Plan 2 NGF
High Deductible Health Plan
Coverage Period: Beginning on or after 10/01/2024
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Coverage for: Individual/Family| Plan Type: PPO
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 www.bcbsks.com/blueaccess or call 1-800-432-3990. 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.bcbsks.com/blueaccess or call 1-800-432-3990 to request a copy.
Important Questions Answers
Why this Matters:
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 . 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/.
What is the overall deductible?
$6,000 person/ $12,000 family. Doesn't apply to In-Network preventive care.
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, preventive care.
No. There are no other specific deductibles . You don ’ t have to meet deductibles for specific services.
Deductible is $6,000 person / $12,000 family. Total out of pocket max is $6,350 person/ $12,700 family. Premiums , balance-billing charges, and health care this plan doesn ’ t cover. 20% non PPO penalty applies annually up to $2,000 person / $4,000 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?
Even though you pay these expenses, they don ’ t count toward the out-of-pocket limit .
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.
Yes. See www.bcbsks.com /providerdirectory or call 1-800-432-3990 for a list of network providers .
Will you pay less if you use a network provider?
Do you need a referral to see a specialist?
specialist you choose without a referral .
No.
You can see the
Questions: Call 1-800-432-3990 or visit us at www.bcbsks.com . If you aren ’ t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-432-3990 to request a copy.
(DT - OMB control number: 1545- 0047/Expiration Date: 12/31/2019) (DOL - OMB control number: 1210- 0147/Expiration Date:5/31/2022) (HHS - OMB control number: 0938- 1146/Expiration date: 10/31/2022)
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