Class Only Model Document s1

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 – 12/31/2018 UMR: RIVER VALLEY LOCAL SCHOOL DISTRICT: 7670-00-411227 003 004 Coverage for: Individual + Family | Plan Type: HDHP

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, visit www.umr.com or by calling 1-800-826-9781. 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.umr.com or call 1-800-826-9781 to request a copy. Important Answers Why this Matters: Questions $2,000 person / $4,000 family In- Generally, you must pay all the costs from providers up to the What is the overall network deductible amount before this plan begins to pay. If you have other deductible? $4,000 person / $8,000 family Out- family members on the plan, the overall family deductible must be of-network met before the plan begins to pay. This plan covers some items and services even if you haven’t yet Are there services met the deductible amount. But a copayment or coinsurance may Yes. Preventive care services are covered before you apply. For example, this plan covers certain preventive services covered before you meet your meet your without cost-sharing and before you meet your deductible. See a deductible. deductible? list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for No. You don’t have to meet deductibles for specific services. specific services? $2,000 person / $4,000 family In- What is the out–of– The out-of-pocket limit is the most you could pay in a year for network pocket limit for this covered services. If you have other family members in this plan, $8,000 person / $16,000 family plan? the overall family out-of-pocket limit must be met. Out-of-network What is not Penalties, premiums, balance billing Even though you pay these expenses, they don’t count toward the included in the out– charges, and health care this plan out-of-pocket limit. of–pocket limit? doesn’t cover.

of 10 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 – 12/31/2018 UMR: RIVER VALLEY LOCAL SCHOOL DISTRICT: 7670-00-411227 003 004 Coverage for: Individual + Family | Plan Type: HDHP

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 Will you pay less if Yes. See www.umr.com or call out-of-network provider, and you might receive a bill from a you use a network 1-800-826-9781 for a list of network provider for the difference between the provider’s charge and what provider? providers. your plan pays (a 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 No. You can see the specialist you choose without a referral. specialist?

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay Common Services You May Limitations, Exceptions, & Other Medical In-network Out-of-network Need Important Information Event (You will pay the (You will pay the least) most)

Primary care visit to treat an injury or No charge 50% Coinsurance None illness

If you visit a health care Specialist visit No charge 50% Coinsurance None provider’s office or clinic You may have to pay for services that Preventive No charge; aren't preventive. Ask your provider if the care/screening/ Not covered Deductible Waived services you need are preventive. Then immunization check what your plan will pay for.

What You Will Pay Common Services You May Limitations, Exceptions, & Other Medical In-network Out-of-network Need Important Information Event (You will pay the (You will pay the least) most)

Diagnostic test No charge 50% Coinsurance None (x-ray, blood work) If you have a test Imaging No charge 50% Coinsurance None (CT/PET scans, MRIs)

If you need Benefits are applied by Benefits are applied Generic drugs (Tier 1) drugs to outside vendor by outside vendor treat your illness or Preferred brand condition. Benefits are applied by Benefits are applied drugs outside vendor by outside vendor More (Tier 2) information None about Non-preferred brand Benefits are applied by Benefits are applied prescription drugs (Tier 3) outside vendor by outside vendor drug coverage is available at www.insura Specialty drugs (Tier Benefits are applied by Benefits are applied ncecompan 4) outside vendor by outside vendor y.com/presc riptions.

What You Will Pay Common Services You May Limitations, Exceptions, & Other Medical In-network Out-of-network Need Important Information Event (You will pay the (You will pay the least) most) Facility fee If you have (e.g., ambulatory No charge 50% Coinsurance None outpatient surgery center) surgery Physician/surgeon No charge 50% Coinsurance None fees Emergency room In-network deductible applies to Out-of- No charge No charge If you care network benefits need Emergency medical In-network deductible applies to Out-of- No charge No charge immediate transportation network benefits medical attention Urgent care No charge 50% Coinsurance None

Facility fee No charge 50% Coinsurance Preauthorization is required. (e.g., hospital room) If you have a hospital stay Physician/surgeon fee No charge 50% Coinsurance None‍

If you have Outpatient services No charge 50% Coinsurance Preauthorization is required for Partial mental hospitalization. health,

What You Will Pay Common Services You May Limitations, Exceptions, & Other Medical In-network Out-of-network Need Important Information Event (You will pay the (You will pay the least) most) behavioral health, or substance Inpatient services No charge 50% Coinsurance Preauthorization is required. abuse needs

No charge; Office visits 50% Coinsurance Deductible Waived Cost sharing does not apply to certain preventive services. Depending on the type Childbirth/delivery If you are No charge 50% Coinsurance of services, deductible, copayment or pregnant professional services coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery No charge 50% Coinsurance facility services

100 Maximum visits per calendar year In- network; Home health care No charge 50% Coinsurance If you 60 Maximum visits per calendar year Out- need help of-network; Preauthorization is required. recovering or have 20 Maximum visits per calendar year OT; Rehabilitation other No charge 50% Coinsurance 20 Maximum visits per calendar year PT; services special 20 Maximum visits per calendar year ST health needs Habilitation services Not covered Not covered None

What You Will Pay Common Services You May Limitations, Exceptions, & Other Medical In-network Out-of-network Need Important Information Event (You will pay the (You will pay the least) most) 180 Maximum days per calendar year In- network; Skilled nursing care No charge 50% Coinsurance 60 Maximum days per calendar year Out- of-network; Preauthorization is required. Durable medical No charge 50% Coinsurance Preauthorization is required. equipment

Hospice service No charge 50% Coinsurance None

No charge; Children’s eye exam Not covered 1 Maximum exam per calendar year Deductible Waived If your child needs Children’s glasses Not covered Not covered None dental or eye care Children’s dental Not covered Not covered None check-up

Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)  Acupuncture  Infertility treatment  Private-duty nursing  Bariatric surgery  Long-term care  Routine foot care  Cosmetic surgery  Non-emergency care when traveling  Weight loss programs outside the U.S.  Dental care (Adult)

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Chiropractic care  Hearing aids  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 U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 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.

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. Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at www.dol.gov/ebsa/healthreform and http://cciio.cms.gov/programs/consumer/capgrants/index.html.

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 the Minimum Value Standard? 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 1-800-826-9781. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-826-9781.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-826-9781.

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

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.

Coinsurance $0 Peg is Having a Baby ManagingWhat isn’t Joe’s covered type 2 Mia’s Simple Fracture (in-network emergency room visit and (9 months of in-network pre-natal care Limits or exclusionsDiabetes $100 and a hospital delivery) follow up care) (a year of routine in-network care $2,10of a The total Peg would pay is  The plan's overall deductible 0  The plan's overall deductible $2,000 $2,000  Specialist coinsurance 0%  Specialist coinsurance 0%  Hospital (facility) coinsurance 0%  Hospital (facility) coinsurance 0%  Other coinsurance 0%  Other coinsurance 0%

This EXAMPLE event includes This EXAMPLE event includes services like: services like: Specialist office visits (prenatal care) Primary care physician office visits Childbirth/Delivery Professional Services (including disease education) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic tests (ultrasounds and blood Prescription drugs work) Durable medical equipment (glucose Specialist visit (anesthesia) meter)

$12,8 $7,40 Total Example Cost Total Example Cost 00 0

In this example, Peg would pay: In this example, Joe would pay: Cost Sharing Cost Sharing Deductibles $2,000 Deductibles* $1,000 Copayments $0 Copayments $0

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 8 of 10 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 – 12/31/2018 UMR: RIVER VALLEY LOCAL SCHOOL DISTRICT: 7670-00-411227 003 004 Coverage for: Individual + Family | Plan Type: HDHP

Coinsurance $0 What isn’t covered Limits or exclusions $6,200 $7,20 The total Joe would pay is 0  The plan's overall deductible $2,000  Specialist coinsurance 0%  Hospital (facility) coinsurance 0%  Other coinsurance 0%

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

$1,90 Total Example Cost 0

In this example, Mia would pay: Cost Sharing Deductibles* $1,900 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $0 $1,90 The total Mia would pay is 0

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 9 of 10 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 – 12/31/2018 UMR: RIVER VALLEY LOCAL SCHOOL DISTRICT: 7670-00-411227 003 004 Coverage for: Individual + Family | Plan Type: HDHP

Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: www.umr.com or call 1-800-826-9781. *Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 10 of 10