2381t02D1070182702

2381t02D1070182702 UnitedHealthcare s A nivion 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 Summary of Coverage: What this Plan Covers & What it Costs coverage tienoa:linnaulo -1 (1/3112017 Coverage for: Employee/Family I Plan Type: POS A 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 plan document at www.welcometouhc.com or by calling 1-800-782-3740. .-,-,--„—n-,. — -Answers . WrIus Matters: What is the overall leductible? Network: $0 Non-Network: $500 Indiv / $1,000 Family Per calendar year. Does not apply to copays, prescription drugs, and services listed below as "No Charge". You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, bur nor always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. ire there other ieductib es for No. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. ipecific services? r.tt there an not-of-. ocket limit Network: $2,500 Indiv I $5,000 Family Non-Network $5,000 Indiv I $10,000 Family The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. ni my expenses? What is not included n the out-of-pocket Premiums, balance-billed charges, health care this plan doesn't cover, penalties for failure to obtain Pre-Notification for services , copays and prescription drugs. Even though you pay these expenses, they don't count toward the out-of- . ocket limit. knit? Is there an overall annual limit on what he plan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specc covered services, such as office visits. Does this plan use a network of Yes. For a list of network providers, see www.welcometouhc.com or call 1-800-782-3740. if you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term providers? 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 to see a specialist? No. You can see the specialist you choose without permission from this plan. Are there services this plan doesn't cover? Yes. Some of the services this plan doesn't cover are listed on page 5. See your policy or document for information plan additional about excluded services. 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 III II IIIIIII IIII III II EFTA00316274 A • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • 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 health care . rovider's office Primary care visit to treat an injury or illness $20 copay per visit 20% co-ins, after ded If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. or clinic Specialist visit $30 copay per visit 20% co-ins, after ded If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. Other practitioner office visit $20 copay per visit 20% co-ins, after ded Cost Share applies for only Manipulative (Chiropractic) Services and is limited to 20 visits per policy period. Pre-Notification required for non-network or benefit reduces to 50% of allowed. Preventive care/screening/immunizati- on No Charge Not Covered No coverage non-Network. Includes preventive health services specified in the health care reform law. If you have a test Diagnostic test (x-ray, blood work) No Charge 20% co-ins, after ded None Imaging (CT/PI-1T scans, MRIs) $200 copay per service 20% co-ins, after ded None 2 of 8 EFTA00316275 ommon Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at waw.welcometouh- c.com. If you have outpatient surgery If you need immediate medical attention If you have a hospital stay ervices ou t ay lee Your Cost If Your Cost If Limitations & Exceptions You Use a You Use a 0 Network Non-Network Provider Provider O Tier 1 - Your Lowest-Cost Option Retail: S10 copay Mail-Order: S25 copay Retail: $10 copay Provider Retail: Up Mail-Order: You may drugs, from Certain drugs result in If you use pharmacy), allowed amount. You may benefits drugs. See the website plan. Not Tier 1 contraceptives Growth 04 means pharmacy for purposes of this section. to a 31 day supply. Up to a 90 day supply. need to obtain certain drugs, including certain specialty a pharmacy designated by us. may have a Pre-Notification requirement or may a higher cost. a non-Network Pharmacy (including a mail order you may be responsible for any amount over the be required to use a lower-cost drug(s) prior to under your policy being available for certain prescribed listed for information on drugs covered by your all drugs are covered. are covered at No Charge. Hormone Therapy : 30% co-ins, ded does not apply. Tier 2 - Your Midrange-Cost Option Retail: S30 copay Mail-Order: $75 copay Retail: $30 copay Tier 3 - Your Highest-Cost Option Retail: $50 copay Mail-Order: $125 copy Retail: $50 copay Tier 4 (if applicable) - Additional High-Cost Options Not applicable Not applicable Facility fee (e.g., ambulatory surgery center) No Charge 20% co-ins, after ded $250 outpatient surgery per occurrence deductible applies prior to the Annual Deductible. Physician/surgeon fees No Charge 20% co-ins, after ded None Emergency room services $200 copay per visit $200 copay per visit None Emergency medical transportation No Charge No Charge None Urgent care S75 copay per visit 20% co-ins, after ded If you receive services in addition to urgent care, additional copays, deductibles, or co-ins may apply. Facility fee (e.g., hospital room) No Charge 20% co-ins, after ded Pre-Notification required for non-network or benefit reduces to 50% of allowed. $500 Inpatient Stay per occurrence deductible applies prior to the Annual Deductible. 3 of 8 III I II I HIM I III II III II II EFTA00316276 Co Ili, Med i vent Services You May Need Physician/surgeon fee Your Cost If You Use a Network Provider No Charge Your Cost If You Use a Non-Network Provider 20% co-ins, after ded Limitat ons None If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $30 copay per visit 20% co-ins, after ded Limited to 20 visits per policy period (combined with Outpatient Substance use). Pre-Notification required for certain services for non-network or benefit reduces to 50% of allowed. Mental/Behavioral health inpatient services No Charge 20% co-ins, after ded Limited to 30 days per policy period (combined with Inpatient Substance use). Pre-Notification required for non-network or benefit reduces to 50% of allowed. Substance use disorder outpatient services $30 copay per visit 20% co-ins, after ded Limited to 20 visits per policy period (combined with Outpatient Mental health). Pre-Notification required for certain services for non-network or benefit reduces to 50% of allowed. Substance use disorder inpatient services No Charge 20% co-ins, after ded Limited to 30 days per policy period (combined with Inpatient Mental health). Pre-Notification required for non-network or benefit reduces to 50% of allowed. If you are pregnant Prenatal and postnatal care No Charge 20% co-ins, after ded Additional copays, deductibles, or co-ins may apply depending on services rendered. Delivery and all inpatient services No Charge 20% co-ins, after ded Inpatient Notification may apply. $500 Inpatient Stay per occurrence deductible applies prior to the Annual Deductible. If you need help recovering or have other special health needs Home health care No Charge 20% co-ins, after ded Limited to 60 visits per policy period. Pre-Notification required for non-network or benefit reduces to 50% of allowed. Rehabilitation services $20 copay per outpatient visit 20% co-ins, after ded Depending on the type of therapy, there is a limit of 20-36 visits per policy period. Habilitative services Not Covered Not Covered No coverage for Habilitative services. Skilled nursing care No Charge 20% co-ins, after ded Limited to 60 days per policy period (combined with Inpatient Rehabilitation). Pre-Notification required for non-network or benefit reduces to 50% of allowed. 4 of 8 EFTA00316277 r . ( ?[ILC.Si ti491:fa mvrc--:. : . -"'"'" ,' . ; Itr::1 . f; ..„ . 1'1, ,,....„4.,; ...: . . • t 1 !- . 7 , 4::4,2%;;U:I41•01, 4 1 aL-t il .`Jr.: 7,,• .;,.., 1 I r:I P .°\q .1 i I .:.!;;;':: 3e " it. ,•.n ii tlx :-•. — . ., ; • i:.) • el o 1. titii,:tfi‘anC:: !,*1:4:1;O4 1 er; , r S,, .. a . , ,.. -L:90 Ir: A .yr a: .4 t-. :ri .. c : ' ,..c .-P, ..... ; ru , iii, , Durable medical equipment No Charge 20% co-ins, after ded Covers I per type of DME (including repair/replace) every 3 years. Pre-Notification required for non-network DMF. over $1000 or no coverage. Hospice service No Charge 20% co-ins, after ded Inpatient Pre-Notification required for non-network or benefit reduces to 50% of allowed. If your child needs dental or eye care Eye exam $20 copay per visit Not Covered I Limited to I exam every 2 years. 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 • Acupuncture • Habilitation services • Bariattic surgery • Infertility treatment • Routine foot care • Weight loss programs a complete list. Check your policy or plan document for other excluded services.) • Cosmetic surgery • Dental care (Adult/Child) • Glasses • Long-term care • Non-emergency care when • Private-duty nursing traveling outside the U.S. 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 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 • Routine eye care (Adult) 5 of 8 III 1111111111 111111111 1111111 11111111111 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 of bow this plan might con costs fora sample medical situation, see the next page. 6 of 8 EFTA00316279 w %.uuluo rius vor my Coverage Examples Coverage Period: 11/01/2016 - 10/31/2017 Coverage for: Employee/Family I Plan Type: POS About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. A This is not a cost estimator. Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of chat care will also be different. See the next page for important information about these examples. Having a baby deb Amount owed to providers: $7,540 Plan pays $7,320 Patient pays $220 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $20 Coinsurance SO Limits or exclusions $200 Total $220 7 of 8 Managing type 2 diabetes "n. ')t 'A. C,):1[1"( tiled Ci :an Amount owed to providers: $5,400 Plan pays $4,260 Patient pays $1,140 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles SO Copays $1,100 Coinsurance SO Limits or exclusions $40 Total $1,140 1101111131111111111111 11111111111 111111 90LZWEOLOTatOVIIICZ EFTA00316280 umtedlietiltheare Choice Plus V6F /H9 Coverage Examples Coverage Period: 11/01/2016 - 10/31/2017 Coverage for: Employee/Family I Plan Type: POS Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don't include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and l luman Services, and aren't specific to a particular geographic area or health plan. • The patient's condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. • If other than individual coverage, the Patient Pays amount may be more. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited. Does the Coverage Example predict my own care needs? x No . Treatments shown are just examples. Th7 care you would receive for this condition could be different based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? x No . Coverage Examples are not cost estimators. You can't use the examples to 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. • Can I use Coverage Examples to compare plans? ,/Yes . When you look at the Summary of I:Zrefits and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? ✓Yes . An important cost is the premium you pay. Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as copayments, deductibles and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 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