Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 04/01/2013 – 03/31/2014
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 plant document at www.abpa.com or by calling 1-877-624-6254.
Important Questions
Q: What is the overall deductible?
A: In-network PPO Provider: $300/person per year; $600/family per year.
Does not apply to preventative care, and outpatient prescription drugs. Copayments, non-covered expenses and a penalty for failure to obtain precertification, do not count towards the deductible.
Why this matters: 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 information below for how much you pay for covered services after you meet the deductible.
Q: Are there other deductibles for specific services?
A: In-network PPO Provider: $300/person per year; $600/family per year.
Does not apply to preventative care, and outpatient prescription drugs. Copayments, non-covered expenses and a penalty for failure to obtain precertification, do not count towards the deductible.
Why this matters: 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.
Q: Is there an out-of-pocket limit on my expenses?
A:Yes, In-network PPO Providers: $1,000/person per year and Non-PPO Providers: $2,000/person per year.
Why this matters: 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 pay for health care expenses.
Q: What is not included in the out-of-pocket limit?
A: Premiums, balance-billed charges, non-covered expenses, copayments, deductibles, charges in excess of benefit maximums, a penalty for failure to obtain precertification, coinsurance for out-of-network preventive care benefits and outpatient retail/mail order prescription drug expenses do not count toward the out-of-pocket limit.
Why this matters: Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Q: Is there an overall annual limit on what the plan pays?
A. Yes, $2 million per person through March 31, 2014, then starting April 1, 2014 the Plan no longer has an overall annual limit on medical plan benefits.
Why this matters: This plan will pay for covered services only up to this limit during each coverage period, even if your own need is greater. You’re responsible for all expenses above this limit. The information below describes specific coverage limits, such as limits on the number of office visits.
Q: Does this plan use a network of providers?
A: Yes. For a list of in-network PPO providers for the medical plan, see www.bcbsnm.com or call 1-800-835-8699. For a list of in-network PPO providers for the vision plan, see www.vsp.com or call 1-800-877-7195.
Why this matters: 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. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred or participating for providers in their network. See the information below for how this plan pays different kinds of providers.
Q: Do I need a referral to see a specialist?
A: No
Why this matters: You can see the specialist you choose without permission from this plan.
Q: Are there services this plan doesn’t cover?
A: Yes
Why this matters: 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.
~ 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, 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 in-network PPO providers by charging you lower deductibles, copayments and coinsurance amounts.
Common Medical Event: If you visit a health care provider’s office or clinic
Services you may need: Primary Care visit to treat an injury or illness.
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost – Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Diagnostic procedures exceeding $1,250 require precertification to avoid a $100 penalty.
Services you may need: Specialist Visit
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost – Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Diagnostic procedures exceeding $1,250 require precertification to avoid a $100 penalty.
Services you may need: Other practitioner office visit
Your Cost – In-Network Provider: Chiropractic/ Acupuncture Services: 10% coinsurance after deductible met.
Your Cost – Out-of-Network Provider: Chiropractic/ Acupuncture Services: 20% coinsurance after deductible met.
Limitations and Exceptions: Any combination of Chiropractic/Acupuncture Services up to a max of 50 visits/year and, you pay any expenses over $30/visit.
Services you may need: Preventive care/screening/immunization
Your Cost – In-Network Provider: Annual adult physical exam, well child visits plus immunizations, mammogram, pap smear, colonoscopy: No charge.
Your Cost -Out-of-Network Provider: Annual adult physical exam, well child visits plus immunizations, mammogram, pap smear, colonoscopy: 20% coinsurance, no deductible.
Limitations and Exceptions: Not all preventive services require by Health Reform law are covered by this Plan. Plan covers annual mammogram for women age 35 and older; annual pap smear, colonoscopy if age 50 or older. Annual flu shot for all plan participants from any provider: No charge up to $25/person/year, and you pay expenses over $25/flu shot.
Common Medical Event: If you have a test
Services you may need: Diagnostic test (x-ray, blood work)
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Diagnostic procedures exceeding $1,250 require precertification to avoid at $100 penalty. Genetic testing and counseling maximum benefit $1,000/person/year.
Services you may need: Imaging (CT/PET scans, MRIs)
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Diagnostic procedures exceeding $1,250 require precertification to avoid a $100 penalty.
Common Medical Event: If you need drugs to treat your illness or condition (More information about prescription drug coverage is available from CVS Caremark at 1-800-770-8014.
Services you may need: Generic drugs
Your Cost – In-Network Provider: Retail pharmacy for 30-day supply: 20% coinsurance; Mail Order for 90-day supply: $20 copayment.
Your Cost -Out-of-Network Provider: You pay 100%. Later you can submit your claim for reimbursement and Plan reimburses 80% of the billed charges.
Limitations and Exceptions: Some prescriptions are subject to preapproval and some prescriptions have quantity limits.
Services you may need: Preferred brand drugs
Your Cost – In-Network Provider: Retail pharmacy for 30-day supply: 20% coinsurance; Mail Order for 90-day supply: $20 copayment.
Your Cost -Out-of-Network Provider: You pay 100%. Later you can submit your claim for reimbursement and Plan reimburses 80% of the billed charges.
Limitations and Exceptions: Some prescriptions are subject to preapproval and some prescriptions have quantity limits.
Services you may need: Specialty drugs
Your Cost – In-Network Provider: For up to a 30-day supply you pay 20% coinsurance to a maximum of $100 per year.
Your Cost -Out-of-Network Provider: Not covered.
Limitations and Exceptions: Specialty drug require preapproval by calling CVS Caremark at 1-800-770-8014.
Common Medical Event: If you have outpatient surgery
Services you may need: Facility fee (e.g., ambulatory surgery center)
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Outpatient surgery exceeding $1,250 requires precertification to avoid a $100 penalty.
Services you may need: Physician/surgeon fees
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: –none–
Common Medical Event: If you need immediate medical attention
Services you may need: Emergency room services
Your Cost – In-Network Provider: $25 ER deductible per visit plus 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: $25 ER deductible per visit plus 20% coinsurance after deductible met.
Limitations and Exceptions: $25 ER deductible waived if admitted within 24 hours of the ER visit.
Services you may need: Emergency medical transportation
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: –none–
Services you may need: Urgent Care
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: –none–
Services you may need: Facility fee (e.g., hospital room)
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Elective hospital admission requires precertification to avoid a $100 penalty.
Services you may need: Physician/Surgeon fee
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: –none–
Common Medical Event: If you have mental health, behavioral health, or substance abuse needs
Services you may need: Mental/Behavioral health outpatient services
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Diagnostic procedures exceeding $1,250 require precertification to avoid a $100 penalty. Contact EAP at 505-265-3785 for up to 3 visits free.
Services you may need: Mental/Behavioral health inpatient services
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Elective hospital admission, residential treatment and partial hospitalization require precertification to avoid a $100 penalty.
Services you may need: Substance use disorder outpatient services
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Diagnostic procedures exceeding $1,250 require precertification to avoid a $100 penalty. Contact EAP at 505-265-3785 for up to 3 visits free.
Services you may need: Substance use disorder inpatient services
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Elective hospital admission, residential treatment and partial hospitalization require precertification to avoid a $100 penalty.
Common Medical Event: If you are pregnant
Services you may need: Prenatal and postnatal care
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Diagnostic procedures exceeding $1,250 require precertification to avoid a $100 penalty. You pay 100% for maternity or delivery expenses for dependent children.
Services you may need: Delivery and all inpatient services
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Precertification required only if hospital stay is more than 48 hours for vaginal delivery or 96 hours for C-section
Common Medical Event: If you need help recovering or have other special health needs
Services you may need: Home health care
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Plan covers part-time or intermittent skilled nursing care.
Services you may need: Rehabilitation services
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Outpatient physical, occupational & speech therapy require precertification to avoid a $100 penalty. Inpatient rehab admission maximum benefit is 60 days/ person per year.
Services you may need: Habilitation services
Your Cost – In-Network Provider: Not covered.
Your Cost -Out-of-Network Provider: Not covered.
Limitations and Exceptions: You pay 100% of these expenses.
Services you may need: Skilled nursing care
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Maximum benefit is 60 days per year.
Services you may need: Durable medical equipment
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Equipment that is needed for 2 months or longer requires precertification to avoid a $100 penalty.
Services you may need: Hospice service
Your Cost – In-Network Provider: 10% coinsurance after deductible met.
Your Cost -Out-of-Network Provider: 20% coinsurance after deductible met.
Limitations and Exceptions: Covered if terminally ill. Hospice requires precertification to avoid a $100 penalty.
Common Medical Event: If your child needs dental or eye care
Services you may need: Eye exam
Your Cost – In-Network Provider: Not covered.
Your Cost -Out-of-Network Provider: Not covered.
Limitations and Exceptions: You pay 100% of these expenses.
Services you may need: Glasses
Your Cost – In-Network Provider: Not covered.
Your Cost -Out-of-Network Provider: Not covered.
Limitations and Exceptions: You pay 100% of these expenses.
Services you may need: Dental check-up
Your Cost – In-Network Provider: No charge.
Your Cost -Out-of-Network Provider: No charge.
Limitations and Exceptions: Covered for children up to 18 years old.
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
~ Eyeglasses (child)
~ Habilitation services
~ Infertility treatment
~ Long-term care
~ Maternity/Delivery: You pay 100% for maternity or delivery expenses for dependent children.
~ Non-emergency care when traveling outside the U.S.
~ Private duty nursing
~ Routine eye care (child)
~ Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plant document for other covered services and your cost for these services.)
~ Acupuncture (Benefit maximum is 50 visits/ year combined with chiropractic services. Also, you pay any expenses over $30/ visit.
~ Chiropractic care (Benefit maximum is 50 visits/ year combined with acupuncture services. Also, you pay any expenses over $30/ visit.)
~ Bariatric surgery (if endogenous condition exists or, exogenous condition + 50% over ideal weight + weight is threat to life + unsuccessful conservative weight loss)
~ Dental care (adult) (maximum benefit is $2,000/ person per year)
~ Hearing aids (maximum benefit $500/ ear per person once in a 3 year period)
~ Routine eye care (adult) (eyeglasses, frames and contact lenses payable maximum of $200 each 12 months)
~ Routine foot care (payable when medically necessary)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending on 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 continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-877-624-6254. 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 Appeal 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 the Administration Office at 1-877-624-6254. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-877-624-6254.
Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-877-624-6254.
Examples of how this plan might cover costs for a sample medical situation
NOTE: 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 care will also be different. See below for important information about these examples.
About these Coverage Examples:
These examples show how this plan might cover medical care in given situations. Use the examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.
Questions and answers about 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 in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.
What does the Coverage Example show?
~ 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.
Does the Coverage Example predict my own care needs?
~ No. Treatments shows are just examples. The care you would receive for this condition could be different based on your doctor’s advices, your age, the seriousness of your condition, and many other factors.
Does the Coverage Example predict my future expenses?
~ No. 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 depend on the care you receive, the prices your providers charge, and the reimbursement your health plan allows for.
Can I use Coverage Examples to compare plans?
~ Yes. When you look at the Summary of 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 the coverage plan provides.
Are there other costs I should consider when comparing plans?
~ Yes. An important cost is the premium you pay. Generally, the lower you premium, the more you’ll pay out-of-pockets costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health saving accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.
Questions: Call 1-877-624-6254 or visit us at www.abpa.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 www.abpa.com or http://www.dol.gov/ebsa/healthreform or call 1-877-624-6254 to request a copy.
