2020 SBC HRA Plan_Mid-America Apartments_3332254_01.01.2020

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Mid-America Apartments, L.P.: Choice Fund Open Access Plus HRA Coverage for: Individual/Individual + Family | Plan Type: OAP 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 online at www.cigna.com/sp. 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-Cigna24 to request a copy. Important Questions Answers Why This Matters: Coverage Period: 01/01/2020 - 12/31/2020

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. 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/. You don't have to meet deductibles for specific services. 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. Even though you pay these expenses, they don't count toward the out-of-pocket limit.

What is the overall deductible?

For in-network providers: $1,500 /individual or $3,000 /family; For out-of-network providers: $3,000 /individual or $6,000 /family

Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan?

Yes. In-network preventive care & immunizations, office visits, prescription drugs, urgent care facility visits, and ambulance services.

No.

For in-network providers $4,000 /individual or $8,000 /family; For out-of-network providers $8,000 /individual or $16,000 /family Combined medical/behavioral and pharmacy out-of-pocket limit Penalties for failure to obtain pre-authorization for services, premiums, balance-billing charges, and health care this plan doesn’t cover.

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

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