Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services HMMG, LLC Employee Benefits Plan: HSA 1600 Plan
Coverage Period: 01/01/2024-12/31/2024 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, call 1-312-906- 8080 or go to www.alliedbenefit.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. www.alliedbenefit.com or call 1-312-906-8080 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, the overall family deductible must be met before the plan begins to pay . 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/.
For network providers:$1,600 person / $3,200 family for out- of-network providers $3,200 person / $9,600 family
What is the overall deductible?
Yes. In-network preventive care services, and all routine x-rays/labs are covered before you meet your deductible.
Are there services covered before you meet your deductible? Are there other deductibles for specific services?
There are no other specific deductibles.
You don’t have to meet deductibles for specific services.
For network providers:$4,000 person / $8,000 family for out- of-network providers $15,000 person / $30,000 family Penalties for failure to obtain precertification/preauthorization, services in excess of Plan maximums or limits, premiums, balance- billing charges, and health care this plan doesn’t cover.
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, the overall family out- of-pocket limit must be met.
What is the out-of-pocket limit for this plan?
Even though you pay these expenses, they don’t count toward the out-of- pocket limit.
What is not included in 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.
Will you pay less if you use a network provider?
Yes. See www.alliedbenefit.com or call 1-312-906- 8080 for a list of network providers.
Page 1 of 7
Made with FlippingBook - professional solution for displaying marketing and sales documents online