EFTA00316273.pdf

2381t02D1070182702 UnitedHealthcare s Anivion Gewgaw•'r UnItedHeatthcare 185 Asylum Street Cityptace I Hartford, CT 06103 August 25, 2016 G/GA272605lM SOUTHERN TRUST COMPANY 6100 RED HOOK QUARTER,B-3 ST THOMAS, VI 008020000 Dear Customer: The Affordable Care Act requires all health plan issuers and group health plans to provide eligible enrollees with a Summary of Benefits and Coverage (SBC). The SBC provides you Information to better understand your plan and allows you to compare coverage options. You are receiving this package due to one of the following plan coverage events that requires you to receive an SBC. • Upon application for coverage, • Prior to any material modification of your plan coverage, • Prior to your plan renewal, or • You are a special enrollee. If you are an Employer, you can find your group's SBC documents by logging into www.emptoyereservices.com and select *Summary of Benefits and Coverage' under the Resources menu. For more information regarding this document, please visit uhc.com/summary or contact the Member Services number on the back of your ID card. Very truly yours, Christopher Hock Broker & Employer Operations UnitedHealthcare EFTA00316273  W .d-." --"-."^•-1 %admit:es nub vur inv coverage tienoa:linnaulo -1(1/3112017 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: Employee/Family I Plan Type: POS This is only a summary.If you want more detail about ,our coverage and costs, you can get the complete terms in the policy or A plan document at www.welcometouhc.com or by calling 1-800-782-3740. .-,-,--„—n-,. — -Answers . WrIus Matters: What is the overall Network: $0 You must pay all the costs up to the deductible amount before this plan begins to leductible? Non-Network: $500 Indiv / $1,000 Family pay for covered services you use. Check your policy or plan document to see when Per calendar year. Does not apply to copays, the deductible starts over (usually, bur nor always,January 1st). See the chart prescription drugs, and services listed below as starting on page 2 for how much you pay for covered services after you meet the "No Charge". deductible. ire there other No. You don't have to meet deductibles for specific services, but see the chart starting ieductib es for on page 2 for other costs for services this plan covers. ipecific services? r.tt there an Network: $2,500 Indiv I $5,000 Family The out-of-pocket limit is the most you could pay during a coverage period not-of-. ocket limit Non-Network $5,000 Indiv I $10,000 Family (usually one year) for your share of the cost of covered services. This limit helps ni my expenses? you plan for health care expenses. What is not included Premiums, balance-billed charges, health care this Even though you pay these expenses, they don't count toward the out-of- . ocket n the out-of-pocket plan doesn't cover, penalties for failure to obtain limit. knit? Pre-Notification for services , copays and prescription drugs. Is there an overall No. The chart starting on page 2 describes any limits on what the plan will pay for specc annual limit on what covered services, such as office visits. he plan pays? Does this plan use a Yes. For a list of network providers, see if you use an in-network doctor or other health care provider, this plan will pay network of www.welcometouhc.com or call some or all of the costs of covered services. Be aware, your in-network doctor or providers? 1-800-782-3740. hospital may use an out-of-network provider for some services. Plans use the term in-network preferred, or participating for . roviders in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral No. You can see the specialist you choose without permission from this plan. to see a specialist? Are there services Yes. Some of the services this plan doesn't cover are listed on page 5. See your policy or this plan doesn't plan document for additional information about excluded services. cover? tuestions: Ca111-800-782-3740 or visit us at www.welcometouhc.com.If you aren't clear about any of the olded terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or zww.dol.gov/ebsa/healthreform or cal11-866-487-2365 to request a copy. /6F 1 of 8 IIIIIIIIIIIIIIII III II EFTA00316274  • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. A • Coinsurance isyour 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 billin2.) • This plan may encourage you to use network providers by charging you lower deductibles copayments and coinsurance amounts. If you visit a Primary care visit to treat an $20 copay per 20% co-ins, after If you receive services in addition to office visit, additional health care injury or illness visit ded copays, deductibles, or co-ins may apply. . rovider's office or clinic Specialist visit $30 copay per 20% co-ins, after If you receive services in addition to office visit, additional visit ded copays, deductibles, or co-ins may apply. Other practitioner office visit $20 copay per 20% co-ins, after Cost Share applies for only Manipulative (Chiropractic) Services visit ded and is limited to 20 visits per policy period. Pre-Notification required for non-network or benefit reduces to 50% of allowed. Preventive No Charge Not Covered No coverage non-Network. care/screening/immunizati- Includes preventive health services specified in the health care on reform law. If you have a test Diagnostic test (x-ray, blood No Charge 20% co-ins, after None work) ded Imaging (CT/PI-1T scans, $200 copay per 20% co-ins, after None MRIs) service ded 2 of 8 EFTA00316275  ommon ervices ou t ay lee Your Cost If Your Cost If Limitations & Exceptions Medical Event You Use a You Use a 0 Network Non-Network Provider Provider O 04 If you need drugs Tier 1 - Your Lowest-Cost Retail: S10 copay Retail: $10 copay Provider means pharmacy for purposes of this section. to treat your Option Mail-Order: S25 Retail: Up to a 31 day supply. illness or copay Mail-Order: Up to a 90 day supply. condition Tier 2 - Your Midrange-Cost Retail: S30 copay Retail: $30 copay You may need to obtain certain drugs, including certain specialty Option Mail-Order: $75 drugs, from a pharmacy designated by us. More information copay Certain drugs may have a Pre-Notification requirement or may about prescription result in a higher cost. drug coverage is Tier 3 - Your Highest-Cost Retail: $50 copay Retail: $50 copay If you use a non-Network Pharmacy (including a mail order available at Option Mail-Order: $125 pharmacy), you may be responsible for any amount over the waw.welcometouh- copy allowed amount. c.com. Tier 4 (if applicable) - Not applicable Not applicable You may be required to use a lower-cost drug(s) prior to Additional High-Cost benefits under your policy being available for certain prescribed Options drugs. See the website listed for information on drugs covered by your plan. Not all drugs are covered. Tier 1 contraceptives are covered at No Charge. Growth Hormone Therapy : 30% co-ins, ded does not apply. If you have Facility fee (e.g., ambulatory No Charge 20% co-ins, after $250 outpatient surgery per occurrence deductible applies prior outpatient surgery surgery center) ded to the Annual Deductible. Physician/surgeon fees No Charge 20% co-ins, after None ded If you need Emergency room services $200 copay per $200 copay per None immediate visit visit medical attention Emergency medical No Charge No Charge None transportation Urgent care S75 copay per 20% co-ins, after If you receive services in addition to urgent care, additional visit ded copays, deductibles, or co-ins may apply. If you have a Facility fee (e.g., hospital No Charge 20% co-ins, after Pre-Notification required for non-network or benefit reduces to hospital stay room) ded 50% of allowed. $500 Inpatient Stay per occurrence deductible applies prior to the Annual Deductible. 3 of 8 IIIIIIIHIMI III IIIII II II EFTA00316276  Co Ili, Services You May Need Your Cost If Your Cost If Limitat ons Med i vent You Use a You Use a Network Non-Network Provider Provider Physician/surgeon fee No Charge 20% co-ins, after None ded If you have mental Mental/Behavioral health $30 copay per 20% co-ins, after Limited to 20 visits per policy period (combined with Outpatient health, behavioral outpatient services visit ded Substance use). health, or Pre-Notification required for certain services for non-network substance abuse or benefit reduces to 50% of allowed. needs Mental/Behavioral health No Charge 20% co-ins, after Limited to 30 days per policy period (combined with Inpatient inpatient services ded Substance use). Pre-Notification required for non-network or benefit reduces to 50% of allowed. Substance use disorder $30 copay per 20% co-ins, after Limited to 20 visits per policy period (combined with Outpatient outpatient services visit ded Mental health). Pre-Notification required for certain services for non-network or benefit reduces to 50% of allowed. Substance use disorder No Charge 20% co-ins, after Limited to 30 days per policy period (combined with Inpatient inpatient services ded Mental health). Pre-Notification required for non-network or benefit reduces to 50% of allowed. If you are Prenatal and postnatal care No Charge 20% co-ins, after Additional copays, deductibles, or co-ins may apply depending pregnant ded on services rendered. Delivery and all inpatient No Charge 20% co-ins, after Inpatient Notification may apply. services ded $500 Inpatient Stay per occurrence deductible applies prior to the Annual Deductible. If you need help Home health care No Charge 20% co-ins, after Limited to 60 visits per policy period. recovering or have ded Pre-Notification required for non-network or benefit reduces to other special 50% of allowed. health needs Rehabilitation services $20 copay per 20% co-ins, after Depending on the type of therapy, there is a limit of 20-36 visits outpatient visit ded per policy period. Habilitative services Not Covered Not Covered No coverage for Habilitative services. Skilled nursing care No Charge 20% co-ins, after Limited to 60 days per policy period (combined with Inpatient ded Rehabilitation). Pre-Notification required for non-network or benefit reduces to 50% of allowed. 4 of 8 EFTA00316277  ., ( 4 1 it. ,•.n ii tlx 1. titii,:tfi‘anC:: er; , S,, .. a r . 1'1, ,,...„4.,; aL-t il !,*1:4:1;O4 1 ?[ILC.Si ti491:fa r -"'"'" mvrc--:. :. ,' . ; f; ..„ . A .yr a: :-•. ,.. -L:90 Ir : .4 ..... ; — . ., t-. :ri ..c: ' ,..c-P, . iii, Itr::1 . ...: . . .`Jr.: 7,,• .;,.., 1 ; • i:.) • el ru, , • t1 !-.7, 4::,42%;;U:I41•01, I r:I P.°\q.1i I.:.!;;;':: 3e " o Durable medical equipment No Charge 20% co-ins, after Covers I per type of DME (including repair/replace) every 3 ded years. Pre-Notification required for non-network DMF. over $1000 or no coverage. Hospice service No Charge 20% co-ins, after Inpatient Pre-Notification required for non-network or benefit ded reduces to 50% of allowed. If your child needs Eye exam $20 copay per Not Covered Limited to I exam every 2 years. dental or eye care visit I No coverage non-Network. Glasses Not Covered Not Covered No coverage for Glasses. Dental check-up Not Covered I Not Covered No coverage for Dental check-up. 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 • Bariattic surgery • Cosmetic surgery • Dental care (Adult/Child) • Glasses • Habilitation services • Infertility treatment • Long-term care • Non-emergency care when • Private-duty nursing traveling outside the U.S. • 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 • Hearing aids • Routine eye care (Adult) Your Rights to Continue Coverage: f you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health :overage. 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. =or more information on your rights to continue coverage, contact the plan at 1-866-747-1019. You may also contact your state insurance department, the J.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 -iuman Services at 1-877-267-2323 x61565 or vrww.cciio.cms.gov. Your Grievance and Appeals Rights: f you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to meal or file a grievance. For questions ibout your rights, this notice, or assistance, you can contact the Employee Benefits Security Administration at 1-866 111 3272 or www.dol.gov/ebsa/healthreform or the United States Virgin Islands Division of Banking and Insurance at 340-774-7166 or 5 of 8 III1111111111 111111111 1111111 1111111111 EFTA00316278  www.ltg.gov.vi/division-of-banking-and-insurance.html. Additionally, a consumer assistance program can help you file your appeal. Contact U.S. Virgin Islands Division of Banking and Insurance at 340-773-6459or visit wwwitg.gov.vi. 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 GO% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Espanol): Pam obtener asistencia en Espanol, (lame al 1-800-782-3740 Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-782-3740 Chinese (1415C): PllAgMrt'XIY3M/ib, iitlitITA4-%4 1-800-782-3740 Navajo (Dine): Dinek'ehgo shika at' ohwol ninisingo, kwiljigo holne' 1-800-782-3740 To see examples ofbow thisplan might con costsfora sample medicalsituation, see the nextpage. 6 of 8 EFTA00316279  w %.uuluo rius vor my Coverage Period: 11/01/2016 - 10/31/2017 Coverage Examples Coverage for: Employee/Family I Plan Type: POS About these Coverage Having a baby Managing type 2 diabetes 90LZWEOLOTatOVIIICZ Examples: deb "n. ')t 'A. C,):1[1"( tiled Ci :an These examples show how this plan might Amount owed to providers: $7,540 Amount owed to providers: $5,400 cover medical care in given situations. Use these Plan pays $7,320 Plan pays $4,260 examples to see, in general, how much financial protection a sample patient might get if they are Patient pays $220 Patient pays $1,140 covered under different plans. Sample care costs: Sample care costs: This is Hospital charges (mother) $2,700 Prescriptions $2,900 A not a cost Routine obstetric care $2,100 Medical Equipment and $1,300 estimator. Hospital charges (baby) $900 Supplies Anesthesia $900 Office Visits and Procedures $700 Don't use these examples to Education $300 estimate your actual costs Laboratory tests $500 under this plan. The actual Prescriptions $200 Laboratory tests $100 care you receive will be Radiology $200 Vaccines, other preventive $100 different from these Total Vaccines, other preventive $40 $5,400 examples, and the cost of chat care will also be Total $7,540 different. Patient pays: Patient pays: Deductibles See the next page for SO important information Deductibles Copays $1,100 $0 about these examples. Copays $20 Coinsurance SO Coinsurance SO Limits or exclusions $40 Limits or exclusions $200 Total $1,140 Total $220 7 of 8 1101111131111111111111 11111111111 111111 EFTA00316280  umtedlietiltheare Choice Plus V6F /H9 Coverage Period: 11/01/2016 - 10/31/2017 Coverage Examples Coverage for: Employee/Family I Plan Type: POS Questions and answers about the Coverage Examples: • What are some of the What does a Coverage Example Can I use Coverage Examples to assumptions behind the show? compare plans? Coverage Examples? For each treatment situation, the Coverage • Costs don't include premiums. Example helps you see how deductibles, ,/Yes . When you look at the Summary of • Sample care costs are based on national copayments and coinsurance can add up. It I:Zrefits and Coverage for other plans, you'll averages supplied by the U.S. Department also helps you see what expenses might be left find the same Coverage Examples. When of Health and l luman Services, and aren't up to you to pay because the service or you compare plans, check the "Patient Pays" specific to a particular geographic area or treatment isn't covered or payment is limited. box in each example. The smaller that health plan. number, the more coverage the plan Does the Coverage Example provides. • The patient's condition was not an excluded or preexisting condition. predict my own care needs? • All services and treatments started and Are there other costs I should ended in the same coverage period. consider when comparing plans? x No . Treatments shown are just examples. • There are no other medical expenses for Th7care you would receive for this any member covered under this plan. condition could be different based on your ✓Yes . An important cost is the premium • Out-of-pocket expenses are based only on doctor's advice, your age, how serious your yo u pay. Generally, the lower your treating the condition in the example. condition is, and many other factors. premium, the more you'll pay in • The patient received all care from out-of-pocket costs, such as copayments, in-network providers. If the patient had Does the Coverage Example deductibles and coinsurance. You should received care from out-of-network predict my future expenses? also consider contributions to accounts such providers, costs would have been higher. as health savings accounts (HSAs), flexible • If other than individual coverage, the spending arrangements (FSAs) or health Patient Pays amount may be more. x No . Coverage Examples are not cost reimbursement accounts (HRAs) that help estimators. You can't use the examples to you pay out-of-pocket expenses. 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. Questions: Call 1-800-782-3740 or visit us at www.welcometouhc.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.cciio.cms.gov or www.dol.goviebsaihealthreform or cal11-866-487-2365 to request a copy. V6F 8 of 8 EFTA00316281