What You Will Pay
Out-of-Network Provider (You will pay the most) Payment of all Out-Of-Network professional services will be limited to 135% of the Medicare fee schedule. Payment of all Out-Of-Network facility services will be limited to 175% of the Medicare fee schedule
Limitations, Exceptions, & Other Important Information
Common Medical Event
Services You May Need
Network Provider (You will pay the least)
Hospice services
0% coinsurance
40% coinsurance
Pre-notification is recommended.
No charge, deductible does not apply
Children’s eye exam
40% coinsurance
Applies from birth through age 5.
If your child needs dental or eye care
Children’s glasses
Not covered
Not covered
Not covered.
Children’s dental check-up Not covered
Not covered
Not covered.
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.)
Glasses (Child) Hearing Aids Long Term Care
• • •
Bariatric Surgery Cosmetic Surgery Dental Care (Adult)
Private-duty nursing
• • • •
• • • •
Routine eye care (Adult)
Routine Foot Care
• Non-emergency care when traveling outside the U.S.
Dental check-ups (Child)
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 (limited to 30 visits per calendar •
Infertility treatment (except promotion of
Acupuncture
•
year)
conception)
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: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. 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 on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or
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