blue shield/indemnity plan summary of benefits · flu vaccine covered in full out-of-network. if...

HUDSON VALLEY COMMUNITY COLLEGESUMMARY OF BENEFITS This is a summary only. It is not intended to be a complete description of benefitswhich are governed by the contract between the College and the insurer.BLUE SHIELD Traditonal Blue 908Annual Deductible $100 Individual/$300 Family

for Major Medical BenefitsCoinsurance 20% of Usual & CustomaryLifetime Out of Pocket Maximum When 20% coinsurance

reaches $500.Annual Maximum Benefit $1,000,000Lifetime Maximum Benefit $1,000,000Dependent Coverage Covered to Age 26

*There is a $240 DeductibleHOSPITAL COVERAGE That Is Reimbursed By HVCC

Inpatient Hospitalization Covered In Full*Outpatient Hospital Services Covered In Full*Outpatient Hospital Surgery Covered In Full*Maternity Covered In Full*Diagnostic Radiology Covered In Full*Diagnostic Laboratory Tests Covered In Full*

MEDICAL/SURGICAL COVERAGE IN NETWORKDiagnostic Radiology Covered In FullDiagnostic Laboratory Tests Covered In FullMaternity Covered In FullSurgical Procedures Covered In FullRoutine Mammograms Covered In FullAnesthesia Covered In FullPhysical Therapy Covered In Full*

MAJOR MEDICAL COVERAGEPrimary Care Physician Office Visit Deductible & CoinsuranceSpecialist Office Visit Deductible & CoinsuranceWell Child Care & Immunizations Covered In FullAnnual Gynecological Visit Deductible & CoinsuranceMental HealthOutpatient Deductible & CoinsuranceDurable Medical Equipment Deductible & CoinsuranceChiropractic Deductible & CoinsuranceAdult Immunizations Covered In FullAnnual Physical Exam Covered In FullDental Not coveredRoutine Vision Exam Not covered

OTHER COVERAGEMental Health Inpatient Covered In full*Alcohol/Substance Abuse Inpatient Covered in Full-Detox/Rehab*Alcohol/Substance Abuse Outpatient Deductible & CoinsurancePrescription Drugs $5 Generic/$20 BrandInpatient Hospitalization Precertification No Primary Care Physician Required No Specialty Referral Required No

Prescription drug coverage is Creditable Coverage with respect to Medicare Part D. This is a traditional Indemnity Plan. It does not require selection of a Primary Care Physician nor do you need a referral for specialty care. You may select any licensed provider. However, benefits are maximized if you use participating providers. Unlike HMO's, many routine services are not covered (or may impose a co-insurance). Physician visits are subject to deductible and coinsurance and you may need to submit claim forms in some cases.

Medical/Surgical benefits for covered services received from out-of-network providers are paid at the in-network fee schedule with any balances paid as a Major Medical Benefit subject to deductible and coinsurance.

1-800-888-1238 bsneny.com

Benefit Summary for Group:Hudson Valley Community College

Effective Date: 1/1/2020Traditional Blue 908

Participating Additional Information

General Information

Provider Network Indemnity

Additional Benefits Deductible $100/$200/$300

Deductible Administration Type Additional Benefits Deductible: $100/$200/$300----------Embedded deductible - once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied.

Additional Benefits Coinsurance 20% coinsurance

Coinsurance Waiver Stop Loss - $2000 Lifetime

Stop Loss Administration Type Embedded - On family plans, one person cannot exceed the individual deductible

and Stop Loss maximum

Benefit Administration Date 1/1

Combined Inpatient & Outpatient Hospital Deductible $240/$720

Dependent Coverage

Dependent Age 26/26

Dependent Coverage Ends Birth date

Domestic Partner and Children Not covered

Prescription Drug Coverage

Prescription Drugs $5 copayment/$20 copayment

Mail Order 2 copays per 90 day supply

Prescription Deductible No

Page 1 of 3

A division of HealthNow New York Inc., an independent licensee of the Blue Cross and Blue Shield Association.

11/13/2019 Quote #: QR-230216 Group ID: 10300200, Class ID: 0001

Traditional Blue 908


Physician and Other Services

Primary Office Visit 20% coinsurance after deductible

Specialist Office Visit 20% coinsurance after deductible

Telemedicine 20% coinsurance after deductible

Outpatient Surgical Procedures (in physician's office) Covered in full

Emergency and Urgent Care Services

Emergency Room Covered in full after hospital deductible

Ambulance - Ground & Air Ambulance Covered in full

Urgent Care Center 20% coinsurance after hospital deductible

Preventive Services

Bone mineral density measurement or test Covered in full

Cholesterol Test (lipid panel) Covered in full

Immunizations Covered in full

Mammogram Covered in full

Prostate Test (Prostate Specific Antigen "PSA") Covered in full

Well Child Visits Covered in full

Hospital Services

Inpatient Hospital Covered in full after hospital deductible

Outpatient Surgical Procedure (Facility) Covered in full after hospital deductible Preauth required for certain procedures. Follow Corporate guidelines.

Skilled Nursing Facility Covered in full after hospital deductible Unlimited days within 30 days of discharge

Diagnostic Testing Services

Radiology Covered in full after hospital deductible

Maternity ServicesPhysician Services: Prenatal and Postnatal Care (initial visit) Covered in full

Inpatient Maternity Covered in full after hospital deductibleMental Health and Substance Abuse

Inpatient Mental Health and Substance Abuse Covered in full after hospital deductible

Outpatient Mental Health and Substance Abuse Covered in full after hospital deductible

Diabetic Supplies and Services

Diabetic Equipment and Medical Supplies $5 copayment/$20 copayment

Insulin and Other Oral Agents $5 copayment/$20 copayment

Page 2 of 311/13/2019 Quote #: QR-230216 Group ID: 10300200, Class ID: 0001

Traditional Blue 908


Rehabilitation Services

Chiropractic Care 20% coinsurance after deductible

Occupational Therapy Covered in full after hospital deductible Unlimited Visits

Physical Therapy Covered in full after hospital deductible Unlimited Visits

Speech Therapy Covered in full after hospital deductible Unlimited Visits

Additional Services

Chemotherapy - Outpatient Facility Covered in full after hospital deductible

Durable Medical Equipment 20% coinsurance after deductible

Hospice Covered in full after hospital deductible 210 days per calendar year

Prosthetics & orthotics 20% coinsurance after deductible

Dialysis Covered in full after hospital deductible

Wellness Card Not covered

Pediatric Vision Services

Routine Exam Covered in full

Medical Eye Exam 20% coinsurance after deductible

Adult Vision Services

Routine Exam Covered in full

Medical Eye Exam 20% coinsurance after deductible

*For paid in full benefits from non-par providers, we will pay 100% of Fee Schedule and rollover the difference between ourpayments and the charges, subject to deductible and reimbursed at 80%.**For a list of Medicare Part D creditable coverage prescription drug plans, please refer to our website.***This is a summary of covered benefits and exclusions and is not intended as an actual contract or groupplan. It does not detail all benefits, limitations and exclusions that may apply

Page 3 of 311/13/2019 Quote #: QR-230216 Group ID: 10300200, Class ID: 0001

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, go to www.bsneny.com or call 1-800-888-1238. 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.bsneny.com or call 1-800-888-1238 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

$0 deductible In-network; $0 deductible Out-of-network See the Common Medical Events chart below for your costs for services this plan covers.

Are there services covered before you meet your deductible?

Yes

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

Yes. $100/$200/$300 additional benefits deductible; 20% coinsurance services; Combined hospital - $240/$720 deductible. There are no other specific deductibles.

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.

What is the out-of-pocketlimit for this plan? Stop Loss - $2000 Lifetime The out-of-pocket limit is the most you could pay in a year for covered services.

What is not included in the out-of-pocket limit?

Premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less if youuse a networkprovider?

Not Applicable This plan does not use a provider network. You can receive covered services from any provider.

Do you need a referral to see a specialist? No You can see the specialist you choose without a referral.

BlueShield of Northeastern New York: Traditional Blue 908

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage for:-All Tiers | Plan Type: Indemnity

Coverage Period: 1/1/2020 - 12/31/2020

1 of 6The plan would be responsible for the other costs of these EXAMPLE covered services. Group ID: 10300200Class: 0001

Date Created: 12/05/2019

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need

What You Will PayLimitations, Exceptions & Other Important

InformationNetwork Provider(You will pay the

least)

Out-of-NetworkProvider

(You will pay the most)

If you visit a healthcare provider’s office or clinic

Primary care visit to treat an injury or illness 20% coinsurance 20% coinsurance None

Specialist visit 20% coinsurance 20% coinsurance None

Preventive care/screening/immunization 0% coinsurance 0% coinsurance

You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Flu vaccine covered in full out-of-network.

If you have a testDiagnostic test (x-ray, blood work)

0% coinsurance for x-ray; 0% coinsurance for blood work

0% coinsurance for x-ray; 0% coinsurance for blood work

None

Imaging (CT/PET scans, MRIs) 0% coinsurance 0% coinsurance Prior authorization required on certain procedures. Call the number on the back of your ID card for details.

If you need drugs totreat your illness or conditionMore informationabout prescriptiondrug coverage is available at www.bsneny.com

Generic drugs (Tier 1) $5 copayment Not covered Some generic drugs may be subject to non-preferred brand cost share.

Preferred brand drugs (Tier 2) $20 copayment Not covered None

Non-preferred brand drugs (Tier 3) Not covered Not covered None

Specialty drugs (Tier 4) See limitations & exceptions

See limitations & exceptions

Specialty drugs could be generic, preferred brand or non-preferred brand. Please visit our website for a copy of our medication guide.

If you haveoutpatient surgery

Facility fee (e.g., ambulatory surgery center) 0% coinsurance 0% coinsuranceSpecialty drugs could be generic, preferred brand or non-preferred brand. Please visit our website for a copy of our medication guide.

Physician/surgeon fees 0% coinsurance 0% coinsurance Prior authorization required on certain procedures. Call the number on the back of your ID card for details.

If you need immediate medical attention

Emergency room care 0% coinsurance 0% coinsurance None

Emergency medical transportation 0% coinsurance 0% coinsurance None

Urgent care 20% coinsurance 20% coinsurance None



http://www.bsneny.com/




least)



If you have a hospital stayFacility fee (e.g., hospital room) 0% coinsurance 0% coinsurance Prior authorization required. 365 Days unlimited rollover

Physician/surgeon fees 0% coinsurance 0% coinsurance None

If you need mentalhealth, behavioral health, or substance abuse services

Outpatient services

0% coinsurance for Mental Health; 0% coinsurance for Substance Abuse

0% coinsurance for Mental Health; 0% coinsurance for Substance Abuse

None

Inpatient services

0% coinsurance for Mental Health; 0% coinsurance for Substance Abuse Detox; 0% coinsurance for Substance Abuse Rehab

0% coinsurance for Mental Health; 0% coinsurance for Substance Abuse Detox; 0% coinsurance for Substance Abuse Rehab

Prior authorization required on certain procedures. Call the number on the back of your ID card for details.

If you are pregnant

Office visits 20% coinsurance 20% coinsurance None

Childbirth/delivery professional services 0% coinsurance 0% coinsurance For participating providers, cost share applies only to initial visit to determine pregnancy.

Childbirth/delivery facility services 0% coinsurance 0% coinsurance Prior authorization required.

If you need helprecovering or have other special health needs

Home health care 0% coinsurance 0% coinsurance Prior authorization required. 40 Visits

Rehabilitation services

0% coinsurance for Occupational; 0% coinsurance for Physical; 0% coinsurance for Speech

0% coinsurance for Occupational; 0% coinsurance for Physical; 0% coinsurance for Speech

Unlimited Visits

Skilled nursing care 0% coinsurance 0% coinsurance Prior authorization required. Unlimited days within 30 days of discharge

Durable medical equipment 20% coinsurance 20% coinsurance Prior authorization required.

Hospice services 0% coinsurance 0% coinsurance 210 days per calendar year






least)



If your child needsdental or eye care

Children’s eye exam 20% coinsurance Not covered None

Children’s glasses See limitations & exceptions

See limitations & exceptions Discounts may apply.

Children’s dental check-up See limitations & exceptions

See limitations & exceptions Contact your group administrator for coverage details.



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.)

• Custodial Care

• Long Term Care

• Weight Loss Programs

• Acupuncture

• Dental

• Routine Eye Care (Adult)

• Cosmetic surgery

• Hearing Aids

• Routine Foot Care

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Elective Abortion

• Private Duty Nursing

• Bariatric surgery

• Infertility treatment

• Chiropractic care

• Non-emergency care when traveling outside the U.S.

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: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA(3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: 1-800-888-1238.

Does this plan provide Minimum Essential Coverage? YesIf you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet Minimum Value Coverage? YesIf your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-888-1238.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-888-1238.Chinese (中文):如果需要中文的帮助，请拨打这个号码 1-800-888-1238.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-888-1238.––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––



http://www.healthcare.gov/

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

In this example, Peg would pay:Cost Sharing

Deductibles* $340Copays $20Coinsurance $40

What isn’t coveredLimits or exclusions $60The total Peg would pay is $460

Peg is Having a Baby(9 months of in-network pre-natal care and a hospital

delivery)

n The plan’s overall deductible $100.00n Specialist coinsurance 20%n Hospital (facility) copayment $240.00n Other coinsurance 20%

Total Example Cost $12,732

This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)

Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: BlueShield of Northeastern New York at www.bsneny.com or call 1-800-888-1238.*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?" row above.

In this example, Joe would pay:Cost Sharing


What isn’t coveredLimits or exclusions $55The total Joe would pay is $1,128

Managing Joe’s type 2 Diabetes(a year of routine in-network care of a well-controlled

condition)



This EXAMPLE event includes services like:Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)

In this example, Mia would pay:Cost Sharing


What isn’t coveredLimits or exclusions $0The total Mia would pay is $246

Mia’s Simple Fracture(in-network emergency room visit and

follow up care)



This EXAMPLE event includes services like:Emergency room care (including medicalsupplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)



https://www.healthcare.gov/sbc-glossary/#plan

https://www.healthcare.gov/sbc-glossary/#provider

https://www.healthcare.gov/sbc-glossary/#cost-sharing

https://www.healthcare.gov/sbc-glossary/#deductible

https://www.healthcare.gov/sbc-glossary/#copayment

https://www.healthcare.gov/sbc-glossary/#coinsurance

https://www.healthcare.gov/sbc-glossary/#excluded-services

https://www.healthcare.gov/sbc-glossary/#excluded-services







https://www.healthcare.gov/sbc-glossary/#specialist





























Notice of Nondiscrimination

BlueShield of Northeastern New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. BlueShield of Northeastern New York does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

BlueShield of Northeastern New York:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

◦ Qualified sign language interpreters

◦ Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

◦ Qualified interpreters

◦ Information written in other languages

If you need these services, please call the customer service number on the back of your ID card or contact the Director, Corporate Compliance and Privacy Officer.

If you believe that BlueShield of Northeastern New York has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Director, Corporate Compliance and Privacy Officer, 257 West Genesee Street, Buffalo, NY 14202, 1-800-798-1453, (716) 887-6056 (fax), [email protected]. You can file a grievance in person or by mail, fax, or email. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Notice of NondiscriminationFor assistance in English, call customer service at the numberlisted on your ID card.

Para obtener asistencia en español, llame al servicio de atención alcliente al número que aparece en su tarjeta de identificación.

請撥打您 ID 卡上的客服號碼以尋求中文協助。

Обратитесь по номеру телефона обслуживания клиентов,указанному на Вашей идентификационной карточке, для помощи на русском языке.

Rele nimewo sèvis kliyantèl ki nan kat ID ou pou jwenn èd nan KreyòlAyisyen.

한국어로 도움을 받고 싶으시면 ID 카드에 있는 고객 서비스 전화번호로 문의해 주십시오.

Per assistenza in italiano chiamate il numero del servizio clienti riportato nella vostra scheda identificativa.

ąđáĊđĠ�čĎđĠþđĉ�öĂƟ��äăĂđĉ�äåĒû�ïđĘûŪ �þđĒĊïđĆĔ Ǐ�Ă˘Ęĉ�ĺƠþđ�ăĒĉĘČąđĠ�ĺĄđĂ�ï˙ĂÞ

Aby uzyskać pomoc w języku polskim, należy zadzwonić do działu obsługi klienta pod numer podany na identyfikatorze.

ں ال ک ردە نم پر رج ک رڈ پر د ا وس آپ شناخ ، کسٹمر ردو م مدد ل ا

Pour une assistance en français, composez le numéro de téléphone du service à la clientèle figurant sur votre carte d’identification.

ال کر یں۔ رج نم پر رڈ پر د ا وس کو اپ آ ڈی ، کسٹمر ان م مدد ل ز ردو ا

Para sa tulong sa Tagalog, tumawag sa numero ng serbisyo sa customer na nasa inyong ID card.

Για βοήθεια στα ελληνικά, καλέστε το τμήμα εξυπηρέτησης πελατώνστον αριθμό που αναφέρεται στην ταυτότητά σας.

Për ndihmë në gjuhën shqipe, merrni në telefon shërbimin klientor në numrin e renditur në kartën tuaj të identitetit.

blue shield/indemnity plan summary of benefits · flu vaccine covered in full out-of-network. if...

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