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PRMC Health Plan Premium

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PRATT REGIONAL MEDICAL CENTER: PREMIUM PLAN Coverage Period: 01/01/201712/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family | Plan Type: PPO
Questions: Call 1-800-290-1368 or visit us at www.bmikansas.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-800-290-1368 to request a copy.
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.bmikansas.com or by calling 1-800-290-1368.
Important Questions Answers Why this Matters:
What is the overall
deductible?
Per Calendar Year: for PRMC Core Network
providers $240/single, $720/family; for PPO
Network $480/single, $1,440/family; Non-
Network $960/single, $2,880/family. Does not
apply to PRMC Core and PPO Network Preventive
Care, Immunizations, Prescription Drugs, Routine
Vision Exam, Pre- and Post-Natal Office visits.
You must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. Check your policy or
plan document to see when the deductible starts over (usually, but
not always, January 1st). See the chart starting on page 2 for how much
you pay for covered services after you meet the deductible.
Are there other deductibles
for specific services?
No.
You don’t have to meet deductibles for specific services, but see the
chart starting on page 2 for other costs for services this plan covers.
Is there an outofpocket
limit on my expenses?
Yes. Per Calendar Year: for PRMC Core and PPO
Network providers $2,400/single, $7,200/family;
for Non-Network Unlimited out-of-pocket expense.
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.
This limit helps you plan for health care expenses.
What is not included in
the outofpocket limit?
Premiums, prescriptions, co-payments, balance-
billed charges, health care this plan doesn’t cover and
penalties for failure to obtain pre-authorization for
services.
Even though you pay these expenses they do not count toward the
out-ofpocket limit.
Is there an overall annual
limit on what the plan
pays?
No
This plan will pay for covered services only up to this limit during each
coverage period, even if your own need is greater. You’re responsible
for all expenses above the limit. The chart starting on page 2 describes
specific coverage limits, such as limits on the number of office visits.
Does this plan use a
network of providers?
Yes. For a list of PPO Network providers see www.
providrscare.net or call (800) 801-9772; or see
www.prmc.org for a list, free-of-charge, of PRMC
Core Network Providers or call (620) 450-1170.
If you use a Network doctor or other health care provider, this plan
will pay some or all of the costs of covered services. Be aware, your
Network doctor or hospital may use a Non-Network provider for
some services. See the chart starting on page 2 for how this plan pays
different kinds of providers.
Do I need a referral to see
a specialist?
No.
You can see the
specialist
you choose without permission from this
plan.
Are there services this
plan doesn’t cover?
Yes.
Some of the services this plan doesn’t cover are listed on page 5. See
your policy or plan document for additional information about
excluded services.
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PRATT REGIONAL MEDICAL CENTER: PREMIUM PLAN Coverage Period: 01/01/201712/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family | Plan Type: PPO
Questions: Call 1-800-290-1368 or visit us at www.bmikansas.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-800-290-1368 to request a copy.
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the
plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you
haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use Core Network and PPO Network providers by charging you lower deductibles, co-payments and co-
insurance amounts.
*Benefit subject to Medical Deductible
Common
Medical
Event
Services You
May Need
Your cost if you use a
Limitations & Exceptions
PRMC Core Network
Provider
PPO Network
Provider
Non-network
Provider
If you visit
a health
care
provider’s
office or
clinic
to treat an injury
$20 co-payment of the first
$250 per visit; thereafter,
20% co-insurance*
$20 co-payment of the first
$250 per visit; thereafter,
20% co-insurance*
50% co-insurance* None
Specialist visit
$20 co-payment of the first
$250 per visit; thereafter,
20% co-insurance*
$20 co-payment of the first
$250 per visit; thereafter,
20% co-insurance*
50% co-insurance* None
Other practitioner
office visit
Chiropractic Care- $20 co-
payment of the first $250
per visit; thereafter, 20%
co-insurance*
Chiropractic Care- $20 co-
payment of the first $250
per visit; thereafter, 20%
co-insurance*
Chiropractic care
50% co-insurance*
Chiropractic Care Coverage is limited to
25 visits/Calendar Year.
Preventive care/
screening/
immunization
No Charge
$20 co-payment per visit
of the first $300/
Calendar Year; thereafter
20% co-insurance*
50% co-insurance*
Preventive Care Services shall be
provided as required by the Patient
Protection and Affordable Care Act.
If you have
a test
laboratory (x-ray,
20% co-insurance* 20% co-insurance* 50% co-insurance* None
20% co-insurance* 20% co-insurance* 50% co-insurance* None
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PRATT REGIONAL MEDICAL CENTER: PREMIUM PLAN Coverage Period: 01/01/201712/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family | Plan Type: PPO
Questions: Call 1-800-290-1368 or visit us at www.bmikansas.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-800-290-1368 to request a copy.
Common
Medical
Event
Services You
May Need
Your cost if you use a
Limitations & Exceptions
PRMC Core
Network Provider
PPO Network
Provider
Non-network
Provider
If you need
drugs to treat
your illness
or condition
More
information
about
prescription
drug
coverage is
available at
www.medtrakr
x.com
Generic drugs
Acute Retail: $10 co-payment
Maintenance: $30 co-payment
Reimbursement is
at the Network
Allowed Amount.
Maintenance and
Specialty
Medications are
Not Covered when
purchased from a
Non-network
pharmacy
Prescription drugs do not apply to the
Medical deductible, co-insurance or out-of-
pocket maximum.
Acute Retail Pharmacy – up to a 30-day
supply.
Maintenance Medications – “MedTrak
Performance 90 Pharmacy” – up to a 90-day
supply.
Specialty Medications-limited to a 30-day
supply
Excluded are experimental and investigational
drugs.
Brand Name drugs
Acute Retail: $50 co-payment
Maintenance: $150 co-payment
Growth Hormone
50% of the Network Allowed Amount
(Max. out-of-pocket $2,500/Month)
Specialty
Medications
10% of the Network Allowed Amount
(Max. out-of-pocket $1,500/Calendar Year)
If you have
outpatient
surgery
Facility fee (e.g.,
ambulatory surgery
center)
20% co-insurance* 20% co-insurance* 50% co-insurance* None
Physician/surgeon
fees
20% co-insurance* 20% co-insurance* 50% co-insurance* None
If you need
immediate
medical
attention
Emergency room
services
20% co-insurance* after PPO Network deductible None
Emergency medical
transportation
20% co-insurance* after PPO Network deductible
To the nearest facility where the necessary
treatment can be provided.
Urgent care 20% co-insurance* 20% co-insurance* 50% co-insurance* None
If you have a
hospital stay
Facility fee (e.g.,
hospital room)
20% co-insurance* 20% co-insurance*
$1,000 co-payment
and 50% co-
insurance*
Pre-certification required. Failure to pre-
certify will result in a $200 penalty/
confinement. Non-Network co-payment
waived if admitted due to an emergency.
Physician/surgeon
fee
20% co-insurance* 20% co-insurance* 50% co-insurance* None
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PRATT REGIONAL MEDICAL CENTER: PREMIUM PLAN Coverage Period: 01/01/201712/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family | Plan Type: PPO
Questions: Call 1-800-290-1368 or visit us at www.bmikansas.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-800-290-1368 to request a copy.
If you have
mental
health,
behavioral
health, or
substance
abuse needs
Mental/Behavioral
health outpatient
services
$20 co-payment of the
first $250 per visit;
thereafter, 20% co-
insurance*
$20 co-payment of the
first $250 per visit;
thereafter, 20% co-
insurance*
50% co-insurance*
Partial Day Visits treated as Inpatient
services.
Mental/Behavioral
health inpatient
services
20% co-insurance* 20% co-insurance*
$1,000 co-payment
and 50% co-insur*
Pre-certification required. Failure to pre-
certify will result in a $200 penalty/
confinement. Non-Network co-payment
waived if admitted due to an emergency.
Substance use
disorder outpatient
services
$20 co-payment of the
first $250 per visit;
thereafter, 20% co-
insurance*
$20 co-payment of the
first $250 per visit;
thereafter, 20% co-
insurance*
50% co-insurance*
Partial Day Visits treated as Inpatient
services.
Substance use
disorder inpatient
services
20% co-insurance* 20% co-insurance*
$1,000 co-payment
and 50% co-insur*
Pre-certification required. Failure to pre-
certify will result in a $200 penalty/
confinement. Non-Network co-payment
waived if admitted due to an emergency.
If you are
pregnant
Prenatal and
postnatal care
$150 co-payment/
Pregnancy
$150 co-payment/
Pregnancy
50% co-insurance*
Includes Pre-Natal & Post-Natal Office Visit,
all other services subject to applicable benefits.
Delivery and all
inpatient services
20% co-insurance* 20% co-insurance*
$1,000 co-payment
and 50% co-insur*
None
If you need
help
recovering or
have other
special health
needs
Home health care
$20 co-payment of the
first $250 per visit;
thereafter, 20% co-
insurance*
$20 co-payment of the
first $250 per visit;
thereafter, 20% co-
insurance*
50% co-insurance* None
Rehabilitation
services
$20 co-payment of the
first $250 per visit;
thereafter, 20% co-
insurance*
$20 co-
payment of the
first $250 per visit;
thereafter, 20% co-
insurance*
50% co-insurance*
Benefit includes: Occupational Therapy,
Physical Therapy and Speech Therapy.
Cardiac Rehabilitation, Pulmonary Rehab,
Respiratory Therapy and Neuropsychological
Testing are subject to applicable deductible
and co-insurance.
Habilitation services
Skilled nursing care 20% co-insurance* 20% co-insurance* 50% co-insurance*
Coverage is limited to 100 days/ Calendar
Year. Pre-certification required. Failure to
pre-certify will result in a $200 penalty/
confinement.
5 of 8
PRATT REGIONAL MEDICAL CENTER: PREMIUM PLAN Coverage Period: 01/01/201712/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family | Plan Type: PPO
Questions: Call 1-800-290-1368 or visit us at www.bmikansas.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-800-290-1368 to request a copy.
Durable medical
equipment
20% co-insurance* 20% co-insurance* 50% co-insurance* None
Hospice service
20% co-insurance*
20% co-insurance*
50% co-insurance*
None
If your child
needs dental
or eye care
Eye exam
20% co-insurance* after PPO Network deductible
Coverage is limited to 1 exam/Calendar Year.
Glasses
Not covered
Not covered
Not covered
Dental check-up
Not covered
Not covered
Not covered
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Acupuncture
Bariatric surgery
Cosmetic surgery
Dental care
Hearing Aids
Infertility treatment
Long-term care
Routine foot care
Weight loss programs
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800-290-1368. You may also contact your state insurance department, 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 at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
Chiropractic care Non-emergency care when traveling outside
the U.S
Private-duty nursing
Routine eye care - limited to 1 exam/year.
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PRATT REGIONAL MEDICAL CENTER: PREMIUM PLAN Coverage Period: 01/01/201712/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family | Plan Type: PPO
Questions: Call 1-800-290-1368 or visit us at www.bmikansas.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-800-290-1368 to request a copy.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: Benefit Management, LLC, at 800-290-1368, or the U.S. Department of Labor,
Employee Benefits Security Administration at 1-866-444-3242 or www.dol.gov/ebsa/healthreform.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-290-1368.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-290-1368.
Chinese (中文): 如果需要中文的帮助,请拨打这个号码 1-800-290-1368.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-290-1368.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
7 of 8
PRATT REGIONAL MEDICAL CENTER: PREMIUM PLAN Coverage Period: 01/01/2017 – 12/31/2017
Coverage Examples Coverage for: Family | Plan Type: PPO
Questions: Call 1-800-290-1368 or visit us at www.bmikansas.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-800-290-1368 to request a copy.
Having a baby
(normal delivery)
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
Amount owed to providers: $7,540
Plan pays $5,040
Patient pays $2,500
Sample care costs:
Hospital charges (mother)
$2,700
Routine obstetric care
$2,100
Hospital charges (baby)
$900
Anesthesia
$900
Laboratory tests
$500
Prescriptions
$200
Radiology
$200
Vaccines, other preventive
$40
Total
$7,540
Patient pays:
Deductibles
$960
Co-pays
$240
Co-insurance
$1,260
Limits or exclusions
$40
Total
$2,500
Estimation represents PPO level of benefits.
Amount owed to providers: $5,400
Plan pays $3,770
Patient pays $1,630
Sample care costs:
Prescriptions
$2,900
Medical Equipment and Supplies
$1,300
Office Visits and Procedures
$700
Education
$300
Laboratory tests
$100
Vaccines, other preventive
$100
Total
$5,400
Patient pays:
Deductibles
$480
Co-pays
$800
Co-insurance
$310
Limits or exclusions
$40
Total
$1,630
Estimation represents PPO level of benefits.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
8 of 8
PRATT REGIONAL MEDICAL CENTER: PREMIUM PLAN Coverage Period: 01/01/2017 – 12/31/2017
Coverage Examples Coverage for: Family | Plan Type: PPO
Questions: Call 1-800-290-1368 or visit us at www.bmikansas.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-800-290-1368 to request a copy.
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from in-
network providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles, co-
payments, and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples
to compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-of-
pocket costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.