40 SimpleCare plans offered in 2017 for small group clients. All 40 plans are available OFF The Health Insurance Marketplace (SHOP)
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1 Products available both ON and OFF The Health Insurance Marketplace 40 Simple plans offered in for small group clients. All 40 plans are available OFF The Health Insurance Marketplace (SHOP) 17 plans available for sale both ON/OFF The Marketplace (SHOP) Alliant Network ONLY EHB Formulary No Mail Order New for, 3 Platinum Choices 17 plans available for sale ONLY OFF The Marketplace. These are in addition to the 17 plans listed above. These plans are similar to the ones above but have added features: Alliant Network plus PHCS network wrap EHB Formulary No Mail Order New for, 3 Platinum choices 17 co-pay plans that have the $10/$35/$70/25% Rx benefit design 1 plan with a 70%/30% co-insurance benefit design 6 HDHP Options are available for sale only OFF the Marketplace. These are strictly deductible and co-insurance plans. Alliant Network plus PHCS network wrap EHB Formulary No Mail Order Alliant will not be offering Mail order in but there is a 90-day retail option available The naming convention follows CMS guidelines of unique HIOS ID# Each plan has a suffix of either 00 or 01; i.e or means sold OFF The Marketplace 01 means sold ON The Marketplace August 5, 2016 Alliant Health Plans 1503 N. Tibbs Rd. Dalton, GA
2 An employer s business address (situs) must be included among the listed counties to be eligible for coverage Rate Areas are identified by large white numbers and correspond to the DOI Rate Area Map; all counties in a given rate area must have the same price. Banks 10 Barrow 2 Bartow 3 Carroll 4 Catoosa 7 Chattooga 13 Cherokee 3 Dade 7 Dawson 10 Fannin 9 Floyd 13 Forsyth 3 Franklin 10 Gilmer 13 Gordon 13 Habersham 10 Hall 10 Haralson 4 Hart 10 Heard 4 Jackson 2 Lumpkin 10 Murray 9 Pickens 13 Polk 13 Rabun 10 Stephens 10 Towns 10 Union 10 Walker 7 White 10 Whitfield 9 August 5, 2016 Alliant Health Plans 1503 N. Tibbs Rd. Dalton, GA
3 ON & OFF The Health Insurance Marketplace (SHOP) In-Network Alliant Network ONLY EHB formulary NO MAIL ORD Out-Of-Network PCP Specialist Simple Platinum PPO % $500/$1,000 $1,750/$3,500 $100 $75 $15 $30 $15 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Platinum PPO % $750/$1,500 $1,500/$3,000 $100 $75 $15 $30 $15 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Platinum PPO % $1,000/$2,000 $1,000/$2,000 $100 $75 $15 $30 $15 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Gold PPO % $1,000/$2,000 $4,000/$8,000 $250 $75 $20 $50 $20 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Gold PPO % $1,500/$3,000 $5,000/$10,000 $250 $75 $20 $50 $20 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Gold PPO % $2,100/$4,200 $4,000/$8,000 $250 $75 $20 $50 $20 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Gold PPO % $2,500/$5,000 $3,000/$6,000 $250 $75 $20 $50 $20 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Gold PPO % $3,000/$6,000 $3,000/$6,000 $250 $75 $20 $50 $20 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $3,500/$7,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 40% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $4,000/$8,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 40% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $4,500/$9,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $5,000/$10,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $5,500/$11,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $6,000/$12,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $6,500/$13,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $7,000/$14,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Bronze PPO % $7,000/$14,000 $7,150/$14,300 $500 and Coinsurance Apply 30% 40% $20,000/$40,000 $40,000/$80,000 August 5, 2016 Alliant Health Plans 1503 N. Tibbs Rd. Dalton, GA
4 OFF The Health Insurance Marketplace (SHOP) Alliant Network PLUS PHCS Network Wrap EHB Formulary NO MAIL ORD In-Network Out-Of-Network PCP Specialist Simple Platinum PPO % $500/$1,000 $1,750/$3,500 $100 $75 $15 $30 $15 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Platinum PPO % $750/$1,500 $1,500/$3,000 $100 $75 $15 $30 $15 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Platinum PPO % $1,000/$2,000 $1,000/$2,000 $100 $75 $15 $30 $15 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Gold PPO % $1,000/$2,000 $4,000/$8,000 $250 $75 $20 $50 $20 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Gold PPO % $1,500/$3,000 $5,000/$10,000 $250 $75 $20 $50 $20 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Gold PPO % $2,100/$4,200 $4,000/$8,000 $250 $75 $20 $50 $20 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Gold PPO % $2,500/$5,000 $3,000/$6,000 $250 $75 $20 $50 $20 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Gold PPO % $3,000/$6,000 $3,000/$6,000 $250 $75 $20 $50 $20 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $3,500/$7,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 40% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $4,000/$8,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 40% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $4,500/$9,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $5,000/$10,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $5,500/$11,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $6,000/$12,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $6,500/$13,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Silver PPO % $7,000/$14,000 $7,150/$14,300 $250 $75 $30 $60 $30 $10/$35/$70/25% ($400 max) 60% $20,000/$40,000 $40,000/$80,000 Simple Bronze PPO % $7,000/$14,000 $7,150/$14,300 $500 and Coinsurance Apply 30% 40% $20,000/$40,000 $40,000/$80,000 August 5, 2016 Alliant Health Plans 1503 N. Tibbs Rd. Dalton, GA
5 Insured Only OFF The Health Insurance Marketplace (SHOP) In-Network Alliant Network PLUS PHCS Network Wrap EHB formulary NO MAIL ORD HSA Eligible Out-Of-Network PCP Speciali st Simple Gold HDHP % $2,000 $2,000 and Coinsurance Apply 60% $20,000 $40,000 Simple Gold HDHP % $1,500 $3,000 and Coinsurance Apply 60% $20,000 $40,000 Simple Silver HDHP % $4,000 $4,000 and Coinsurance Apply 60% $20,000 $40,000 Simple Silver HDHP % $2,500 $5,000 and Coinsurance Apply 60% $20,000 $40,000 Simple Bronze HDHP % $6,500 $6,500 and Coinsurance Apply 60% $20,000 $40,000 Simple Bronze HDHP % $5,500 $6,550 and Coinsurance Apply 60% $20,000 $40,000 2 or More Insured OFF The Health Insurance Marketplace (SHOP) PCP Speciali st Alliant Network PLUS PHCS Network Wrap EHB formulary NO MAIL ORD HSA Eligible Simple Gold HDHP % $4,000 $4,000 and Coinsurance Apply 60% $40,000 $80,000 Simple Gold HDHP % $3,000 $6,000 and Coinsurance Apply 60% $40,000 $80,000 Simple Silver HDHP % $8,000* $8,000 and Coinsurance Apply 60% $40,000 $80,000 Simple Silver HDHP % $5,000 $10,000 and Coinsurance Apply 60% $40,000 $80,000 Simple Bronze HDHP % $13,000* $13,000 and Coinsurance Apply 60% $40,000 $80,000 Simple Bronze HDHP % $11,000* $13,100 and Coinsurance Apply 60% $40,000 $80,000 *HDHP Plans with 2+ INSURED: Any 1 (one) person will not be responsible for more than $6,550 August 5, 2016 Alliant Health Plans 1503 N. Tibbs Rd. Dalton, GA
6 Chiropractic care is covered at a primary care cost-share. Limits: Home Health day limit Skilled Nursing - 60-day limit Chiropractic - 20-visit limit Employers who purchase a Simple plan ON The Health Insurance Marketplace [SHOP] may elect a single carrier or elect Employee Choice. When Employee Choice is elected the employer chooses a metal level all employees will choose among. ALL available plans within that metal level, from all carriers participating in SHOP in that employer s county, will be shown to the employee to choose among. The employee elects which carrier s plan best suits their need. For example, a 10 person group could have 4 EE s going to AETNA; 2 going to BSBSGa and 4 going to Alliant. Minimum participation is required in all enrollment months, except for January. Minimum participation on/off SHOP The Health Insurance Marketplace is 70%. If an employer is seeking tax-credits, coverage must be purchased on SHOP. Tax credits are not available on products/purchases outside of SHOP. Those employers purchasing coverage through SHOP on The Health Insurance Marketplace should be aware that CMS does NOT administer COBRA benefits. Alliant will not administer COBRA benefits for plans purchased through SHOP. COBRA or State Continuation administration will remain an employer responsibility. Medicare primary rules continue to apply for groups with 19 or fewer employees. There are no reduced rates for Medicare-primary enrollees. Alliant makes no representation regarding the completeness, accuracy, or timeliness of any information, or that the data represented in this document is error free. See your Summary of Benefits and Coverage for full plan benefits. August 5, 2016 Alliant Health Plans 1503 N. Tibbs Rd. Dalton, GA
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$800 individual/$1,600 family network. $1,600 individual/$3,200 family out-ofnetwork.
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Are there services covered before you meet your deductible?
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You don t have to meet deductibles for specific services.
$start Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services $$ Coverage Period: 7/1/2018-6/30/2019 Hol-Dav, Inc. dba Johnson Automotive: HSA Coverage for: Individual/Family
$300 individual/$900 family network. $1,200 individual/$3,600 family out-ofnetwork.
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You don t have to meet deductibles for specific services.
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You don t have to meet deductibles for specific services.
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What is the overall deductible?
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You don t have to meet deductibles for specific services.
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Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthscopebenefits.com or by calling 1-877-385-8816.
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