Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 08/10/2019 – 08/09/2020 Commercial Casualty Insurance Company: College of Saint Benedict Student Health Insurance Plan Coverage for: Individual | Plan Type: PPO 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.wellfleetstudent.com or call toll free 1-877-657-5030. 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 1-800-318-2596 to request a copy. Important Questions Answers Why This Matters: In-Network Provider: What is the overall $150/Individual Generally, you must pay all of the costs from providers up to the deductible amount before this deductible? Out-of-Network Provider: plan begins to pay. $300/Individual Yes. In-Network Preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But Are there services and Student Health Care/Infirmary a copayment or coinsurance may apply. For example, this plan covers certain preventive services covered before you meet expenses are covered before you without cost-sharing and before you meet your deductible. See a list of covered preventive your deductible? meet your deductible. services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific No. You don’t have to meet deductible for specific services. services? In-Network Provider: What is the out-of-pocket $6,350/individual The out-of-pocket limit is the most you could pay in a year for covered services. limit for this plan? Out-of-Network Provider: $14,300/Individual What is not included in Premiums, balance-billing Even though you pay these expenses, they don’t count toward the out–of–pocket limit. the out-of-pocket limit? charges, and health care this plan doesn’t cover. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. Yes. See www.firsthealth.com or You will pay the most if you use an out-of-network provider, and you might receive a bill from a Will you pay less if you call 1-877-657-5030 for a list of provider for the difference between the provider’s charge and what your plan pays (balance use a network provider? Preferred Providers. 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 No. You can see the specialist you choose without a referral. see a specialist? OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016 1 of 6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Important Services You May Need In-Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most) Primary care visit to treat an $20 copay/visit, $20 copay/visit, Limited to 1 visit per day. injury or illness 20% coinsurance 40% coinsurance $20 copay/ visit, $20 copay/visit, When requested and approved by the 20% coinsurance 40% coinsurance attending Physician If you visit a health Limited to 1 visit per day. Specialist visit care provider’s office or clinic Chiropractor: Chiropractor: Pre-Certification Required 20% coinsurance 40% coinsurance You may have to pay for services that aren’t Preventive care/screening/ preventive. Ask your provider if the services No charge 40% coinsurance immunization you need are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood 20% coinsurance 40% coinsurance When prescribed by a physician. If you have a test work) Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance When prescribed by a physician. $20 copay/prescription, $20 copay/prescription, If you need drugs to Tier 1 20% coinsurance 20% coinsurance Out-of-Network Provider benefits are provided treat your illness or on a reimbursement basis. Claim forms must condition $40 copay/prescription, $40 copay/prescription, Tier 2 be received within 90 days. More information about 20% coinsurance 20% coinsurance No cost sharing applies to ACA Preventive prescription drug $40 copay/prescription, $40 copay/prescription, Care medications and certain Generic Drugs. coverage is available at Tier 3 20% coinsurance 20% coinsurance Per 30-day supply. www.wellfleetstudent.co $40 copay/prescription, $40 copay/prescription, m Specialty drugs 20% coinsurance 20% coinsurance Facility fee (e.g., ambulatory 20% coinsurance 40% coinsurance -----------------none ---------------- If you have outpatient surgery center) surgery Physicians: limited to one visit per day. Physician/surgeon fees 20% coinsurance 40% coinsurance Pre-Certification Required 2 of 6 Common What You Will Pay Limitations, Exceptions, & Other Important Services You May Need In-Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most) $100 copay/visit, $100 copay/visit, Emergency room care Copay waived if admitted. 20% coinsurance 20% coinsurance If you need immediate Emergency medical Including ground and/or air, water 20% coinsurance 40% coinsurance medical attention transportation transportation. $100 copay/visit, $100 copay/visit, Urgent care Copay waived if admitted. 20% coinsurance 20% coinsurance Pre-Certification is required. Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Subject to Semi-Private room rate unless intensive care unit is required. If you have a hospital stay Pre-Certification is required. Physician/surgeon fees 20% coinsurance 40% coinsurance Physicians: limited to one visit per day. Pre-Certification required except for office If you need mental Outpatient services 20% coinsurance 40% coinsurance health, behavioral visits health, or substance abuse services Inpatient services 20% coinsurance 40% coinsurance Pre-Certification is required. $20 copay/visit, $20 copay/visit, Office visits Cost sharing does not apply to certain 20% coinsurance 40% coinsurance preventive services. Depending on the type of Childbirth/delivery professional services, coinsurance may apply. Maternity 20% coinsurance 40% coinsurance services care may include tests and services described elsewhere in the SBC (i.e. ultrasound). If you are pregnant Up to 48 hours for normal vaginal delivery and 96 hours (not including the day of surgery) for Childbirth/delivery facility 20% coinsurance 40% coinsurance a caesarean section delivery unless the services caesarean section delivery is the result of Complications of Pregnancy. 3 of 6 Common What You Will Pay Limitations, Exceptions, & Other Important Services You May Need In-Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most) Home health care 20% coinsurance 40% coinsurance -----------------none---------------- Includes Cardiac, Pulmonary, Physical, Occupational, and Speech therapies. Rehabilitation services 20% coinsurance 40% coinsurance Outpatient: Limit of one visit per day. Pre-Certification is required. If you need help When prescribed by the attending Physician, recovering or have limited to one visit per day. Covered to the Habilitation services 20% coinsurance 40% coinsurance other special health extent that they are Medically Necessary. needs Pre-certification required. Covered to the extent of Medical Necessity. Skilled nursing care 20% coinsurance 40% coinsurance Pre-Certification is required. $100 copay, $100 copay, Durable medical equipment Pre-Certification is required. 20% coinsurance 40% coinsurance Hospice services 20% coinsurance 40% coinsurance -----------------none---------------- To the end of the month when the insured Children’s eye exam 0% coinsurance 0% coinsurance turns age 19. Limited to 1 visit per Policy Year. To the end of the month when the insured turns age 19. Limited to 1 pair of prescribed If your child needs Children’s glasses 0% coinsurance 0% coinsurance dental or eye care lenses and frames or contact lenses (in lieu of eyeglasses) per Policy Year. Limited to 2 exams every 12 months To the end of the month in which the Insured Children’s dental check-up 0% coinsurance 0% coinsurance Person turns age 19. For Preventive. 4 of 6 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.) • Acupuncture • Cosmetic surgery • Routine foot care • Bariatric surgery • Long-term care • 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 (Pre-certification required) • Dental care (Adult) (Adult Dental and Accidental • Infertility treatment (Pre-certification required) • Private-duty Nursing (outpatient) Injury) • Non-emergency care when traveling outside the • Routine eye care (Adult) (age 19 and older, • Hearing aids (limited to 1 hearing aid for each ear U.S. Routine Eye Exam once every 12 months) every three years) 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: Toll Free Consumer Line: In the Twin Cities metro area call 1-651-539-1600 or statewide toll free at 1-800-657-3602 or https://mn.gov/commerce/consumers/your-insurance/health-insurance/ and contact the insurer at 1-877-657-5030. For more information on your rights to continue coverage, contact the plan at 1-877-657-5030.