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 HSA 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
For in-network providers: $2,000 /individual - employee only or $4,000 /family maximum; For out-of-network providers: $4,000 /individual - employee only or $8,000 /family maximum Combined medical/behavioral and pharmacy deductible Deductible per individual applies when the employee is the only individual covered under the plan. Amount your employer contributes to your account: Up to $250 /individual or $500 /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 policy, the overall family deductible must be met before the plan begins to pay.
What is the overall 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.
Are there services covered before you meet your deductible?
Yes. In-network preventive care & immunizations, in-network preventive drugs.
Are there other deductibles for specific services?
For in-network providers: $5,000 /individual - employee only or $10,000 /family maximum (no more than $6,900 per individual - within a family); For out-of-network providers: $10,000 /individual - employee only or $20,000 /family maximum (no more than $13,800 per individual - within a 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 the out-of-pocket limit for this plan?
What is not included in the out-of-pocket limit?
Even though you pay these expenses, they don't count toward the out-of-pocket limit.
1 of 8
Made with FlippingBook Online newsletter