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Vasey Heating and Air: HDHPCoverage Period: 1/1/2016-12/31/2016Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: Single/Family Plan Type: HDHPThis 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.iuhealthplans.com/vasey or by calling 1.800.873.2022.Important QuestionsAnswersIU Health 2,600/ 5,200*Encore 3,000/ 6,000*Out-of-Network 6,000 / 12,000*(*individual/family)Why this Matters:You must pay all the costs up to the deductible amount before this plan begins to payfor covered services you use. Check your policy or plan document to see when thedeductible starts over (usually, but not always, January 1st). See the chart starting onpage 2 for how much you pay for covered services after you meet the deductible.Are there otherdeductibles for specificservices?NoYou must pay all of the costs for these services up to the specific deductible amountbefore this plan begins to pay for these services.Is there an out–of–pocket limit on myexpenses?Yes.IU Health 5,000/ 10,000*Encore 6,000/ 12,000*Out-of-Network 12,000 / 24,000*(*individual/family)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.What is not included inthe out–of–pocketlimit?Premium,Even though you pay these expenses, they don’t count toward the out-of-pocketlimit.Is there an overallannual limit on whatthe plan pays?NoThe chart starting on page 2 describes any limits on what the plan will pay for specificcovered services, such as office visits.What is the overalldeductible?Does this plan use anetwork of providers?Do I need a referral tosee a specialist?Are there services thisplan doesn’t cover?Yes. For a list of in-networkproviders call 1.800.873.2022 orSee – www.iuhealthplans.com/vaseyNoYesIf you use an in-network doctor or other health care provider, this plan will pay someor all of the costs of covered services. Be aware, your in-network doctor or hospitalmay 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 chart starting onpage 2 for how this plan pays different kinds of providers.You can see the specialist you choose without permission from this plan.Some of the services this plan doesn’t cover are listed on page 6. See your policy orplan document for additional information about excluded services.Questions: Call 1.800.873.2022 or visit us at www.iuhealthplans.com/vaseyIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/sbc or call 1.800.873.2022 to request a copy.1 of 8
Vasey Heating and Air: HDHPCoverage Period: 1/1/2016-12/31/2016Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: Single/Family Plan Type: HDHP 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, ifthe plan’s allowed amount for an overnight hospital stay is 1,000, your coinsurance 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, copayments and coinsurance amounts.CommonMedical EventServices You May NeedPrimary care visit to treat aninjury or illnessSpecialist visitIf you visit a healthcare provider’s officeor clinicIf you have a testOther practitioner office visitYour Cost If You UseIU Health BusinessSolutions or EncoreProviders 30 copay afterdeductible 60 copay afterdeductibleIU Health and Encore0% coinsurance afterdeductibleYour Cost If YouLimitations & ExceptionsUse an Out-ofNetwork Provider20% coinsurance20% coinsuranceNoneNone20% coinsuranceSpinal Manipulation ChiropracticAnnual Max of 20 VisitsPreventivecare/screening/immunizationNo chargeNo coverageBased on IU Health Planscomprehensive preventive guidelinesDiagnostic test (x-ray, bloodwork)IU Health and Encore0% coinsurance afterdeductible20% coinsuranceNoneQuestions: Call 1.800.873.2022 or visit us at www.iuhealthplans.com/vaseyIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/sbc or call 1.800.873.2022 to request a copy.2 of 8
Vasey Heating and Air: HDHPCoverage Period: 1/1/2016-12/31/2016Summary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventYour Cost If You UseIU Health BusinessSolutions or EncoreProvidersIU Health and Encore0% coinsurance afterdeductibleNetwork/NonNetwork Pharmacy30-90 day supply20% coinsuranceGeneric drugs 10 copay afterdeductible 25 copay afterdeductibleNonePreferred brand drugs 30 copay afterdeductible 75 copay afterdeductibleNoneNon-preferred brand drugs 50 copay afterdeductible 125 copay afterdeductibleNoneServices You May NeedImaging (CT/PET scans, MRIs)If you need drugs totreat your illness orconditionMore informationabout prescriptiondrug coverage isavailable atwww.iuhealthplans.orgSpecialty; BiotechIf you haveoutpatient surgeryFacility fee (e.g., ambulatorysurgery center)Physician/surgeon feesIf you needimmediate medicalattentionCoverage for: Single/Family Plan Type: HDHPEmergency room servicesEmergency medicaltransportation 50 copay afterdeductibleIU Health and Encore0% coinsurance afterdeductibleIU Health and Encore0% coinsurance afterdeductible0% after deductible and 250 copay per visit.IU Health and Encore0% coinsurance afterdeductibleYour Cost If YouLimitations & ExceptionsUse an Out-ofNetwork ProviderNoneMail Order Up to90- day supplyN/APrecertification Required20% coinsuranceafter deductibleNone.20% coinsuranceafter deductibleNone.20% coinsuranceafter deductibleNotification required if confined in anon-Network Hospital0% coinsuranceafter deductiblePrior authorization required for nonemergency ambulanceQuestions: Call 1.800.873.2022 or visit us at www.iuhealthplans.com/vaseyIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/sbc or call 1.800.873.2022 to request a copy.3 of 8
Vasey Heating and Air: HDHPCoverage Period: 1/1/2016-12/31/2016Summary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventServices You May NeedYour Cost If YouLimitations & ExceptionsUse an Out-ofNetwork Provider20% coinsuranceafter deductibleAdditional coinsurance applies foradvanced imaging, nuclear medicine,pharmaceutical products, scopicprocedures, surgery, therapeutictreatments20% coinsurancePrior authorization is required.20% coinsurancePrior authorization is required.20% coinsurance26 visits per year20% coinsurance30 days per year. Prior authorizationrequired. Failure to obtain priorauthorization will result in a reduction inreimbursement.20% coinsurance26 visits per year20% coinsurance30 days per year. Prior authorizationrequired. Failure to obtain priorauthorization will result in a reduction inreimbursement.Prenatal and postnatal careIU Health and Encore0% coinsurance afterdeductible20% coinsuranceNoneDelivery and all inpatient servicesIU Health and Encore0% coinsurance afterdeductible20% coinsuranceNoneUrgent careFacility fee (e.g., hospital room)If you have a hospitalstayPhysician/surgeon feeMental/Behavioral healthoutpatient servicesIf you have mentalhealth, behavioralhealth, or substanceabuse needsYour Cost If You UseIU Health BusinessSolutions or EncoreProvidersCoverage for: Single/Family Plan Type: HDHPMental/Behavioral healthinpatient servicesSubstance use disorder outpatientservicesSubstance use disorder inpatientservicesIf you are pregnant0% after deductible and 100 copay per visit.IU Health and Encore0% coinsurance afterdeductibleIU Health and Encore0% coinsurance afterdeductible 30 copayment afterdeductibleIU Health and Encore0% coinsurance afterdeductible 30 copayment afterdeductibleIU Health and Encore0% coinsurance afterdeductibleQuestions: Call 1.800.873.2022 or visit us at www.iuhealthplans.com/vaseyIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/sbc or call 1.800.873.2022 to request a copy.4 of 8
Vasey Heating and Air: HDHPCoverage Period: 1/1/2016-12/31/2016Summary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventServices You May NeedHome health careIf you need helprecovering or haveother special healthneedsYour Cost If YouLimitations & ExceptionsUse an Out-ofNetwork Provider20% coinsurance60 visits per year. Prior authorizationrequired.Rehabilitation services 30 copay afterdeductible20% coinsurance60 visits combined per year.Occupational, Physical and SpeechTherapy.Habilitation servicesIU Health and Encore0% coinsurance afterdeductible20% coinsuranceCalendar year maximum: 20 visits. Priorauthorization required for therapy.Skilled nursing careIU Health and Encore0% coinsurance afterdeductible20% coinsurance60 days per year. Prior authorizationrequired.Durable medical equipmentHospice serviceIf your child needsdental or eye careYour Cost If You UseIU Health BusinessSolutions or EncoreProvidersIU Health and Encore0% coinsurance afterdeductibleCoverage for: Single/Family Plan Type: HDHPEye examGlassesDental check-upIU Health and Encore0% coinsurance afterdeductibleIU Health and Encore0% coinsurance afterdeductible 30 copay afterdeductibleNot coveredNot covered20% coinsurance20% coinsurance 2,500 per year and are limited to asingle purchase of a type of DurableMedical Equipment (including repair andreplacement) every three years.*Prior authorization is required forDurable Medical Equipment in excess of 500.Prior authorization required. Failure toobtain prior authorization will result in areduction in reimbursement.Not covered1 exam every 2 yearsNot coveredNot coveredNoneNoneQuestions: Call 1.800.873.2022 or visit us at www.iuhealthplans.com/vaseyIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/sbc or call 1.800.873.2022 to request a copy.5 of 8
Vasey Heating and Air: HDHPCoverage Period: 1/1/2016-12/31/2016Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: Single/Family Plan Type: HDHPExcluded 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.) Weight loss programs Infertility treatment Cosmetic procedures Dental care (Adult) AcupunctureOther Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.) Chiropractic care Private-duty nursing Hearing aidsYour 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 healthcoverage. 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 paywhile 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 800.873.2022. You may also contact your state insurance department, theU.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 andHuman 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. Forquestions about your rights, you can contact: IU Health Plans, ATTN: Grievance Specialist, P.O. Box 627, Columbus, Indiana 47202-0627or call1.800.873.2022, or contact the Department of Labor’s Employee Benefits Security Administration at 1.866.444.EBSA (3272) orwww.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 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 �––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next –––––––Questions: Call 1.800.873.2022 or visit us at www.iuhealthplans.com/vaseyIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/sbc or call 1.800.873.2022 to request a copy.6 of 8
Vasey Heating and Air: HDHPCoverage Period: 1/1/2016-12/31/2016Summary of Benefits and Coverage: What this Plan Covers & What it CostsAbout these CoverageExamples:These examples show how this plan might covermedical 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 for: Single/Family Plan Type: HDHPHaving a babyManaging type 2 diabetes(normal delivery)(routine maintenance ofa well-controlled condition) Amount owed to providers: 7,540 Plan pays 4,910 Patient pays 2,630 Amount owed to providers: 5,400 Plan pays 2,560 Patient pays 2,840Sample 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 preventiveTotal 2,900 1,300 700 300 100 100 5,400Patient pays:DeductiblesCopaysCoinsuranceLimits or exclusionsTotal 2,600 30 0 0 2,630Patient pays:DeductiblesCopaysCoinsuranceLimits or exclusionsTotal 2,600 240 0 0 2,840Questions: Call 1.800.873.2022 or visit us at www.iuhealthplans.com/vaseyIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/sbc or call 1.800.873.2022 to request a copy.7 of 8
Vasey Heating and Air: HDHPCoverage Period: 1/1/2016-12/31/2016Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: Single/Family Plan Type: HDHPQuestions 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.What does a Coverage Exampleshow?Can I use Coverage Examplesto compare plans?For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance 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. Yes. When you look at the Summary ofDoes 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. Yourown costs will be different depending onthe care you receive, the prices yourproviders charge, and the reimbursementyour 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. 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 copayments,deductibles, and coinsurance. 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.Questions: Call 1.800.873.2022 or visit us at www.iuhealthplans.com/vaseyIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/sbc or call 1.800.873.2022 to request a copy.8 of 8
Vasey Heating and Air: HDHP Coverage Period: 1/1/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family .
