City of Muncie: Red Plan Coverage Period: 01/01/2017 12/31/2017

City of Muncie: Red Plan Coverage Period: 01/01/2017 – 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at website www.iuhealthplans.org or by calling 1-800-873-2022.

Important Questions Answers Why this Matters: Individual $500 You must pay all the costs up to the deductible amount before this plan begins to pay What is the overall for covered services you use. Check your policy or plan document to see when the Family $1000 deductible? deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other You must pay all of the costs for these services up to the specific deductible amount NO deductibles for specific before this plan begins to pay for these services. services? Is there an out–of– IUHBS Ind$1,500/Fam$3,000 The out-of-pocket limit is the most you could pay during a coverage period (usually pocket limit on my Encore Ind$2,000/Fam$4,000 one year) for your share of the cost of covered services. This limit helps you plan for expenses? OON Ind$2,500/Fam$5,000 health care expenses. What is not included in excluded services, non- Even though you pay these expenses, they don’t count toward the out-of-pocket limit. the out–of–pocket emergent ER visit copay limit? Is there an overall The chart starting on page 2 describes any limits on what the plan will pay for specific annual limit on what None covered services, such as office visits. the plan pays? If you use an in-network doctor or other health care provider, this plan will pay some or Yes. See website all of the costs of covered services. Be aware, your in-network doctor or hospital may Does this plan use a www.iuhealthplans.org or call use an out-of-network provider for some services. Plans use the term in-network, network of providers? 1-800-873-2022 for a list of preferred, or participating for providers in their network. See the chart starting on participating providers. page 2 for how this plan pays different kinds of providers. Do I need a referral to No You can see the specialist you choose without permission from this plan. see a specialist? Are there services this Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan Yes plan doesn’t cover? document for additional information about excluded services.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Questions: Call 1-800-873-2022 or visit us at website www.iuhealthplans.org. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 1 of 13 at www.dol.gov/ebsa/pdf/ SBC Uniform Glossary or call 1-800-873-2022 to request a copy. City of Muncie: Red Plan Coverage Period: 01/01/2017 – 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: PPO

 Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.  Co-insurance is your 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 co-insurance 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 billing.)  This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts.

Your cost if you use a Common Non- Services You May Need Participating Limitations & Exceptions Medical Event Participating Provider Provider Muncie Clinic Muncie clinic is no cost to members Primary care visit to treat an injury or Free or dependents. If clinic is unable to $50 copay illness IUHBS $50 copay treat member or dependents co-pay is Encore $50 copay $25.00. Muncie Clinic Muncie clinic is no cost to members Free or dependents. If clinic is unable to Specialist $35 copay IUHBS $25 copay treat member or dependents co-pay is If you visit a health Encore $30 copay $25.00. care provider’s Muncie clinic is no cost to members Muncie Clinic office or clinic or dependents. If clinic is unable to Free Other practitioner office visit $50 copay treat member or dependents co-pay is IUHBS $50 copay $25.00. Chiropractor: 26 visit max Encore $50 copay per calendar year. Muncie Clinic Free Subject to covered preventative Preventive care/screening/immunization 100% paid IUHBS 100% paid services. Encore 100% paid If you have a test Diagnostic test (x-ray, blood work) IUHBS 20% 40% After deductible. Encore 30%

Questions: Call 1-800-873-2022 or visit us at website www.iuhealthplans.org. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 2 of 13 at www.dol.gov/ebsa/pdf/ SBC Uniform Glossary or call 1-800-873-2022 to request a copy. City of Muncie: Red Plan Coverage Period: 01/01/2017 – 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: PPO Your cost if you use a Common Non- Services You May Need Participating Limitations & Exceptions Medical Event Participating Provider Provider IUHBS 20% After deductible. Imaging (CT/PET scans, MRIs) 40% Encore 30% If you need drugs to $10 copay + 10% Generic drugs NA treat your illness or coinsurance $0 copay if purchased at the Clinic condition $10 copay + 20% Preferred brand drugs NA coinsurance More information $10 copay + 20% about prescription Non-preferred brand drugs coinsurance + see NA drug coverage is limitations Plus difference between the cost of available at website the non-preferred and the generic www.iuhealthplans.or $10 copay + 20% drug. g Specialty drugs coinsurance + see NA . limitations Facility fee (e.g., ambulatory surgery IUHBS 20% 40% After deductible If you have center) Encore 30% outpatient surgery IUHBS 20% Physician/surgeon fees 40% After deductible Encore 30% IUHBS $100 Co- Non-emergent ER visits have no pay + 20% $100 Co-pay + Emergency room services coverage. If you need Encore $100 Co- 40% immediate medical pay + 30% attention Emergency medical transportation 100% 100% After deductible IUHBS $35 copay Urgent care $45 copay Encore $40 copay IUHBS 20% Facility fee (e.g., hospital room) 40% After deductible If you have a Encore 30% hospital stay IUHBS 20% Physician/surgeon fee 40% After deductible Encore 30%

Questions: Call 1-800-873-2022 or visit us at website www.iuhealthplans.org. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 3 of 13 at www.dol.gov/ebsa/pdf/ SBC Uniform Glossary or call 1-800-873-2022 to request a copy. City of Muncie: Red Plan Coverage Period: 01/01/2017 – 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: PPO Your cost if you use a Common Non- Services You May Need Participating Limitations & Exceptions Medical Event Participating Provider Provider Mental/Behavioral health outpatient IUHBS $25 copay $35 copay services Encore $30 copay If you have mental IUHBS 20% Mental/Behavioral health inpatient services 40% After deductible health, behavioral Encore 30% health, or substance IUHBS $25 copay Substance use disorder outpatient services $35 copay abuse needs Encore $30 copay IUHBS 20% Substance use disorder inpatient services 40% After deductible Encore 30% IUHBS $25 copay Prenatal and postnatal care $35 copay Encore $30 copay If you are pregnant IUHBS 20% Delivery and all inpatient services 40% After deductible Encore 30% IUHBS 20% After deductible Home health care 40% Encore 30% IUHBS 20% After deductible Rehabilitation services 40% Encore 30% If you need help IUHBS 20% After deductible Habilitation services 40% recovering or have Encore 30% other special health IUHBS 20% After deductible Skilled nursing care 40% needs Encore 30% IUHBS 20% After deductible Durable medical equipment 40% Encore 30% IUHBS 20% After deductible Hospice service 40% Encore 30% Eye exam NA NA See vision plan If your child needs Glasses NA NA See vision plan dental or eye care Dental check-up NA NA See dental plan

Questions: Call 1-800-873-2022 or visit us at website www.iuhealthplans.org. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 4 of 13 at www.dol.gov/ebsa/pdf/ SBC Uniform Glossary or call 1-800-873-2022 to request a copy. City of Muncie: Red Plan Coverage Period: 01/01/2017 – 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: PPO

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.)

 Hearing Aids  Acupuncture  Food Supplements  Wigs (unless due to cancer treatment)  Marital Counseling  Infertility  Cosmetic Surgery (unless due to accident)  Private Duty Nursing

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  Physical Therapy  Skilled Nursing Facility

Your Rights to Continue Coverage:

** Individual health insurance sample – ** Group health coverage sample –

Federal and State laws may provide protections that allow If you lose coverage under the plan, then, depending upon the you to keep this health insurance coverage as long as you pay circumstances, Federal and State laws may provide your premium. There are exceptions, however, such as if: protections that allow you to keep health coverage. Any such OR rights may be limited in duration and will require you to pay a  You commit fraud premium, which may be significantly higher than the premium you pay while covered under the plan. Other  The insurer stops offering services in the State limitations on your rights to continue coverage may also  You move outside the coverage area apply.

For more information on your rights to continue coverage, For more information on your rights to continue coverage, contact the insurer at [contact number]. You may also contact contact the plan at [contact number]. You may also contact your state insurance department at [insert applicable State your state insurance department, the U.S. Department of Department of Insurance contact information]. Labor, Employee Benefits Security Administration at 1-866- 444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.”

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: IU Health Plans, ATTN: Appeals, 950 N. Meridian Street Suite 200, Indianapolis, IN 46204 - or call 1.800.873.2022 or contact the Department of Labor’s Employee Benefits Security Administration at 1.866.444.EBSA (3272) or www.dol.gov/ebsa/healthreform.

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 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

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

Questions: Call 1-800-873-2022 or visit us at website www.iuhealthplans.org. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 7 of 13 at www.dol.gov/ebsa/pdf/ SBC Uniform Glossary or call 1-800-873-2022 to request a copy. City of Muncie: Red Plan Coverage Period: 01/01/2017 – 12/31/2017 Coverage Examples Coverage for: Individual/Family | Plan Type: PPO

About these Coverage Having a baby Managing type 2 diabetes Examples: (normal delivery) (routine maintenance of a well-controlled condition) These examples show how this plan might  Amount owed to providers: $7,540  Amount owed to providers: $4,100 cover medical care in given situations. Use  Plan pays $5,520  Plan pays $2,350 these examples to see, in general, how much  Patient pays $2,020  Patient pays $ 1,750 financial protection a sample patient might get if they are covered under different plans. Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $1,500 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 This is Hospital charges (baby) $900 Office Visits and Procedures $730 not a cost Anesthesia $900 Education $290 Laboratory tests $140 estimator. Laboratory tests $500 Prescriptions $200 Vaccines, other preventive $140 Don’t use these examples to Radiology $200 Total $4,100 estimate your actual costs Vaccines, other preventive $40 under this plan. The actual Total $7,540 Patient pays: care you receive will be Deductibles $500 different from these examples, Patient pays: Co-pays $930 and the cost of that care will Deductibles $500 Co-insurance $240 also be different. Co-pays $20 Limits or exclusions $80 Co-insurance $1350 Total $1,750 See the next page for Limits or exclusions $150 important information about Total $2,020 these examples.

Questions and answers about the Coverage Examples:

What are some of the What does a Coverage Example depending on the care you receive, the prices your providers charge, and the assumptions behind the show? reimbursement your health plan allows. Coverage Examples? For each treatment situation, the Coverage Can I use Coverage Examples Example helps you see how deductibles, to compare plans?  Costs don’t include premiums. co-payments, and co-insurance can add up.  Sample care costs are based on national It also helps you see what expenses might be Yes. When you look at the Summary of averages supplied by the U.S. left up to you to pay because the service or Department of Health and Human treatment isn’t covered or payment is Benefits and Coverage for other plans, Services, and aren’t specific to a limited. you’ll find the same Coverage Examples. particular geographic area or health When you compare plans, check the plan. “Patient Pays” box in each example. The  The patient’s condition was not an Does the Coverage Example smaller that number, the more coverage excluded or preexisting condition. predict my own care needs? the plan provides.  All services and treatments started and No. Treatments shown are just examples. ended in the same coverage period.  Are there other costs I should  There are no other medical expenses for The care you would receive for this consider when comparing any member covered under this plan. condition could be different based on  Out-of-pocket expenses are based only your doctor’s advice, your age, how plans? on treating the condition in the serious your condition is, and many other Yes. An important cost is the premium example. factors.   The patient received all care from in- you pay. Generally, the lower your network providers. If the patient had premium, the more you’ll pay in out-of- Does the Coverage Example pocket costs, such as co-payments, received care from out-of-network predict my future expenses? providers, costs would have been deductibles, and co-insurance. You higher. should also consider contributions to  No. Coverage Examples are not cost accounts such as health savings accounts estimators. You can’t use the examples to (HSAs), flexible spending arrangements estimate costs for an actual condition. (FSAs) or health reimbursement accounts They are for comparative purposes only. (HRAs) that help you pay out-of-pocket Your own costs will be different expenses.

Discrimination is Against the Law Indiana University Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Indiana University Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Indiana University Health Plans:  Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o 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: o Qualified interpreters o Information written in other languages

If you need these services, contact Allison Shelton.

If you believe that Indiana University Health Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Allison Shelton, Civil Rights Coordinator, Indiana University Health Plans, 950 N Meridian St, Suite 400, Indianapolis, IN 46204, (317) 963-9788 , TTY: (800) 743-3333, Fax (317) 963-9801, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Allison Shelton, Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Language Assistance Services English: ATTENTION: Our Member Services department has free language interpreter services available for non-English speakers. Call 855.413.2432. (TTY: 800.743.3333)

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 855.413.2432 (TTY: 800.743.3333).

Chinese:注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 855.413.2432（TTY: 800.743.3333）。

Burmese:

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 855.413.2432 (TTY: 800.743.3333).

French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 855.413.2432 (ATS : 800.743.3333).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 855.413.2432 (TTY: 800.743.3333).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 855.413.2432 (TTY: 800.743.3333).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 855.413.2432 (TTY: 800.743.3333)번으로 전 화해 주십시오.

Questions: Call 1-800-873-2022 or visit us at website www.iuhealthplans.org. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 11 of 13 at www.dol.gov/ebsa/pdf/ SBC Uniform Glossary or call 1-800-873-2022 to request a copy. City of Muncie: Red Plan Coverage Period: 01/01/2017 – 12/31/2017 Coverage Examples Coverage for: Individual/Family | Plan Type: PPO Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 855.413.2432 (телетайп: 800.743.3333).

Arabic:

Hindi: धधध्यान दद: धदद आप दहहिंदद बबोलतत हह तबो आपकत ललए ममफत मद भध्याषध्या सहध्याधतध्या सतवध्याएहिं उपलबब हह। 855.413.2432 (TTY: 800.743.3333) पर ककॉल करद।

Pennsylvania Dutch: Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 855.413.2432 TDD/TTY 800.743.3333 uffrufe.

Dutch: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel 855.413.2432 (TDD/TTY 800.743.3333).

Punjabi: ਧਧਿਆਨ ਧਦਿਓ: ਜਜੇ ਤਤੁਸਸੀਂ ਪਪੰਜਜਾਬਬੀ ਬਬੋਲਦਿਜੇ ਹਬੋ, ਤਤਾਂ ਭਜਾਸ਼ਜਾ ਧਵਵਿੱਚ ਸਹਜਾਇਤਜਾ ਸਜੇਵਜਾ ਤਤੁਹਜਾਡਜੇ ਲਈ ਮਤੁਫਤਉਪਲਬਧਿਹਹ। 855.413.2432 (TTY: 800.743.3333) 'ਤਜੇ ਕਜਾਲ

ਕਰਬੋ।

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 855.413.2432（TTY: 800.743.3333）まで、お電話にてご連絡ください。

Questions: Call 1-800-873-2022 or visit us at website www.iuhealthplans.org. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 13 of 13 at www.dol.gov/ebsa/pdf/ SBC Uniform Glossary or call 1-800-873-2022 to request a copy.