2017 Individual Rates STANDARD PLANS TRADITION PLANS VALUE PLANS Bronze HSA Platinum Gold Silver Bronze Bronze HSA Catastrophic Platinum 30/30 Gold 30/50 Silver 40/60 Platinum 100% Gold 100% Silver 100% Silver 75% 70% IN-NETWORK COST-SHARE 50% 50% 3 Free PCP 30% 2 Free PCP 2 Free PCP 2 Free PCP 2 Free PCP $25 after $30 after coinsurance coinsurance Visits/Covered coinsurance Visits/Covered Visits/Covered Visits/Covered Visits/25% Primary Care $15 $30 $30 $40 deductible deductible after after in full after after in full after in full after in full after coinsurance deductible deductible deductible deductible deductible deductible deductible after deductible 50% 50% 30% 25% Covered in Covered in Covered in Covered in $40 after $50 after coinsurance coinsurance coinsurance coinsurance Specialist $35 full after $30 $50 $60 full after full after full after deductible deductible after after after after deductible deductible deductible deductible deductible deductible deductible deductible Emergency 50% 50% 30% 25% Covered in Covered in Covered in Covered in Room (waived if $150 after $250 after coinsurance coinsurance coinsurance coinsurance $100 full after $200 $200 $350 full after full after full after admitted within deductible deductible after after after after deductible deductible deductible deductible 24 hours) deductible deductible deductible deductible $1,000 $1,500 50% 50% 10% 20% 30% 25% Covered in Covered in Covered in Covered in Inpatient Surgery $500 per admit per admit coinsurance coinsurance $500 coinsurance coinsurance coinsurance coinsurance full after full after full after full after Facility Fee per admission after after after after per admission after after after after deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible 50% 50% 10% 30% 25% Outpatient Covered in Covered in Covered in Covered in $100 after $100 after coinsurance coinsurance coinsurance coinsurance coinsurance Surgery Facility $100 full after $200 $350 full after full after full after deductible deductible after after after after after Fee deductible deductible deductible deductible deductible deductible deductible deductible deductible Deductible (2x for Family) $0 $600 $2,000 $4,000 $5,500 $7,150 $0 $1,000 $4,250 $5,500 $1,200 $2,250 $4,600 $3,000 Coinsurance 10% 20% 30% 50% 50% 0% 10% 10% 20% 30% 0% 0% 0% 25% Maximum Out-Of-Pocket $2,000 $4,000 $6,750 $7,150 $6,550 $7,150 $1,000 $3,000 $7,150 $6,550 $1,200 $2,250 $4,600 $6,850 (2x for Family) $15/$35/$75 $0 Generic/ $10/$50/50% $10/$50/50% $0 Generic/ $0 Generic/ $0 Generic/ $10/$35/$70 $10/$35/$70 Covered in after $100 Rx $15/$35/$75 Tier 2 and 3 Prescription coinsurance coinsurance Tier 2 and 3 Tier 2 and 3 Tier 2 and 3 $10/$30/$60 $10/$35/$70 $10/$35/$70 after after full after deductible after 25% coinsurance Drugs (up to max (up to max covered in full covered in full covered in full deductible deductible deductible (deductible waived deductible after deductible $250) $250) after deductible after deductible after deductible for Tier 1) (max $500) 2017 RATES Single $746 $637 $544 $430 $443 $203 $761 $649 $565 $436 $688 $625 $501 $487 Couple $1,492 $1,274 $1,088 $860 $886 $406 $1,522 $1,298 $1,130 $872 $1,376 $1,250 $1,002 $974 Parent with $1,268 $1,083 $925 $731 $753 $345 $1,294 $1,103 $961 $741 $1,170 $1,063 $852 $828 Child(ren) Family $2,126 $1,815 $1,550 $1,226 $1,263 $579 $2,169 $1,850 $1,610 $1,243 $1,961 $1,781 $1,428 $1,388 n 855-706-7545 n CareConnect.com North Shore-LIJ CareConnect Insurance Company, Inc. Individual Rates Our Plans: Benefits: The Basics Standard, Tradition and Value Copay: An amount that members are required to pay toward the cost of a covered service (like a doctor’s visit) We offer a variety of plans to fit your clients’ needs and after their deductible has been met. The copay is usually budget. Standard, Tradition or Value—all provide easy expressed as a fixed dollar amount—say, $15 or $25. access to affordable, superior care. Coinsurance: A percent of the bill for a covered service Standard plans have the classic “deductible first” design that members are required to pay after their deductible that your clients will find familiar. In other words, most has been met. After a member pays the coinsurance, of these plans have a deductible that members must meet CareConnect is responsible for the rest of the bill for the before CareConnect starts to pay for covered, medically covered service. necessary health services. After members with the plans Worry-Free Access to meet their deductible, they are responsible only for Deductible: The amount members are responsible for cost-sharing, which can take the form of copays or paying for covered medical expenses each policy period High-Quality Care coinsurance. (Standard Platinum plans are an exception before CareConnect starts paying. The amount of the to this rule. With a zero deductible made possible by deductible depends on the plan the member has selected. We know that budgets can be tight and higher premiums, Platinum plans offer members a way to After the member meets the deductible for a policy period, 2016 spread their medical costs more predictably over the year. we will take care of the bill for covered services, although life can be hectic for your clients. Health Members receiving covered, medically necessary services the member may have to pay a copay or coinsurance. If are responsible only for cost-sharing.) services are not covered by the plan, the member must insurance should make things easier, Tradition plans offer “first dollar” coverage. Members pay those costs out of pocket, and they do not count not more stressful. That’s why all need not meet a deductible before CareConnect will start toward the deductible. covering doctor visits; instead, they are responsible only Maximum Out of Pocket: The maximum amount the CareConnect plans can save your clients for cost-sharing. Members do have to meet a deductible member has to pay toward covered services during a for inpatient or outpatient hospital care and for ambulance policy period, including deductible, copays and time and money —while giving them easy services; they also have a small, separate deductible for coinsurance for covered services. After the member pays access to top-rated doctors and hospitals pharmacy costs. After these deductibles are met, members the Maximum Out Of Pocket (MOOP), CareConnect will are responsible only for cost-sharing. pay 100% of the cost of covered services. Out of pocket throughout the New York region. Value plans serve the needs of clients looking for simplicity. payments for services not covered by the plan do not New for 2016, this product line is designed to be one of count toward the MOOP. the most affordable in the marketplace. Value plans have a deductible; after it is met, members are responsible only for coinsurance and for some services have no cost-sharing at all. Members are also entitled to two no-cost PCP visits each plan year, in addition to preventive services. n Broker Services: 855-228-0541 n CareConnect.com CCIndividualGroupRateCardProducerV8 09. 15 North Shore-LIJ CareConnect Insurance Company, Inc. Broker Services: 855-228-0541 n CareConnect.com CareConnect Facilities Manhattan Hospitals Yale-New Haven Northern Harlem Westchester Bridgeport Metropolitan Lenox Hill Manhattan Eye, Ear & Throat Phelps Memorial Lenox Health Greenwich Greenwich Montefiore White Plains Village Medical Bellevue Centers Peconic Bay Medical Center North Central Bronx Jacobi Huntington Glen Cove Lincoln Syosset North Shore University Zucker Hillside Plainview Elmhurst LIJ Medical Center Cohen Children’s LIJ Forest Nassau University Hills Queens Medical Center Southside Woodhull Wyckoff Heights South Oaks Kings County LIJ Valley Stream Staten Island Maimonides University (North) Coney Island Staten Island University (South) For a searchable list of CareConnect’s providers, visit CareConnect.com/providersearch Hospitals • Bellevue Hospital Center, 462 First Avenue, New York, NY 10016, P: 212-562-4141 • Bridgeport Hospital, 267 Grant St, Bridgeport, CT 06610, P: 203-688-8412 • Coney Island Hospital, 2601 Ocean Parkway, Brooklyn, NY 11235, P: 718 616-3000 • Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY, 11373, P: 718-334-4000 • Glen Cove Hospital, 101 St. Andrews Lane, Glen Cove, NY 11542, P: 516-674-7540 • Greenwich Hospital, 5 Perryridge Road, Greenwich, CT 06 830, P: 203-688-8412 • Harlem Hospital Center, 506 Lenox Avenue, New York, NY 10037, P: 212-939-1000 • Huntington Hospital, 270 Park Avenue, Huntington, NY 11743, P: 631-351-2000 • Jacobi Medical Center, 1400 Pelham Parkway South, Bronx, NY 10461, P: 718-918-5000 • Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, P: 718-245-3131 • Lenox Health Greenwich Village, 30 Seventh Avenue, New York, NY 10011, P: 646-665-6000 • Lenox Hill Hospital, 100 East 77th Street, New York, NY 10021, P: 212-434-2000 • Lincoln Medical & Mental Health Center, 234 East 149th Street, Bronx, NY 10451, P: 718-579-5000 • Long Island Jewish Forest Hills, 102-01 66th Road, Forest Hills, NY 11375, P: 718-830-4000 • Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY 11040, P: 718-470-7000 • Long Island Jewish Valley Stream, 900 Franklin Avenue, Valley Stream, NY 11580, P: 516-256-6000 • Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, P: 718-283-6000 • Manhattan Eye, Ear & Throat Hospital, 210 East 64th Street, New York, NY 10021, P: 212-838-9200 • Metropolitan Hospital Center, 1901 First Avenue, New York, NY 10029, P: 212-423-6262 • Montefiore Medical Center - Westchester Square, 2475 Saint Raymonds Avenue, Bronx, NY 10461, P: 718-430-7300 • Montefiore Medical Center - Montefiore Hospital, 111 East 210th Street, Bronx, NY 10467, P: 718-920-4321 • Montefiore Medical Center - Wakefield Hospital, 600 East 233rd Street, Bronx, NY 10466, P: 718-920-9000 • Montefiore Medical Center - Weiler Hospital, 1825 Eastchester Road, Bronx, NY 10461, P: 718-904-2000 • Montefiore Mt.