Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Geisinger Health Plan: Extra HMO 10/50/500
Coverage Period: 01/01/2018 - 12/31/2018 Coverage for: Individual and Family | Plan Type: HMO
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, call 1-866-379-4489 or visit www.geisinger.org/health-plan. 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.healthcare.gov/sbc-glossary or call 1-866-379-4489 to request a copy. Important Questions What is the overall deductible?
Answers $500 person / $1,000 family
Why This Matters: 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 www.healthcare.gov/coverage/preventive-care-benefits.
Yes. Preventive care and Are there services covered primary care services are before you meet your covered before you meet your deductible? deductible. Are there other deductibles Yes. $500 person/$1,000 family You must pay all of the costs for these services up to the specific deductible amount before this plan for specific services? for prescription drug coverage. begins to pay for these services. $5,000 person / $10,000 The out-of-pocket limit is the most you could pay in a year for covered services. If you have other What is the out-offamily family members in this plan, they have to meet their own out-of-pocket limits until the overall family pocket limit for this out-of-pocket limit has been met. plan?
What is not included in the out-of-pocket limit?
Copayments for certain services, premiums, balance Even though you pay these expenses, they don't count toward the out-of-pocket limit. billing charges, and health care this plan doesn't cover.
Will you pay less if you use a network provider?
Yes. See www.geisinger.org/health-plan or call 1-866-379-4489 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 choose without a referral.
Geisinger Health Plan Marketplace GOLD Extra HMO 10/50/500
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016
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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
If you visit a health care provider's office or clinic
If you have a test
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.geisinger.org/ health-plan
If you have outpatient surgery
What You Will Pay Services You May Need Primary care visit to treat an injury or illness Specialist visit
Network Provider (You will pay the least) $50 copayment Extra site: $10 copayment $50 copayment
Out-of-Network Provider (You will pay the most) Not covered
None
Not covered
None Limited to 1 routine exam per year. You may have to pay for services that are not preventative. Ask your provider if the services needed are preventative. Then check what your plan will pay for.
Preventive care/screening/immunization
No charge
Not covered
Diagnostic test (x-ray, blood work)
$0 copayment
Not covered
Imaging (CT/PET scans, MRIs) Generic drugs (Tier 1)
$300 copayment
Not covered
$3 copayment
Not covered
Diagnostic: Deductible (if any) applies. Imaging: Deductible (if any) applies.
$20 copayment Preferred brand drugs (Tier 2) Non-preferred brand drugs
Limitations, Exceptions, & Other Important Information
Precertification/prior authorization required.
Deductible (if any) applies.
$45 copayment
Not covered
$80 copayment
Not covered
50% coinsurance after deductible up to MOOP
Not covered
Facility fee (e.g., ambulatory surgery center)
20% coinsurance
Not covered
Deductible (if any) applies. Precertification/prior authorization may be required.
Physician/surgeon fees
$400 copayment
Not covered
Deductible (if any) applies. Precertification/prior authorization may be required.
(Tier 3) Specialty drugs (Tier 4)
Covers up to a 34-day supply. Mail order 2x copayment No mail order option.
Geisinger Health Plan Marketplace GOLD Extra HMO 10/50/500
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Common Medical Event
What You Will Pay Services You May Need
Network Provider (You will pay the least) $200 copayment
Out-of-Network Provider (You will pay the most) $200 copayment
$150 copayment/ground
$150 copayment/ground
$500 copayment/air
$500 copayment/air
Urgent care
$50 copayment
$50 copayment
Facility fee (e.g., hospital room)
$300 copayment per admit
Not covered
Physician/surgeon fees
20% coinsurance
Not covered
Emergency room care If you need immediate medical attention
If you have a hospital stay If you need mental health, behavioral health, or substance abuse services
If you are pregnant
Emergency medical transportation
Outpatient services
$50 copayment
Not covered
Inpatient services Office visits
$300 copayment per admit
Not covered
No charge
Not covered
Childbirth/delivery professional services
No charge
Childbirth/delivery facility services
$400 copayment
Not covered
Limitations, Exceptions, & Other Important Information Emergency services: None Urgent care: None Emergency medical transportation: None Deductible (if any) applies. Precertification/prior authorization required. 90 days/non-par/benefit period. Deductible (if any) applies. Precertification/prior authorization required. Outpatient Services: Deductible (if any) applies. Inpatient Services: Deductible (if any) applies, precertification/prior authorization required, 90 days/non par/ benefit period. Pregnancy office visits: Deductible (if any) applies. Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. Inpatient professional and facility services: Deductible (if any) applies, precertification/prior authorization, 90 days/non par/benefit period.
Not covered
Geisinger Health Plan Marketplace GOLD Extra HMO 10/50/500
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Common Medical Event
If you need help recovering or have other special health needs
If your child needs dental or eye care
What You Will Pay Services You May Need
Limitations, Exceptions, & Other Important Information
Home health care
Network Provider (You will pay the least) $0 copayment
Not covered
Limited to 60 visits/member/benefit period.
Rehabilitation services Habilitation services
$50 copayment $50 copayment
Not covered Not covered
Deductible (if any) applies.
Skilled nursing care
$50 copayment per day
Not covered
Durable medical equipment Hospice services
20% coinsurance
Not covered
Out-of-Network Provider (You will pay the most)
Residential: $50 copayment/ Not covered visit Facility: $100 copayment/day
Deductible (if any) applies. 120 days/period of confinement/person. Deductible (if any) applies. Deductible (if any) applies.
Children's eye exam
$50 copayment
Not covered
1 exam/member/benefit period.
Children's glasses
50% coinsurance
50% coinsurance
Up to age 19 only. 1 frame every 12 months.
Children's dental check-up
No charge
Not covered
Up to age 19 only.
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.) • Private-Duty Nursing • Acupuncture • Hearing Aids • Routine Foot Care • Bariatric Surgery • Long-Term Care • Routine eye care • Cosmetic Surgery • Non-Emergency Care When Traveling Outside the U.S. (Adult) • Dental Care (Adult) • Weight Loss Programs Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) • Chiropractic Care • Infertility Treatment 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: The U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform, or the U.S Department of Health and Human Services 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. Geisinger Health Plan Marketplace GOLD Extra HMO 10/50/500
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Your Grievance and Appeals Rights: There are agencies that can help you 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 1-877-881-6388. 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 Standard, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: To access our Language helpline, please call 1-866-379-4489. –––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––
Geisinger Health Plan Marketplace GOLD Extra HMO 10/50/500
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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.
Peg is Having a Baby
(9 months of in-network pre-natal care and a hospital delivery) The plan's overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance
$500 $50 0% 0%
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 In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn't covered Limits or exclusions The total Peg would pay is
Managing Joe's type 2 Diabetes
(a year of routine in-network care of a wellcontrolled condition) The plan's overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance
$500 $50 0% 0%
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)
$12,800
$540
Total Example Cost In this example, Joe would pay: Cost Sharing Deductibles
$300 $0
Copayments Coinsurance
$10 $850
What isn't covered Limits or exclusions The total Joe would pay is
Mia's Simple Fracture
(in-network emergency room visit and follow up care) The plan's overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance
$500 $50 0% 0%
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) $7,400
$980 $870 $0 $60 $1,910
Total Example Cost In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn't covered Limits or exclusions The total Mia would pay is
$1,900
$500 $500 $0 $0 $1,000
The plan would be responsible for the other costs of these EXAMPLE covered services. Geisinger Health Plan Marketplace GOLD Extra HMO 10/50/500
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Discrimination is against the law Geisinger Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Geisinger Health Plan does not exclude `S_`[S_bdbSNddWS]RXůSbS^d[iPSQNecS_TbNQSQ_[_b national origin, age, disability, sex, gender identity, or sexual orientation. Geisinger Health Plan: • Provides free aids and services to people with disabilities d_Q_]]e^XQNdSSůSQdXfS[igXdWecceQWNc • DeN[XűSRcXV^[N^VeNVSX^dSb`bSdSbc • Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: • DeN[XűSRX^dSb`bSdSbc • Information written in other languages If you need these services, call Geisinger Health Plan at 800-447-4000 or TTY: 711.
If you believe that Geisinger Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, gender XRS^dXdi_bcSheN[_bXS^dNdX_^i_eQN^ű[SNVbXSfN^QSgXdW Civil Rights Grievance Coordinator Geisinger Health Plan Appeals Department 100 North Academy Avenue, Danville, PA 17822-3220 Phone: 866-577-7733, TTY: 711 Fax: 570-271-7225
[email protected] L_eQN^ű[SNVbXSfN^QSX^`Sbc_^_bPi]NX[TNh_bS]NX[Ͷ
ΝΝ Ν ͥG66ͦ Complaint forms are available at Wdd`ώώgggͶWWcͶV_fώ_Qbώ_ŶQSώű[SώX^RShͶWd][Ͷ
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