.gov/sbc-glossary/#grievance
https://www.healthcare.gov/sbc-glossary/#plan
http://www.dol.gov/ebsa/healthreform
https://www.healthcare.gov/sbc-glossary/#minimum-essential-coverage
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#health-insurance
https://www.healthcare.gov/sbc-glossary/#marketplace
https://www.healthcare.gov/sbc-glossary/#minimum-essential-coverage
https://www.healthcare.gov/sbc-glossary/#premium-tax-credits
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#minimum-value-standard
https://www.healthcare.gov/sbc-glossary/#premium-tax-credits
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#marketplace
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 + Routine Foot Care
Non-emergency care when traveling outside the U.S. * 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.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 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 (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.
4o0f5
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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.
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#specialist
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#specialist
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#specialist
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#provider
https://www.healthcare.gov/sbc-glossary/#cost-sharing
https://www.healthcare.gov/sbc-glossary/#deductible
https://www.healthcare.gov/sbc-glossary/#copayment
https://www.healthcare.gov/sbc-glossary/#coinsurance
https://www.healthcare.gov/sbc-glossary/#excluded-services
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#plan
https://www.healthcare.gov/sbc-glossary/#deductible
bout these Coverage Examples:
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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