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The Home Depot Medical PlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2014-12/31/2014Coverage for: Associate Only Plan Type: HMOThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at www.livetheorangelife.com or by calling 1-800-555-4954.Important QuestionsAnswersWhy this Matters:What is the overalldeductible? 0See the chart starting on page 2 for your costs for services this plan covers.Are there otherdeductibles for specificservices?Yes. 750 individual/ 1,500 familycalendar year deductible forYou must pay all of the costs for these services up to the specific deductible amountinpatient facility services applies.before this plan begins to pay for these services.There are no other specificdeductibles.Is there an out–of–pocket limit on myexpenses?Yes. 5,000 individual/ 10,000 familyWhat is not included inthe out–of–pocketlimit?Premiums, some co-payments, and Even though you pay these expenses, they don't count toward the out-of-pockethealth care this plan doesn't cover.limit.Is there an overallannual limit on whatthe plan pays?No.The chart starting on page 2 describes any limits on what the plan will pay for specificcovered services, such as office visits.Does this plan use anetwork of providers?Yes. Seewww.livetheorangelife.com(Health Care Medical andPrescription Drug) or call1-800-587-9503.If you use an in-network doctor or other health care provider, this plan will paysome or all of the costs of covered services. Be aware, your in-network doctor orhospital may use an out-of-network provider for some services. Plans use the termin-network, preferred, or participating for providers in their network. See the chartstarting on page 2 for how this plan pays different kinds of providers.Do I need a referral tosee a specialist?Yes. However members may selfrefer using the Access Self Referralfeature.The plan will pay some or all of the costs to see a specialist for covered services butonly if you have the plan's permission before you see the specialist.Are there services thisplan doesn’t cover?Yes.Some of the services this plan doesn't cover are listed on page 5. See your policy orplan document for additional information about excluded services.The out-of-pocket limit is the most you could pay during a coverage period (usuallyone year) for your share of the cost of covered services. This limit helps you plan forhealth care expenses.Questions: Call 1-800-555-4954 or visit us at www.livetheorangelife.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.livetheorangelife.com/SBCor call 1-800-555-4954 to request a copy.Blue Shield of California is an independentmember of the Blue Shield Association.1 of 8
The Home Depot Medical PlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2014-12/31/2014Coverage for: Associate Only Plan Type: HMO Co-payments are fixed dollar amounts (for example, 15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, ifthe plan’s allowed amount for an overnight hospital stay is 1,000, your co-insurance payment of 20% would be 200. This may change ifyou 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 theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges 1,500 for an overnight stay andthe 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 preferred providers by charging you lower deductibles, co-payments and co-insurance amounts.CommonMedical EventIf you visit a healthcare provider’s officeor clinicIf you have a testYour Cost If YouUse a Out-ofNetwork ProviderServices You May NeedYour Cost If You Use a InNetwork ProviderPrimary care visit to treat aninjury or illness 25 co-pay per visitNot pecialist visit 25 co-pay per visit if referredby personal physician.Not covered 50 co-pay per visit for Access Specialist Self Referral.Other practitioner office visit 15 co-pay per visit forchiropractic services.Not coveredLimited to 30 visits per calendaryear for chiropractic services.Provided by American SpecialtyHealth Network.Preventive care/screening/immunizationNo chargeNot iagnostic test (x-ray, bloodwork)No chargeNot maging (CT/PET scans,MRIs)No chargeNot uestions: Call 1-800-555-4954 or visit us at www.livetheorangelife.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.livetheorangelife.com/SBCor call 1-800-555-4954 to request a copy.Limitations & ExceptionsBlue Shield of California is an independentmember of the Blue Shield Association.2 of 8
The Home Depot Medical PlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventServices You May NeedGeneric drugsIf you need drugs totreat your illness orconditionMore informationabout prescriptiondrug coverage isavailable atwww.livetheorangelife.com (Health Care Medical andPrescription Drug).Preferred brand drugsNon-preferred brand drugsSpecialty drugsYour Cost If You Use a InNetwork ProviderCoverage Period: 01/01/2014-12/31/2014Coverage for: Associate Only Plan Type: HMOYour Cost If YouUse a Out-ofNetwork ProviderRetail: 20% co-insurance ( 10maximum per prescription)Not coveredMail order: 20% co-insurance( 20 maximum per prescription)Retail: 20% co-insurance( 50 maximum per prescription)Mail order: 20% co-insuranceNot covered( 100 maximum perprescription)Retail: 40% co-insurance( 150 maximum perprescription)Not coveredMail order: 40% co-insurance( 300 maximum perprescription) 75 co-pay per prescriptionNot coveredLimitations & ExceptionsCovers up to a 30-day supply(retail); 31-90 day supply (mail).Select formulary and non-formularydrugs require prior authorization.Covers up to a 30-day supply.Prior authorization is required.If you haveoutpatient surgeryIf you needimmediate medicalattentionIf you have ahospital stayFacility fee (e.g., ambulatorysurgery center)Physician/surgeon feesEmergency room servicesEmergency medicaltransportationUrgent careFacility fee (e.g., hospitalroom)Physician/surgeon fee20% co-insuranceNot o charge20% co-insuranceNot covered20% co-insurance 100 co-pay pertransportNot -----------------none-------------------Not ot covered-------------------none------------------- 100 co-pay per transport 25 co-pay per visit20% co-insurance afterdeductibleNo chargeQuestions: Call 1-800-555-4954 or visit us at www.livetheorangelife.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.livetheorangelife.com/SBCor call 1-800-555-4954 to request a ---------------none-------------------Blue Shield of California is an independentmember of the Blue Shield Association.3 of 8
The Home Depot Medical PlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventIf you have mentalhealth, behavioralhealth, or substanceabuse needsIf you are pregnantIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careCoverage Period: 01/01/2014-12/31/2014Coverage for: Associate Only Plan Type: HMOYour Cost If YouUse a Out-ofNetwork ProviderServices You May NeedYour Cost If You Use a InNetwork ProviderMental/Behavioral healthoutpatient services 25 co-pay per visitNot ental/Behavioral healthinpatient servicesSubstance use disorderoutpatient servicesSubstance use disorderinpatient services20% co-insurance afterdeductibleNot covered-------------------none------------------- 25 co-pay per visitNot 0% co-insurance afterdeductibleNot renatal and postnatal careNo chargeNot covered 25 co-pay initial visit only.Delivery and all inpatientservices20% co-insurance afterdeductibleNot ome health care 25 co-pay per visitNot coveredCovers up to 100 visits per calendaryear.Rehabilitation services 25 co-pay per visitNot abilitation services 25 co-pay per visitNot killed nursing care20% co-insuranceNot coveredCovers up to 100 pre-authorizeddays per calendar year.Durable medicalequipmentNo chargeNot ospice serviceNo chargeNot coveredCo-insurance may apply for otherhospice services.Eye examGlassesDental check-upNo chargeNot coveredNot coveredNot coveredNot coveredNot --------none-------------------Questions: Call 1-800-555-4954 or visit us at www.livetheorangelife.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.livetheorangelife.com/SBCor call 1-800-555-4954 to request a copy.Limitations & ExceptionsBlue Shield of California is an independentmember of the Blue Shield Association.4 of 8
The Home Depot Medical PlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2014-12/31/2014Coverage for: Associate Only Plan Type: HMOExcluded 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.) Acupuncture Infertility treatment Routine eye care (Adult) Cosmetic surgery Long-term care Routine foot care Dental care (Adult/Child) Non-emergency care when traveling outsidethe U.S. Weight loss programs Hearing aids Private -duty nursingOther Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.) Bariatric surgery Chiropractic careYour 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 keephealth coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premiumyou 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 1-800-555-4954. 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 Healthand Human Services at 1-877-267-2323 X 61565 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. Forquestions about your rights, this notice, or assistance, you can contact: 1-800-555-4954 or the Department of Labor’s Employee Benefits SecurityAdministration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file yourappeal. Contact California Department of Managed Health Care Help at 1-888-466-2219 or visit http://www.healthhelp.ca.gov.Questions: Call 1-800-555-4954 or visit us at www.livetheorangelife.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.livetheorangelife.com/SBCor call 1-800-555-4954 to request a copy.Blue Shield of California is an independentmember of the Blue Shield Association.5 of 8
The Home Depot Medical PlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2014-12/31/2014Coverage for: Associate Only Plan Type: HMODoes 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 or policy doesprovide minimum essential coverage.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). Thishealth coverage does meet the minimum value standard for the benefits it provides.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-555-4954.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-555-4954.Chinese (中文): �1-800-555-4954.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' �––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next –––––––Questions: Call 1-800-555-4954 or visit us at www.livetheorangelife.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.livetheorangelife.com/SBCor call 1-800-555-4954 to request a copy.Blue Shield of California is an independentmember of the Blue Shield Association.6 of 8
The Home Depot Medical PlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsAbout these CoverageExamples:These examples show how this plan mightcover medical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.This isnot a costestimator.Don’t use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.See the next page forimportant information aboutthese examples.Coverage Period: 01/01/2014-12/31/2014Coverage for: Associate Only Plan Type: HMOHaving a babyManaging type 2 diabetes(normal delivery)(routine maintenance ofa well-controlled condition) Amount owed to providers: 7,540 Plan pays 5,890 Patient pays 1,650 Amount owed to providers: 5,400 Plan pays 4,500 Patient pays 900Sample care costs:Hospital charges (mother)Routine obstetric careHospital charges (baby)AnesthesiaLaboratory testsPrescriptionsRadiologyVaccines, other preventiveTotal 2,700 2,100 900 900 500 200 200 40 7,540Sample care costs:PrescriptionsMedical Equipment and SuppliesOffice Visits and ProceduresEducationLaboratory testsVaccines, other preventiveTotalPatient pays:DeductiblesCo-paysCoinsuranceLimits or exclusionsTotal 750 0 750 150 1,650Questions: Call 1-800-555-4954 or visit us at www.livetheorangelife.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.livetheorangelife.com/SBCor call 1-800-555-4954 to request a copy.Patient pays:DeductiblesCopaysCoinsuranceLimits or exclusionsTotalBlue Shield of California is an independentmember of the Blue Shield Association. 2,900 1,300 700 300 100 100 5,400 0 250 570 80 9007 of 8
The Home Depot Medical PlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2014-12/31/2014Coverage for: Associate Only Plan Type: HMOQuestions and answers about the Coverage Examples:What are some of theassumptions behind theCoverage Examples? Costs don’t include premiums.Sample care costs are based on nationalaverages supplied by the U.S.Department of Health and HumanServices, and aren’t specific to aparticular geographic area or health plan.The patient’s condition was not anexcluded or preexisting condition.All services and treatments started andended in the same coverage period.There are no other medical expenses forany member covered under this plan.Out-of-pocket expenses are based onlyon treating the condition in the example.The patient received all care from innetwork providers. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.Plan and patient payments are based ona single person enrolled on the plan orpolicy.What does a Coverage Exampleshow?For each treatment situation, the CoverageExample helps you see how deductibles, copayments, and co-insurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn’t covered or payment is limited.Does the Coverage Examplepredict my own care needs? No. Treatments shown are just examples.The care you would receive for thiscondition could be different based on yourdoctor’s advice, your age, how serious yourcondition is, and many other factors.Does the Coverage Examplepredict my future expenses? No. Coverage Examples are not costestimators. You can’t use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Your owncosts will be different depending on the careyou receive, the prices your providers charge,Questions: Call 1-800-555-4954 or visit us at www.livetheorangelife.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.livetheorangelife.com/SBCor call 1-800-555-4954 to request a copy.and the reimbursement your health planallows.Can I use Coverage Examplesto compare plans? Yes. When you look at the Summary ofBenefits and Coverage for other plans,you’ll find the same Coverage Examples.When you compare plans, check the“Patient Pays” box in each example. Thesmaller that number, the more coveragethe plan provides.Are there other costs I shouldconsider when comparingplans? Yes. An important cost is the premiumyou pay. Generally, the lower yourpremium, the more you’ll pay in out-ofpocket costs, such as co-payments,deductibles, and co-insurance. Youshould also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements(FSAs) or health reimbursement accounts(HRAs) that help you pay out-of-pocketexpenses.Blue Shield of California is an independentmember of the Blue Shield Association.8 of 8
Blue Shield of California is an independent 1 of 8 member of the Blue Shield Association. The Home Depot Medical Plan Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Associate Only Plan Type: HMO Questions: Call 1-800-555-4954 or visit us at www.livetheorangelife.com. If you aren’t File Size: 537KB
