Summary of Benefits and Coverage: What this Plan Covers and What You Pay for Covered Services Coverage Period: 01/01/2018 12/31/2018 SBHB2 GE Health Benefits: Option 2 Coverage for: 1 Person/2 Person/3 or More Plan Type: CDHP - HRA 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 1-800-252-5259. 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 https://www.ge.com/hbsbc or call 1-800-252-5259 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-ofpocket limit for this plan? 1 Person 2 Person 3 or More Deductible: $1200 $2,400 $3,000 HRA Credit: $600 $900 $1,200 The HRA Credit is allocated by GE each year to use toward out-of-pocket health care costs, including those that count toward meeting the deductible. The deductible does not to 1) preventive care 2) diabetes supplies and 3) targeted or specialty drugs. Out-ofnetwork charges over the maximum payment allowance, the difference in cost between a brand and generic drug when a generic is available, and charges for excluded services do not count toward the deductible. No It is based on annual pay and coverage tier. Includes deductible and coinsurance maximum. Annual Pay 1 Person 2 Person 3 or More Less than $50,000 $2,650 $4,575 $5,900 $50,000 - $74,999 $2,950 $5,025 $6,500 $75,000 - $99,999 $3,450 $5,775 $7,500* $100,000 or higher $4,200 $6,900 $9,000* *No individual family member can pay more out-ofpocket than $7,350. 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 contributes to the deductible until the total amount of deductible expenses paid by all family members is met. The deductible starts over January 1st of each calendar year. See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may. For example, this plan covers certain preventive services without costsharing and before you meet your deductible. See a list of covered preventive services at https://www.gehealthahead.com/sites/default/files/health_benefits_preventive_grid.pdf The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. If you have other family members in this plan, you and they will need to meet the plan s applicable out-of-pocket limit. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016 1 of 6
Important Questions Answers Why This Matters: What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? Premiums, balance-billing charges, the difference in cost between a brand and generic drug when a generic is available, manufacturers coupons and rebates, and health care this plan doesn t cover. Yes. Go to https://www.globalempservices.com/healthcarehub for direct links to provider information or call the number on your Medical ID card for information. No. 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. You can see the specialist you choose without permission from this plan. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need What You Will Pay Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance None Specialist visit 20% coinsurance 40% coinsurance None Preventive care/screening/ immunization No charge, deductible does not Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Limitations, Exceptions, & Other Important Information Covered in-network only. You may have to pay for services that aren t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. None 2 of 6
Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.optumrx.com If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services Services You May Need Generic drugs Brand drugs Targeted drugs Specialty drugs What You Will Pay Network Provider (You will pay the least) $12/retail; $24/mail order 30% coinsurance/retail; 20% coinsurance /mail order $12/retail; $24/mail order, deductible does not $90/retail; $270/mail order, deductible does not Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Covers up to a 30-day supply (retail subscription); Up to 90-day supply (mail order prescription and at certain retail pharmacies). Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance None Physician/surgeon fees 20% coinsurance 40% coinsurance None Emergency room care 20% coinsurance 20% coinsurance Emergency room care: No charge, No charge, deductible does not Emergency medical deductible does not transportation Urgent care 20% coinsurance 40% coinsurance Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance You pay 40% coinsurance, if not a true emergency Emergency medical transportation: If not medically necessary, not covered. Urgent care Covered on same basis as emergency room services if a true emergency Semi-private room rate Physician/surgeon fees 20% coinsurance 40% coinsurance None Outpatient services 20% coinsurance 40% coinsurance Pre-authorization not required of you, but innetwork providers may need to obtain preauthorization based on their contracts with the Claims Administrator(s). EAP available at no Inpatient services 20% coinsurance 40% coinsurance cost for outpatient mental health and behavioral health services. 3 of 6
Common Medical Event If you are pregnant If you need help recovering or have other special health needs Services You May Need Office visits What You Will Pay Network Provider (You will pay the least) Prenatal office visits: no charge, deductible does not Postnatal: 20% coinsurance Out-of-Network Provider (You will pay the most) Prenatal office visits: not covered Postnatal: 40% coinsurance Limitations, Exceptions, & Other Important Information Cost sharing does not to certain preventive services. Even if services are preventive, they are not covered out-ofnetwork. Depending on the type of services, coinsurance may. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional services 20% coinsurance 40% coinsurance Childbirth/delivery facility services 20% coinsurance 40% coinsurance Home health care 20% coinsurance 40% coinsurance None Rehabilitation services 20% coinsurance 40% coinsurance None. Includes physical therapy, speech Habilitation services 20% coinsurance 40% coinsurance therapy, and occupational therapy. Limited to 120 continuous days/per stay/per Skilled nursing care 20% coinsurance 40% coinsurance diagnosis Durable medical equipment 20% coinsurance 40% coinsurance Hospice services No charge, deductible does not No charge, deductible does not See exclusions set forth in the plan or Your Benefits Handbook. None Children s eye exam Covered based on Schedule Covered based on Schedule Covered every calendar year in the Vision Premium Option and Vision Standard Option If your child needs dental or eye care Children s glasses Covered based on Schedule Covered based on Schedule Covered every calendar year for children under age 19 in the Vision Premium Option and Vision Standard Option Children s dental check-up Covered under Dental Plan 4 of 6
Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check Your Benefits Handbook for more information and a list of any other excluded services.) Cosmetic Surgery Dental Care Long Term Care Private Duty Nursing (inpatient) Routine Foot Care Weight loss programs Other Covered Services (Limitations may to these services. This isn t a complete list. Please see Your Benefits Handbook) Acupuncture Infertility Treatment ($15,000 lifetime Non-emergency care when traveling outside the Bariatric Surgery (covered in-network only, once limit/person/in-network only) U.S. (at out-of-network level) per lifetime) Chiropractic Care (15 visits per year) Routine eye care (under Vision plan) Hearing Aids (one every three years per ear) 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: the U.S. Department of Labor, Employee Benefits Security Administration, at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, at 1-877-267-2323 x61565 or www.cciio.cms.gov. You may also contact the plan at 1-800-252-5259 or your state insurance department. 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 to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, you can contact your health plan at the telephone number shown on your Medical ID card. You may also contact the GE Benefits Center at 1-800-252-5259, or the Department of Labor s Employee Benefits Security Administration at 1-866-444-EBSA (3272), or www.dol.gov/ebsa/healthreform. Does this plan provide Minimum Essential Coverage? Yes. If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: [Spanish (Español): Para obtener asistencia en Español, llame al 1-800-252-5259.] [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-252-5259.] [Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 1-800-252-5259.] [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-252-5259.] To see examples of how this plan might cover costs for a sample medical situation, see the next section. 5 of 6
About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on 3 or more coverage, for three different families. Peg is Having a Baby 1 (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes 1 (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture 1 (in-network emergency room visit and follow up care) n The plan s overall deductible $3000 n Specialist coinsurance 20% n Hospital (facility) 2 coinsurance 20% n Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing 3 Deductibles $3,000 Copayments $40 Coinsurance $1,700 What isn t covered Limits or exclusions $60 The total Peg would pay is $4,800 n The plan s overall deductible $3000 n Specialist coinsurance 20% n Hospital (facility) coinsurance 20% n Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing 3 Deductibles $1,240 Copayments $320 Coinsurance $0 What isn t covered Limits or exclusions $0 The total Joe would pay is $1,560 n The plan s overall deductible $3000 n Specialist coinsurance 20% n Hospital (facility) coinsurance 20% n Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing 3 Deductibles $1,330 Copayments $0 Coinsurance $0 What isn t covered Limits or exclusions $0 The total Mia would pay is $1,330 Note: 1 Example assumes 3 or More coverage and annual pay of $60,000. 2 Hospital charges for the baby are covered only if the baby is enrolled within 90 days of birth. 3 The Health Reimbursement Account (HRA) established by GE ($1,200 contribution for 3 or More coverage) offsets the amount you pay toward covered services. 6 of 6