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Hospital Sisters Health System: Eastern Wisconsin: Healthy Plan - High Option
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: ALL | Plan Type: EPO
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 www.hshs.org/benefits or by calling Dean Health Plan at 1-888-895-1188.
Important Questions
Answers
Why this Matters:
What is the overall deductible?
Network Facility/Network PCP: $0
Network Specialist
$800 Individual/$1,600 Family
The deductible does not apply to preventive care,
physician office visit charges, Network Facility
charges, Network PCP charges or prescription
drugs
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, 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 deductibles for specific
services?
Yes. $150 per person for prescription drug
expenses
You must pay all of the costs for these services up to the specific deductible
amount before this plan begins to pay for these services.
Yes. Network Facility/Network PCP/Network
Specialist
Is there an out–of–pocket limit on my
expenses?
What is not included in the out–of–
pocket limit?
$2,750 Individual /$5,500 Family Limit
Separate Prescription Drug Out-of-Pocket Limit
$1,300 per person/$2,600 Family Limit
Premiums, non-compliance penalties, balancedbilled charges and health care this plan doesn’t
cover.
Is there an overall annual limit on
what the plan pays?
No.
Does this plan use a network of
providers?
Yes. For a list of Network providers, see
www.deancare.com/aso or call
1-888-895-1188
Do I need a referral to see a specialist?
No.
Are there services this plan doesn’t
cover?
Yes.
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.
Even though you pay these expenses, they don’t count toward the out-of-pocket
limit.
The chart starting on page 2 describes any limits on what the plan will pay for
specific covered services, such as office visits.
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. Plans use the term in-network,
preferred, or participating for providers in their network. See the chart starting on
page 2 for how this plan pays different kinds of providers.
You can see the network specialist you choose without permission from this plan.
A referral is needed for an out of network specialist.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or
plan document for additional information about excluded services.
Questions: Call 1-888-895-1188 or visit www.deanhealth.com/aso.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.
1 of 10
Hospital Sisters Health System: Eastern Wisconsin: Healthy Plan - High Option
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: ALL | Plan Type: EPO
· Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
· Coinsurance 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 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 billing.)
· This plan may encourage you to use Network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health care
provider’s office or clinic
If you have a test
Services
You May
Need
Your Costs if You Use a
Limitations &
Exceptions
Network
Facility
Network PCP
Network
Specialist
Out of Network
Primary care
visit to treat an
injury or illness
Not Applicable
5% Coinsurance
Not Applicable
Not Covered
---none---
Specialist visit
Not Applicable
Not Applicable
20%
Coinsurance
Not Covered
---none--
Not Applicable
Not Covered
20%
Coinsurance
Not Covered
Coverage is limited to 10 visits
per calendar year for Chiropractic
Care.
No Charge
No Charge
No Charge
Not Covered
---none---
10% Coinsurance
10% Coinsurance
10%
Coinsurance
Not Covered
Network Specialist deductible
does not apply
10% Coinsurance
10% Coinsurance
10%
Coinsurance
Not Covered
Network Specialist deductible
does not apply.
Other
practitioner
office visit
Preventive
care/screening/
immunization
Diagnostic test
(x-ray, blood
work)
Imaging
(CT/PET
scans, MRIs)
Questions: Call 1-888-895-1188 or visit www.deanhealth.com/aso.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.
2 of 10
Hospital Sisters Health System: Eastern Wisconsin: Healthy Plan - High Option
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: ALL | Plan Type: EPO
Yours Costs if You Use a
Common
Medical Event
Services You May Need
Network Pharmacy
Generic drugs
20% coinsurance
Non-Network
Pharmacy
Not Covered
Limitations & Exceptions
A separate prescription drug out-ofpocket limit of $1,300 per
person/$2,600 Family Limit applies.
Drugs not listed on the formulary are
not covered.
Preferred brand drugs
30% coinsurance
Not Covered
If you need drugs to treat
your illness or condition
More information about
prescription drug
coverage is available at
www.navitus.com
Non-preferred brand drugs
Specialty drugs
Retail - $15 copay then 30%
coinsurance
Mail Order - $45 copay then
30% coinsurance
30% coinsurance
Not Covered
Retail - 30 day supply
Mail - 90 day supply
If you choose to receive a brand
name medication when a direct
generic equivalent is available, you
must pay the difference in price
between the brand drug and its
generic equivalent in addition to the
applicable copay and coinsurance.
Mail order required for coverage of
maintenance medications after the
second fill at a retail pharmacy.
Not Covered
Questions: Call 1-888-895-1188 or visit www.deanhealth.com/aso.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.
After the initial fill, specialty
medications must be filled through
Prime Specialty to be covered.
Prior authorization may be required.
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Hospital Sisters Health System: Eastern Wisconsin: Healthy Plan - High Option
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you have outpatient
surgery
If you need immediate
medical attention
Services
You May
Need
Your Costs if You Use a
Limitations &
Exceptions
Network
Facility
Network PCP
Network
Specialist
Out of Network
10% Coinsurance
Not Applicable
Not Applicable
Not Covered
---none---
Not Applicable
5% Coinsurance
20% Coinsurance
Not Covered
---none---
Emergency
room services
$100 copay then 10%
Coinsurance
Not Applicable
20% Coinsurance
$100 copay then 10%
Coinsurance
Emergency
medical
transportation
10% Coinsurance
5% Coinsurance
10% Coinsurance
10% Coinsurance
Facility fee
(e.g.,
ambulatory
surgery center)
Physician/
surgeon fees
Urgent care
If you have a hospital
stay
Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: ALL | Plan Type: EPO
Facility fee
(e.g., hospital
room)
Physician/
surgeon fee
10% Coinsurance
Not Applicable
10% Coinsurance
Not Covered
10% Coinsurance
Not Applicable
Not Applicable
Not Applicable
Not Applicable
5% Coinsurance
20% Coinsurance
Not Covered
Questions: Call 1-888-895-1188 or visit www.deanhealth.com/aso.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.
Out of Network non-emergency
use of the emergency room is not
covered.
Deductible does not apply.
Assumes services provided by an
urgent care facility. If you are
travelling outside of your service
area, you pay 10% coinsurance
for out-of-network urgent care
services.
Precertification is required.
---none---
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Hospital Sisters Health System: Eastern Wisconsin: Healthy Plan - High Option
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services
You May
Need
Mental/
Behavioral
health
outpatient
services
Mental/
Behavioral
health
If you have mental
inpatient
health, behavioral health, services
or substance abuse needs Substance
abuse disorder
outpatient
services
Substance
abuse disorder
inpatient
services
Prenatal and
postnatal care
If you are pregnant
Delivery and
all inpatient
services
Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: ALL | Plan Type: EPO
Your Costs if You Use a
Limitations &
Exceptions
Network
Facility
Network PCP
Network
Specialist
Out of Network
10% Coinsurance
5% Coinsurance
10% Coinsurance
Not Covered
Network Specialist deductible
does not apply.
10% Coinsurance
5% Coinsurance
10% Coinsurance
Not Covered
Network Specialist deductible
does not apply.
10% Coinsurance
5% Coinsurance
10% Coinsurance
Not Covered
Network Specialist deductible
does not apply.
10% Coinsurance
5% Coinsurance
10% Coinsurance
Not Covered
Network Specialist deductible
does not apply.
Not Applicable
5% Coinsurance
20% Coinsurance
Not Covered
---none---
10% Coinsurance
5% Coinsurance
20% Coinsurance
Not Covered
Notification is required.
Questions: Call 1-888-895-1188 or visit www.deanhealth.com/aso.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.
5 of 10
Hospital Sisters Health System: Eastern Wisconsin: Healthy Plan - High Option
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you need help
recovering or have other
special health needs
Services
You May
Need
Home health
care
Rehabilitation
services
Habilitation
services
Skilled nursing
care
Durable
medical
equipment
Hospice
service
Eye exam
If your child needs dental Glasses
or eye care
Dental checkup
Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: ALL | Plan Type: EPO
Your Costs if You Use a
Limitations &
Exceptions
Network
Facility
Network PCP
Network
Specialist
Out of Network
10% Coinsurance
5% Coinsurance
10% Coinsurance
Not Covered
120 visits per benefit period.
Deductible does not apply.
10% Coinsurance
5% Coinsurance
10% Coinsurance
Not Covered
Deductible does not apply
10% Coinsurance
5% Coinsurance
10% Coinsurance
Not Covered
Deductible does not apply
10% Coinsurance
5% Coinsurance
10% Coinsurance
Not Covered
90 days per admission,
renewable after 180 days
between discharge and readmission.
10% Coinsurance
5% Coinsurance
10% Coinsurance
Not Covered
Deductible does not apply.
10% Coinsurance
5% Coinsurance
10% Coinsurance
Not Covered
Deductible does not apply.
Not Covered
Not Covered
Not Covered
Not Covered
---none---
Not Covered
Not Covered
Not Covered
Not Covered
---none---
Not Covered
Not Covered
Not Covered
Not Covered
---none---
Questions: Call 1-888-895-1188 or visit www.deanhealth.com/aso.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.
6 of 10
Hospital Sisters Health System: Eastern Wisconsin: Healthy Plan - High Option
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: ALL | Plan Type: EPO
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.)
·
·
Cosmetic Surgery
Dental Care (routine adult)
·
·
·
Hearing Aids
Infertility treatments
Long-term care
·
·
·
Routine eye care (Adult)
Routine foot care (with the exception of those
with diabetes)
Weight loss programs
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.)
·
·
Acupuncture
Bariatric surgery (HSHS Facility only)
Chiropractic Care
·
·
Dental care (specified services only)
Coverage when traveling/living outside the
USA is for urgent/emergency care only
·
Private-duty Nursing (excluding inpatient
services)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. 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.
For more information on your rights to continue coverage, contact the plan at 1-888-895-1188. You may also contact your state insurance department, the
U.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
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 Dean Health Plan at 1-888-895-1188 or visit www.deanhealth.com/aso, or contact
the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA or visit 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 does provide
minimum essential coverage.
Questions: Call 1-888-895-1188 or visit www.deanhealth.com/aso.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.
7 of 10
Hospital Sisters Health System: Eastern Wisconsin: Healthy Plan - High Option
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: ALL | Plan Type: EPO
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.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-327-8497.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-327-8497.
Chinese (中文): 如果需要中文的帮助,请拨打这个号码1-800-327-8497.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-327-8497.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-888-895-1188 or visit www.deanhealth.com/aso.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.
8 of 10
Hospital Sisters Health System: Eastern Wisconsin: Healthy Plan - High Option
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
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.
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
that care will also be
different.
See the next page for
important information about
these examples.
Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: ALL | Plan Type: EPO
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
n Amount owed to providers: $7,540
n Plan pays $5,800
n Patient pays $1,740
n Amount owed to providers: $5,400
n Plan pays $4,260
n Patient pays $1,140
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$820
$0
$770
$150
$1,740
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$150
$0
$910
$80
$1,140
Example assumes all care is received from Network
Facilities and Network Specialists. Some
prescriptions in this example are over-the-counter
medications which are not covered by the plan (see
limits or exclusions).
Example assumes all care is received from Network
Facilities, Network PCPs and Network Specialists.
Some prescriptions in this example are over-thecounter medications which are not covered by the
plan (see limits or exclusions)
Questions: Call 1-888-895-1188 or visit www.deanhealth.com/aso.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.
9 of 10
Hospital Sisters Health System: Eastern Wisconsin: Healthy Plan - High Option
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: All | Plan Type: EPO
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 Human
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 innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
Can I use Coverage Examples
to compare plans?
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.
üYes. When you look at the Summary of
Does the Coverage Example
predict my own care needs?
û No. Treatments shown are just examples.
The 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?
ûNo. 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.
Benefits 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?
üYes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket 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 1-888-895-1188 or visit us at www.deanhealth.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 http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.
10 of 10
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