Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services HMMG, LLC Employee Benefits Plan: Copay 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, 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 Tier I providers:$500 person / $1,000 family; For Tier II.network providers:$1,000 person / $2,000 family for Tier III.out- of-network providers $2,000 person / $4,000 family Yes. Tier I prescription drugs, the following services for Tier 1 and Tier II only preventive care, physician/specialist exam charges, urgent care exam charges, second surgical opinions, allergy testing/serum/injections, Physical/Occupational/Speech therapy, chiropractic care, home health care, hospice care, bereavement counseling, and nutritional counseling, the following services for all Tiers: outpatient/office/independent laboratory diagnostic tests, radiology and pathology administration and interpretation services, renal dialysis, emergency room services, and ambulance services are covered before you meet your deductible.
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/.
Are there services covered before you meet your deductible?
You must pay all of the costs for these services (other than Tier I medications) up to the specific deductible amount before this plan begins to pay for these 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 other deductibles for specific services?
Yes. $200 person/ $400 family for prescription drug coverage.
For Tier I providers:$4,000 person / $8,000 family; For Tier II network providers:$4,000 person / $8,000 family for Tier III out- of-network providers $10,000 person / $20,000 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.
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.
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