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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 1/1/2020 – 12/31/2020

HMO HDHP Bronze 6900 Coverage for: Individual/Family | Plan Type: HMO

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, visit aspirusarise.com or call 1-800-332-6290 . 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 https://www.healthcare.gov/sbc-glossary /or call 1-800-332-6290 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

For participating providers: $6,900 / Covered Person or $13,800 / Family.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Preventive care services are covered before you meet your deductible.

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?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

For participating providers: $6,900 / Covered Person or $13,800 / Family.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

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 you use a network provider?

Yes. See https://secure.wecareforwisconsin.com/aspirus_arise/find_a_doctor/

or call 1-800-332-6290 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No. You can see the participating specialist you choose without a referral.

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Common

Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Participating Provider (You will pay the least)

Non-Participating Provider

(You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

0% coinsurance Not covered None

Specialist visit 0% coinsurance Not covered None

Preventive care/screening/ immunization

No charge Not covered

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.

If you have a test

Diagnostic test (x-ray, blood work)

0% coinsurance Not covered Certain genetic tests and high-technology

imaging may require prior authorization. Benefits may not be payable if you do not obtain prior authorization.

Imaging (CT/PET scans, MRIs)

0% coinsurance Not covered

If you need drugs to treat your illness or condition More information about

prescription drug

coverage is available at

https://www.aspirusaris

e.com/wps/wcm/conne

ct/whi/5053e398-9389-

4a90-bc4d-

ffea09a53785/31713_2

020-individual-small-

group-drug-

formulary.pdf?MOD=AJ

PERES&CVID=mPtRiQj

Generic drugs 0% coinsurance Not covered Covers up to a 30-day supply retail / 90-day supply home delivery. Specialty drugs are always limited to a 30-day supply. If brand is dispensed when a generic is available, you are responsible for the cost difference between brand and generic which does not count toward your out-of-pocket limits. Specialty drugs and drugs provided by an entity other than a pharmacy require prior authorization. Benefits may not be payable if you do not obtain prior authorization.

Preferred brand drugs 0% coinsurance Not covered

Non-preferred brand drugs 0% coinsurance Not covered

Specialty drugs 0% coinsurance Not covered

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

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Common

Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Participating Provider (You will pay the least)

Non-Participating Provider

(You will pay the most)

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

0% coinsurance Not covered None

Physician/surgeon fees 0% coinsurance Not covered None

If you need immediate medical attention

Emergency room care 0% coinsurance 0% coinsurance

None Emergency medical transportation

0% coinsurance 0% coinsurance

Urgent care 0% coinsurance 0% coinsurance

If you have a hospital stay

Facility fee (e.g., hospital room)

0% coinsurance Not covered

Non-emergent inpatient hospital stays require prior authorization. Benefits may not be payable if you do not to obtain prior authorization.

Physician/surgeon fees 0% coinsurance Not covered Non-emergent inpatient hospital stays require prior authorization. Benefits may not be payable if you do not obtain prior authorization.

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

Outpatient services 0% coinsurance Not covered Non-emergent inpatient hospital stays require prior authorization. Benefits may not be payable if you do not obtain prior authorization. Inpatient services 0% coinsurance Not covered

If you are pregnant

Office visits 0% coinsurance Not covered Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Non-emergent inpatient hospital stays require prior authorization. Benefits may not be payable if you do not obtain prior authorization.

Childbirth/delivery professional services

0% coinsurance Not covered

Childbirth/delivery facility services

0% coinsurance Not covered

If you need help recovering or have

Home health care 0% coinsurance Not covered Coverage is limited to 60 visits/year

Rehabilitation services 0% coinsurance Not covered Rehabilitation services:

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Common

Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Participating Provider (You will pay the least)

Non-Participating Provider

(You will pay the most)

other special health needs

Habilitation services 0% coinsurance Not covered

Coverage is limited to 20 visits/year for physical therapy; 20 visits/year for occupational therapy; and 20 visits/year for speech therapy. Habilitation services: Coverage is limited to 20 visits/year for physical therapy; 20 visits/year for occupational therapy; and 20 visits/year for speech therapy.

Skilled nursing care 0% coinsurance Not covered

Coverage is limited to 30 days per confinement in a skilled nursing facility. Non-emergent admissions require prior authorization. Benefits may not be payable if you do not obtain prior authorization.

Durable medical equipment 0% coinsurance Not covered

Coverage is limited to a single purchase of a type of durable medical equipment every three years. Prior authorization required for: • All CPAP purchases and rentals • Purchases over $1,000 • All other rentals as stated on our website Benefits may not be payable if you do not obtain prior authorization.

Hospice services 0% coinsurance Not covered Hospice services require prior authorization. Benefits may not be payable if you do not obtain prior authorization.

If your child needs dental or eye care

Children’s eye exam No charge Not covered Coverage limited to one exam/year.

Children’s glasses 0% coinsurance Not covered Coverage limited to one pair of glasses/year.

Children’s dental check-up Not covered Not covered No coverage for dental check-ups.

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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.)

• Abortion (except in cases of rape, incest, or when the life of the mother is endangered)

• Acupuncture

• Bariatric Surgery

• Cosmetic Surgery

• Dental Care

• Infertility Treatment

• Long Term Care

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

• Private Duty Nursing

• Routine eye care (Adult)

• Routine Foot Care

• Weight Loss Programs

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

• Chiropractic Care • Hearing Aids

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: for the Wisconsin Office of the Commissioner of Insurance at 1-800-236-8517; or the Department of Health and Human Services at 1-877-267-2323 x

61565 or www.cciio.cms.gov. 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: Aspirus Arise at 1-800-332-6290 . You may also contact your state insurance department at 1-800-236-8517. Does this plan provide Minimum Essential Coverage? Yes. If 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 Standards? Yes. If 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.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. ––––––––––––––––––––––

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The plan would be responsible for the other costs of these EXAMPLE covered services.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well-controlled condition)

◼ The plan’s overall deductible $6,900 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,800

In this example, Peg would pay:

Cost Sharing

Deductibles $6,900

Copayments $0

Coinsurance $0

What isn’t covered

Limits or exclusions $10

The total Peg would pay is $6,910

◼ The plan’s overall deductible $6,900 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost $7,400

In this example, Joe would pay:

Cost Sharing

Deductibles $6,900

Copayments $0

Coinsurance $0

What isn’t covered

Limits or exclusions $0

The total Joe would pay is $6,900

◼ The plan’s overall deductible $6,900 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $1,900

In this example, Mia would pay:

Cost Sharing

Deductibles $1,900

Copayments $0

Coinsurance $0

What isn’t covered

Limits or exclusions $0

The total Mia would pay is $1,900

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.

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