Download Pflugerville ISD

Pflugerville ISD Employee Handbook 2017
Pflugerville ISD
Relationships are built on trust. Respect for an individual’s privacy goes a long way toward building trust.
Humana values our relationship with you, and we take your personal privacy seriously. Humana’s Notice
of Privacy Practices outlines how Humana may use or disclose your personal and health information. It
also tells how we protect this information. The notice provides an explanation of your rights concerning
your information, including how you can access this information and how to limit access to your
information. In addition, it provides instructions on how to file a privacy complaint with Humana or to
exercise any of your rights regarding your information.
If you’d like a copy of Humana’s Notice of Privacy Practices, you can request a copy by:
•
•
•
Visiting Humana.com and clicking the Privacy Practices link at the bottom of the home page
E-mailing us at privacyoffice@humana.com
Sending a written request to:
Humana Privacy Office
P.O. Box 1438
Louisville, KY 40202
Pflugerville ISD
Medical Plan Options for January 1, 2017
Low Plan
Medical Benefits
Deductible
Individual
Family
Co-Insurance
Medical Out of Pocket Maximum
Individual
Family
Preventive Care
Annual Physical
Routine Mammogram
Routine Colonoscopy
Routine Lab & X-ray
Vision Exam (1 every 12
months)
Office Visit
Primary & Specialist
Urgent Care
Hospital
Inpatient Services
Outpatient Surgery
Emergency - Facility
(true emergency)
Emergency - Physician
Lab / X-Ray
Billed By Doctors Office (1)
Billed By Outside Facility (1)
Physical Therapy / Occupational Therapy /
Chiropractic Services
(Visit Limits Apply)
Prescriptions
Mid Plan
Out of Network
Network
Out of Network
Network
Out of Network
$2,500
$5,000
70%
$4,350
$8,700
50%
$1,500
$3,000
80%
$3,100
$6,200
60%
$1,000
$2,000
90%
$2,350
$4,700
70%
$6,500
$13,000
$12,150
$24,300
$5,000
$10,000
$9,600
$19,200
$4,000
$8,000
$7,850
$15,700
100% no deductible
100% no deductible
100% no deductible
100% no deductible
50% after deductible
50% after deductible
50% after deductible
50% after deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
60% after deductible
60% after deductible
60% after deductible
60% after deductible
100% no deductible
100% no deductible
100% no deductible
100% no deductible
70% after deductible
70% after deductible
70% after deductible
70% after deductible
$30 copay
50% after deductible
$30 copay
60% after deductible
$30 copay
70% after deductible
$30 / $30 copay
$40 copay
50% after deductible
50% after deductible
$30 / $30 copay
$40 copay
60% after deductible
60% after deductible
$30 / $30 copay
$40 copay
70% after deductible
70% after deductible
70% after deductible
70% after deductible
50% after deductible
50% after deductible
80% after deductible
80% after deductible
60% after deductible
60% after deductible
90% after deductible
90% after deductible
70% after deductible
70% after deductible
$300 copay
$300 copay
$300 copay
70% after deductible
80% after deductible
90% after deductible
Included in office copay
100% no deductible
50% after deductible
50% after deductible
Included in office copay
100% no deductible
60% after deductible
60% after deductible
Included in office copay
100% no deductible
70% after deductible
70% after deductible
$30 copay
50% after deductible
$30 copay
60% after deductible
$30 copay
70% after deductible
$10 / $40 / $60 / 10% copay
capped at $2,500
$10 / $40 / $60 / 10% copay
capped at $2,500
Retail (30 days)
Mail Order (90 days)
High Plan
Network
$10 / $30 / $50 / 10% copay
capped at $2,500
2.5 X Retail
N/A
2.5 X Retail
N/A
2.5 X Retail
N/A
Total Out of Pocket Maximum
(Medical and Prescriptions)
$6,500 Individual / $13,000
Family
N/A
$6,500 Individual / $13,000
Family
N/A
$6,500 Individual / $13,000
Family
N/A
2017 Monthly Employee Rates
Employee Only
Employee + Spouse
Employee + Children
Employee + Family
iNGAGED
$40
$480
$322
$762
Non-Engaged
$125
$610
$407
$892
iNGAGED
$125
$650
$504
$986
Non-Engaged
$225
$780
$604
$1,116
iNGAGED
$221
$842
$703
$1,240
Non-Engaged
$321
$972
$803
$1,370
*See your Humana Summary of Benefits for Out of Network benefit levels.
Provider Search: Log on to www.humana.com to find a provider. For the network, you will select the National POS - Open Access.
(1) Certain Diagnostic Procedures: Bone Scan, Cardiac Stress Test, CT Scan (with or without contrast), Ultrasound, MRI, Myelogram & PET Scan are subject to deductible and coinsurance.
If a procedure is in question, please contact Customer Service at 1-800-4HUMANA (1-800-448-6262) with the diagnosis and procedure code.
This summary is intended only to highlight your benefits and should not be relied upon to fully determine coverage. Please refer to your Summary of Benefits and Summary Plan Description for a complete listing of services, limitations and exclusions. If there is a conflict in the benefits the Summary Plan Description
will prevail.
LOW PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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 by calling 1-512-594-0019 or email benefits@pfisd.net
Important Questions
What is the overall
deductible?
Are there other deductibles
for specific services?
Is there an out–of–pocket
limit on my expenses?
What is not included in the
out–of–pocket limit?
Is there an overall annual
limit on what the plan
pays?
Answers
PAR: $2,500 single/$5,000 family;
NONPAR: $4,350 single/$8,700family;
PAR Preventive care is not subject to the
deductible. Coinsurance & copayments
don’t apply to the deductible.
No.
Yes. Medical:
PAR: $6,500 single/$13,000 family;
NONPAR: $12,150 single/$24,300 family.
Plan Maximum OOP: PAR: $6,500
single/$13,000 family; NONPAR: NA
Specialty Medications $2,500/
individual
Premiums, balance-billed charges,
penalties, non-Humana Nat’l Transplant
Network transplants, & health care this
plan doesn’t cover.
Why this Matters:
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.
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.
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.
Even though you pay these expenses, they don’t count toward the out-ofpocket limit.
No.
The chart starting on page 2 describes any limits on what the plan will pay
for specific covered services, such as office visits.
Does this plan use a
network of providers?
Yes. See www.humana.com for a list of
PAR providers.
Do I need a referral to see a
specialist?
No. You don’t need a referral to see a
specialist.
If you use an in-network doctor or other health care provider, this plan will
pay some or all of the costs of covered services. Be aware, your in-network
doctor or hospital may use an out-of-network provider for some services.
Plans use the term in-network, preferred, or participating for providers in
their network. See the chart starting on page 2 for how this plan pays
different kinds of providers.
You can see the specialist you choose without permission from this plan.
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
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LOW PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Are there services this plan
doesn’t cover?
Yes.
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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.
• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance 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 coinsurance 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 PAR providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health
care provider’s office
or clinic
If you have a test
Services You May Need
Primary care visit to treat an injury or
illness
Specialist visit
Other practitioner office visit
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
Limitations & Exceptions
$30 copay/visit
50% after deductible
–––––––––––none–––––––––––
$30 copay/visit
$30 copay/visit
50% after deductible
50% after deductible
Preventive care/screening/immunization No charge
Hearing exam
$30 copay/visit
50% after deductible
50% after deductible
–––––––––––none–––––––––––
–––––––––––none–––––––––––
-NONPAR immunizations for age’s
newborn to age 6 are covered at no charge.
Ages 6 to 18 will be covered at 50% after
deductible.
-Immunization limitations for adult and
child are based on the CDC guidelines.
-Vision & hearing exam limited to 1 each.
Diagnostic test (x-ray, blood work)
Clinic
Outpatient
Imaging (CT/PET scans, MRIs)
50% after deductible
50% after deductible
50% after deductible
No charge
30% after deductible
30% after deductible
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
–––––––––––none–––––––––––
–––––––––––none–––––––––––
2 of 9
LOW PLAN: PFLUGERVILLE ISD
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.ExpressScripts.com
Services You May Need
If you need
immediate medical
attention
Your Cost If You
Use a
NONPAR Provider
Generic drugs/Tier 1
$10 Copay 30 day
supply at Retail
NA
Preferred Brand/Tier 2
$40 Copay 30 day
supply at Retail
NA
Non-Preferred Brand/Tier 3
$60 Copay 30 day
supply at Retail
NA
Specialty Medications
If you have
outpatient surgery
Your Cost If You
Use a
PAR
Provider
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
Emergency room services True Emergency Facility:
True Emergency Physician Services:
10% Coinsurance with
$2500 Maximum Out
of Pocket per calendar
year per individual
NA
30% after deductible
50% after deductible
30% after deductible
50% after deductible
$300 copay/visit
30% coinsurance after
deductible
$300 copay and 30%
coinsurance
30% after deductible
$300 copay/visit
30% coinsurance
after deductible
$300 copay and 50%
after deductible
50% after deductible
Emergency medical transportation
30% after deductible
30% after deductible
Urgent care
$40 copay/visit
50% after deductible
Non-Emergency Facility:
Non-Emergency Physician Services:
Limitations & Exceptions
$20 Copay for 31-60 day supply through
Retail/$30 Copay for 61-90 day supply
through Retail/$25 Copay for 90 day
supply through Mail
$80 Copay for 31-60 day supply through
Retail/$120 Copay for 61-90 day supply
through Retail/$100 Copay for 90 day
supply through Mail
$120 Copay for 31-60 day supply through
Retail/$180 Copay for 61-90 day supply
through Retail/$150 Copay for 90 day
supply through Mail
Limited to a 30 day supply and may require
prior authorization. Can be ordered from
Express Scripts/Medco at 1-800-803-2523
Prior auth may be required; There is a
$250 penalty for not obtaining prior auth.
–––––––––––none–––––––––––
NONPAR true emergency physician
services are subject to the PAR deductible.
NONPAR is subject to the PAR
deductible.
–––––––––––none–––––––––––
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
3 of 9
LOW PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you have a
hospital stay
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
If you need help
recovering or have
other special health
needs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
Facility fee (e.g., hospital room)
30% after deductible
50% after deductible
Physician/surgeon fee
Mental/Behavioral health outpatient
services (Therapies & Exams)
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services (Therapies & Exams)
30% after deductible
50% after deductible
$30 copay/visit
50% after deductible
30% after deductible
50% after deductible
$30 copay/visit
50% after deductible
Substance use disorder inpatient services
30% after deductible
50% after deductible
Prenatal and postnatal care
$30 copay
50% after deductible
Delivery and all inpatient services
30% after deductible
50% after deductible
Home health care
30% after deductible
50% after deductible
Services You May Need
Rehabilitation services Physical and Occupational Therapy (at
a clinic or outpatient location):
All other therapies and locations
covered by the plan:
Habilitation servicesPhysical and Occupational Therapy (at
a clinic or outpatient location):
All other therapies and locations
covered by the plan:
$30 copay/visit
50% after deductible
30% after deductible
50% after deductible
$30 copay/visit
50% after deductible
30% after deductible
50% after deductible
Limitations & Exceptions
Prior auth required; There is a $250
penalty for not obtaining prior auth.
–––––––––––none–––––––––––
–––––––––––none–––––––––––
Prior auth required; There is a $250
penalty for not obtaining prior auth.
–––––––––––none–––––––––––
Prior auth required; There is a $250
penalty for not obtaining prior auth.
-Dependent daughter maternity care is
covered.
- Office visit copayment applies to the
initial visit only
–––––––––––none–––––––––––
-Limited to 60 visits
- Prior auth required; There is a $250
penalty for not obtaining prior auth.
Physical therapy and occupational therapy
in a clinic or outpatient locations is limited
to 20 visits each per calendar year.
Physical therapy and occupational therapy
in a clinic or outpatient locations is limited
to 20 visits each per calendar year.
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
4 of 9
LOW PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If your child needs
dental or eye care
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
Skilled nursing care
30% after deductible
50% after deductible
Durable medical equipment
30% after deductible
50% after deductible
Hospice service
30% after deductible
50% after deductible
Eye exam
Glasses
Dental check-up
$30 copay
Not covered
Not covered
50% after deductible
Not covered
Not covered
Services You May Need
Limitations & Exceptions
-Limited to 60 visits
- Prior auth required; There is a $250
penalty for not obtaining prior auth.
Prior auth required; There is a $250
penalty for not obtaining prior auth.
Prior auth required; There is a $250
penalty for not obtaining prior auth.
–––––––––––none–––––––––––
No coverage for glasses.
No coverage for dental check-ups.
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
•
Dental care (adult and child)
•
Private-duty nursing
•
Bariatric surgery
•
Infertility treatment
•
•
Behavioral health half-way house services
•
Long-term care
Routine eye care (adult and child, excludes
vision exam and screening )
•
Non-emergency care when traveling outside
the U.S.
•
Routine foot care
•
Weight loss programs
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 (Limited to 20 visits)
•
Cosmetic surgery (Requires prior auth.
Services will only be considered if due to a
bodily injury or illness and functional
impairment is present.)
•
Dependent Daughter Maternity
•
Hearing aids (Limited to $1,000 per 36
months)
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
5 of 9
LOW PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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 1-512-594-0019. 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 1-877267-2323 x61565 or www.cciio.cms.gov.
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
6 of 9
LOW PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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: 1-512-594-0019 or email Kristin.baum@pfisd.net.
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 1-512-594-0019.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
7 of 9
LOW PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
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.
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.
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $3,810
 Patient pays $3,730
 Amount owed to providers: $5,400
 Plan pays $2,590
 Patient pays $2,810
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,150
$20
$1,410
$150
$3,730
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,150
$580
$0
$80
$2,810
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
8 of 9
LOW PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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 innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
Can I use Coverage Examples
to compare plans?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance 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.
Yes. When you look at the Summary of
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.
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-ofpocket costs, such as copayments,
deductibles, and coinsurance. 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.
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
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MID PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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 by calling 1-512-594-0019 or email benefits@pfisd.net
Important Questions
What is the overall
deductible?
Are there other deductibles
for specific services?
Is there an out–of–pocket
limit on my expenses?
What is not included in the
out–of–pocket limit?
Is there an overall annual
limit on what the plan pays?
Answers
PAR: $1,500 single/$3,000 family;
NONPAR: $3,100 single/$6,200 family;
PAR Preventive care is not subject to the
deductible.
Coinsurance & copayments don’t apply
to the deductible.
No.
Yes. Medical:
PAR: $5,000 single/$10,000 family;
NONPAR: $9,600 single/$19,200 family.
Plan Maximum OOP: PAR: $6,500
single/$13,000 family; NONPAR: NA
Specialty Medications
$2,500/Individual
Premiums, balance-billed charges,
penalties, non-Humana Nat’l Transplant
Network transplants, & health care this
plan doesn’t cover.
No.
Does this plan use a network Yes. See www.humana.com for a list of
of providers?
PAR providers.
Why this Matters:
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.
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.
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.
Even though you pay these expenses, they don’t count toward the out-ofpocket limit.
The chart starting on page 2 describes any limits on what the plan will pay for
specific covered services, such as office visits.
If you use an in-network doctor or other health care provider, this plan will
pay some or all of the costs of covered services. Be aware, your in-network
doctor or hospital may use an out-of-network provider for some services.
Plans use the term in-network, preferred, or participating for providers in
their network. See the chart starting on page 2 for how this plan pays
different kinds of providers.
Do I need a referral to see a No. You don’t need a referral to see a
You can see the specialist you choose without permission from this plan.
specialist?
specialist.
Are there services this plan
Some of the services this plan doesn’t cover are listed on page 5. See your
Yes.
doesn’t cover?
policy or plan document for additional information about excluded services.
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
OMB Control Numbers 1545-2229,
1 of 8
1210-0147, and 0938-1146
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
Corrected on May 11, 2012
MID PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance 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 coinsurance 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 PAR providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health
care provider’s office
or clinic
If you have a test
Services You May Need
Primary care visit to treat an injury or
illness
Specialist visit
Other practitioner office visit
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
Limitations & Exceptions
$30 copay/visit
40% after deductible
–––––––––––none–––––––––––
$30 copay/visit
$30 copay/visit
40% after deductible
40% after deductible
Preventive care/screening/immunization No charge
Hearing exam
$30 copay/visit
40% after deductible
40% after deductible
–––––––––––none–––––––––––
–––––––––––none–––––––––––
-NONPAR immunizations for age’s
newborn to age 6 are covered at no charge.
Ages 6 to 18 will be covered at 40% after
deductible.
-Immunization limitations for adult and
child are based on the CDC guidelines.
-Vision & hearing exam limited to 1 each.
Diagnostic test (x-ray, blood work)
Clinic
Outpatient
Imaging (CT/PET scans, MRIs)
40% after deductible
40% after deductible
40% after deductible
No charge
20% after deductible
20% after deductible
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
–––––––––––none–––––––––––
–––––––––––none–––––––––––
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MID PLAN: PFLUGERVILLE ISD
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.ExpressScripts.com
Services You May Need
If you need
immediate medical
attention
Your Cost If You
Use a
NONPAR Provider
Generic drugs/Tier 1
$10 Copay 30 day
supply at Retail
NA
Preferred Brand/Tier 2
$40 Copay 30 day
supply at Retail
NA
Non-Preferred Brand/Tier 3
$60 Copay 30 day
supply at Retail
NA
Specialty Medications
If you have
outpatient surgery
Your Cost If You
Use a
PAR
Provider
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
Emergency room services True Emergency Facility:
True Emergency Physician Services:
10% Coinsurance with
$2500 Maximum Out
of Pocket per calendar
year per individual
NA
20% after deductible
40% after deductible
20% after deductible
40% after deductible
$300 copay/visit
20% coinsurance after
deductible
$300 copay and 20%
coinsurance
20% after deductible
$300 copay/visit
20% coinsurance
after deductible
$300 copay and 40%
after deductible
40% after deductible
Emergency medical transportation
20% after deductible
20% after deductible
Urgent care
$40 copay/visit
40% after deductible
Non-Emergency Facility:
Non-Emergency Physician Services:
Limitations & Exceptions
$20 Copay for 31-60 day supply through
Retail/$30 Copay for 61-90 day supply
through Retail/$25 Copay for 90 day
supply through Mail
$80 Copay for 31-60 day supply through
Retail/$120 Copay for 61-90 day supply
through Retail/$100 Copay for 90 day
supply through Mail
$120 Copay for 31-60 day supply through
Retail/$180 Copay for 61-90 day supply
through Retail/$150 Copay for 90 day
supply through Mail
Limited to a 30 day supply and may require
prior authorization. Can be ordered from
Express Scripts/Medco at 1-800-803-2523
Prior auth may be required; There is a
$250 penalty for not obtaining prior auth.
–––––––––––none–––––––––––
NONPAR true emergency physician
services are subject to the PAR deductible.
NONPAR is subject to the PAR
deductible.
–––––––––––none–––––––––––
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
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MID PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you have a
hospital stay
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
If you need help
recovering or have
other special health
needs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
Facility fee (e.g., hospital room)
20% after deductible
40% after deductible
Physician/surgeon fee
Mental/Behavioral health outpatient
services (Therapies & Exams)
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services (Therapies & Exams)
20% after deductible
40% after deductible
$30 copay/visit
40% after deductible
20% after deductible
40% after deductible
$30 copay/visit
40% after deductible
Substance use disorder inpatient services
20% after deductible
40% after deductible
Prenatal and postnatal care
$30 copay
40% after deductible
Delivery and all inpatient services
20% after deductible
40% after deductible
Home health care
20% after deductible
40% after deductible
Services You May Need
Rehabilitation services Physical and Occupational Therapy (at
a clinic or outpatient location):
All other therapies and locations
covered by the plan:
Habilitation servicesPhysical and Occupational Therapy (at
a clinic or outpatient location):
All other therapies and locations
covered by the plan:
$30 copay/visit
40% after deductible
20% after deductible
40% after deductible
$30 copay/visit
40% after deductible
20% after deductible
40% after deductible
Limitations & Exceptions
Prior auth required; There is a $250
penalty for not obtaining prior auth.
–––––––––––none–––––––––––
–––––––––––none–––––––––––
Prior auth required; There is a $250
penalty for not obtaining prior auth..
–––––––––––none–––––––––––
Prior auth required; There is a $250
penalty for not obtaining prior auth.
-Dependent daughter maternity care is
covered.
- Office visit copayment applies to the
initial visit only
–––––––––––none–––––––––––
-Limited to 60 visits
- Prior auth required; There is a $250
penalty for not obtaining prior auth..
Physical therapy and occupational therapy
in a clinic or outpatient locations is limited
to 20 visits each per calendar year.
Physical therapy and occupational therapy
in a clinic or outpatient locations is limited
to 20 visits each per calendar year.
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
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MID PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If your child needs
dental or eye care
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
Skilled nursing care
20% after deductible
40% after deductible
Durable medical equipment
20% after deductible
40% after deductible
Hospice service
20% after deductible
40% after deductible
Eye exam
Glasses
Dental check-up
$30 copay
Not covered
Not covered
40% after deductible
Not covered
Not covered
Services You May Need
Limitations & Exceptions
-Limited to 60 visits
- Prior auth required; There is a $250
penalty for not obtaining prior auth.
Prior auth required; There is a $250
penalty for not obtaining prior auth..
Prior auth required; There is a $250
penalty for not obtaining prior auth.
–––––––––––none–––––––––––
No coverage for glasses.
No coverage for dental check-ups.
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
•
Dental care (adult and child)
•
Private-duty nursing
•
Bariatric surgery
•
Infertility treatment
•
•
Behavioral health half-way house services
•
Long-term care
Routine eye care (adult and child, excludes
vision exam and screening )
•
Non-emergency care when traveling outside
the U.S.
•
Routine foot care
•
Weight loss programs
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 (Limited to 20 visits)
•
Cosmetic surgery (Requires prior auth.
Services will only be considered if due to a
bodily injury or illness and functional
impairment is present.)
•
Dependent Daughter Maternity
•
Hearing aids (Limited to $1,000 per 36
months)
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
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MID PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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 1-512-594-0019. 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 1-877267-2323 x61565 or www.cciio.cms.gov.
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: 1-512-594-0019 or email Kristin.baum@pfisd.net.
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 1-512-594-0019.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
6 of 8
MID PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
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.
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.
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $4,880
 Patient pays $2,660
 Amount owed to providers: $5,400
 Plan pays $3,180
 Patient pays $2,220
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$1,400
$20
$1,090
$150
$2,660
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$1,400
$740
$0
$80
$2,220
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
7 of 8
MID PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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 innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
Can I use Coverage Examples
to compare plans?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance 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.
Yes. When you look at the Summary of
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.
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-ofpocket costs, such as copayments,
deductibles, and coinsurance. 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.
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
8 of 8
HIGH PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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 by calling 1-512-594-0019 or email benefits@pfisd.net
Important Questions
What is the overall
deductible?
Are there other deductibles
for specific services?
Is there an out–of–pocket
limit on my expenses?
What is not included in the
out–of–pocket limit?
Is there an overall annual
limit on what the plan pays?
Answers
PAR: $1,000 single/$2,000 family;
NONPAR: $2,350 single/$4,700 family;
PAR Preventive care is not subject to the
deductible.
Coinsurance & copayments don’t apply
to the deductible.
No.
Yes. Medical:
PAR: $4,000 single/$8,000 family;
NONPAR: $7,850 single/$15,700 family.
Plan Maximum OOP: PAR: $6,500
single/$13,000 family; NONPAR: NA
Specialty Medications
$2,500/Individual
Premiums, balance-billed charges,
penalties, non-Humana Nat’l Transplant
Network transplants, & health care this
plan doesn’t cover.
No.
Does this plan use a network Yes. See www.humana.com for a list of
of providers?
PAR providers.
Why this Matters:
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.
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.
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.
Even though you pay these expenses, they don’t count toward the out-ofpocket limit.
The chart starting on page 2 describes any limits on what the plan will pay for
specific covered services, such as office visits.
If you use an in-network doctor or other health care provider, this plan will
pay some or all of the costs of covered services. Be aware, your in-network
doctor or hospital may use an out-of-network provider for some services.
Plans use the term in-network, preferred, or participating for providers in
their network. See the chart starting on page 2 for how this plan pays
different kinds of providers.
Do I need a referral to see a No. You don’t need a referral to see a
You can see the specialist you choose without permission from this plan.
specialist?
specialist.
Are there services this plan
Some of the services this plan doesn’t cover are listed on page 5. See your
Yes.
doesn’t cover?
policy or plan document for additional information about excluded services.
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary OMB Control Numbers 1545-2229,
1 of 8
1210-0147, and 0938-1146
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
Corrected on May 11, 2012
HIGH PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance 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 coinsurance 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 PAR providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health
care provider’s office
or clinic
If you have a test
Services You May Need
Primary care visit to treat an injury or
illness
Specialist visit
Other practitioner office visit
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
Limitations & Exceptions
$30 copay/visit
30% after deductible
–––––––––––none–––––––––––
$30 copay/visit
$30 copay/visit
30% after deductible
30% after deductible
Preventive care/screening/immunization No charge
Hearing exam
$30 copay/visit
30% after deductible
30% after deductible
–––––––––––none–––––––––––
–––––––––––none–––––––––––
-NONPAR immunizations for age’s
newborn to age 6 are covered at no charge.
Ages 6 to 18 will be covered at 30% after
deductible.
-Immunization limitations for adult and
child are based on the CDC guidelines.
-Vision & hearing exam limited to 1 each.
Diagnostic test (x-ray, blood work)
Clinic
Outpatient
Imaging (CT/PET scans, MRIs)
30% after deductible
30% after deductible
30% after deductible
No charge
10% after deductible
10% after deductible
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
–––––––––––none–––––––––––
–––––––––––none–––––––––––
2 of 8
HIGH PLAN: PFLUGERVILLE ISD
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.ExpressScripts.com
Services You May Need
If you need
immediate medical
attention
Your Cost If You
Use a
NONPAR Provider
Generic drugs/Tier 1
$10 Copay 30 day
supply at Retail
NA
Preferred Brand/Tier 2
$30 Copay 30 day
supply at Retail
NA
Non-Preferred Brand/Tier 3
$50 Copay 30 day
supply at Retail
NA
Specialty Medications
If you have
outpatient surgery
Your Cost If You
Use a
PAR
Provider
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
Emergency room services True Emergency Facility:
True Emergency Physician Services:
10% Coinsurance with
$2500 Maximum Out
of Pocket per calendar
year per individual
NA
10% after deductible
30% after deductible
10% after deductible
30% after deductible
$300 copay/visit
10% coinsurance after
deductible
$300 copay and 10%
coinsurance
10% after deductible
$300 copay/visit
10% coinsurance
after deductible
$300 copay and 30%
after deductible
30% after deductible
Emergency medical transportation
10% after deductible
10% after deductible
Urgent care
$40 copay/visit
30% after deductible
Non-Emergency Facility:
Non-Emergency Physician Services:
Limitations & Exceptions
$20 Copay for 31-60 day supply through
Retail/$30 Copay for 61-90 day supply
through Retail/$25 Copay for 90 day
supply through Mail
$60 Copay for 31-60 day supply through
Retail/$90 Copay for 61-90 day supply
through Retail/$75 Copay for 90 day
supply through Mail
$100 Copay for 31-60 day supply through
Retail/$150 Copay for 61-90 day supply
through Retail/$125 Copay for 90 day
supply through Mail
Limited to a 30 day supply and may require
prior authorization. Can be ordered from
Express Scripts/Medco at 1-800-803-2523
Prior auth may be required; There is a
$250 penalty for not obtaining prior auth.
–––––––––––none–––––––––––
NONPAR true emergency physician
services are subject to the PAR deductible.
NONPAR is subject to the PAR
deductible.
–––––––––––none–––––––––––
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
3 of 8
HIGH PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you have a
hospital stay
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
If you need help
recovering or have
other special health
needs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
Facility fee (e.g., hospital room)
10% after deductible
30% after deductible
Physician/surgeon fee
Mental/Behavioral health outpatient
services (Therapies & Exams)
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services (Therapies & Exams)
10% after deductible
30% after deductible
$30 copay/visit
30% after deductible
10% after deductible
30% after deductible
$30 copay/visit
30% after deductible
Substance use disorder inpatient services
10% after deductible
30% after deductible
Prenatal and postnatal care
$30 copay
30% after deductible
Delivery and all inpatient services
10% after deductible
30% after deductible
Home health care
10% after deductible
30% after deductible
Services You May Need
Rehabilitation services Physical and Occupational Therapy (at
a clinic or outpatient location):
All other therapies and locations
covered by the plan:
Habilitation servicesPhysical and Occupational Therapy (at
a clinic or outpatient location):
All other therapies and locations
covered by the plan:
$30 copay/visit
30% after deductible
10% after deductible
30% after deductible
$30 copay/visit
30% after deductible
10% after deductible
30% after deductible
Limitations & Exceptions
Prior auth required; There is a $250
penalty for not obtaining prior auth.
–––––––––––none–––––––––––
–––––––––––none–––––––––––
Prior auth required; There is a $250
penalty for not obtaining prior auth.
–––––––––––none–––––––––––
Prior auth required; There is a $250
penalty for not obtaining prior auth.
-Dependent daughter maternity care is
covered.
- Office visit copayment applies to the
initial visit only
–––––––––––none–––––––––––
-Limited to 60 visits
- Prior auth required; There is a $250
penalty for not obtaining prior auth.
Physical therapy and occupational therapy
in a clinic or outpatient locations is limited
to 20 visits each per calendar year.
Physical therapy and occupational therapy
in a clinic or outpatient locations is limited
to 20 visits each per calendar year.
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
4 of 8
HIGH PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If your child needs
dental or eye care
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Your Cost If You
Use a
PAR
Provider
Your Cost If You
Use a
NONPAR Provider
Skilled nursing care
10% after deductible
30% after deductible
Durable medical equipment
10% after deductible
30% after deductible
Hospice service
10% after deductible
30% after deductible
Eye exam
Glasses
Dental check-up
$30 copay
Not covered
Not covered
30% after deductible
Not covered
Not covered
Services You May Need
Limitations & Exceptions
-Limited to 60 visits
- Prior auth required; There is a $250
penalty for not obtaining prior auth.
Prior auth required; There is a $250
penalty for not obtaining prior auth.
Prior auth required; There is a $250
penalty for not obtaining prior auth.
–––––––––––none–––––––––––
No coverage for glasses.
No coverage for dental check-ups.
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
•
Dental care (adult and child)
•
Private-duty nursing
•
Bariatric surgery
•
Infertility treatment
•
•
Behavioral health half-way house services
•
Long-term care
Routine eye care (adult and child, excludes
vision exam and screening )
•
Non-emergency care when traveling outside
the U.S.
•
Routine foot care
•
Weight loss programs
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 (Limited to 20 visits)
•
Cosmetic surgery (Requires prior auth.
Services will only be considered if due to a
bodily injury or illness and functional
impairment is present.)
•
Dependent Daughter Maternity
•
Hearing aids (Limited to $1,000 per 36
months)
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
5 of 8
HIGH PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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 1-512-594-0019. 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 1-877267-2323 x61565 or www.cciio.cms.gov.
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: 1-512-594-0019 or email Kristin.baum@pfisd.net.
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 1-512-594-0019. ––––––––––––––––––––––
To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
6 of 8
HIGH PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
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.
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.
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $6,100
 Patient pays $1,444
 Amount owed to providers: $5,400
 Plan pays $3,760
 Patient pays $1,640
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$650
$20
$620
$150
$1,444
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$650
$910
$0
$80
$1,640
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
7 of 8
HIGH PLAN: PFLUGERVILLE ISD
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2017-12/31/2017
Coverage for: Single & Family | Plan Type: NPOS
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 innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
Can I use Coverage Examples
to compare plans?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance 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.
Yes. When you look at the Summary of
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.
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-ofpocket costs, such as copayments,
deductibles, and coinsurance. 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.
Questions: Call 1-512-594-0019 or email benefits@pfisd.net.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-512-594-0019 to request a copy.
8 of 8
Life made easier
Who can use EAP and Work-Life?
All employees as well as household family members.
Who pays for these services?
Your company pays all costs when you and
members of your household use the program.
If additional assistance or services are needed,
you will receive referrals that consider your
preferences, medical plan, and financial
circumstances. Please refer to your insurance
plan booklet or your human resources department
for specific information about your medical plan.
How do I access these services?
EAP and
Work-Life
Services
EAP and Work-Life are convenient, confidential,
and provided at no cost to you and members of
your household. We’re here 24 hours a day, seven
days a week, so call or sign in anytime.
For free and confidential
assistance, call 1-866-440-6556
or visit us at Humana.com/eap
Username: eap3
Password: eap3
Personal information about participants remains confidential
according to all applicable state and federal laws, unless
disclosure is required by such laws. Services provided by
Humana EAP and Work-Life Services.
GCHHSKQEN 0214
Your company understands that when your life is in balance and your personal
needs are being met, it’s easier to be happy and productive at work. That’s why
your company offers free access to EAP and Work-Life – to help you manage
life’s challenges and maintain a happy and well-balanced life.
What is an EAP?
What is Work-Life?
An Employee Assistance Program (EAP) offers
short-term counseling up to 3 visits per issue per
year to help you and members of your household
manage everyday life issues. Caring counselors are
available to assist you with:
Work-Life offers extensive
assistance, information, and
support to help you achieve a
better balance between work,
life, and family to help make your life easier.
You can access information and self-search
locators to find resources and providers that
can help you with:
• Everyday needs and life events
• Emotional issues
• Relationship concerns
• Family relationships
• Coping with a serious illness
• Weight control
• Sleeping difficulties
• Loss of a loved one
• Eating disorders
• Workplace concerns
• Smoking cessation
• Convenience services
• Housing options
• Child care
• Financing college
• Home ownership
• Caregiving from a distance
• Moving and relocation
• Finding colleges and universities
• Services and education for children with
special needs
What is the Legal and Financial Program?
As part of the EAP, you also have access to a free
30-minute consultation with a local attorney or
financial counselor on issues such as real estate,
retirement planning, divorce and separation,
budgeting/debt reconstruction, and trusts and
estates. Further legal and tax preparation services
are discounted 25 percent.
What if I’m just looking for information?
You can access many useful articles, tip sheets,
and checklists by calling or signing in to the EAP
and Work-Life website. Many helpful topics are
available, including relationships, communication,
life in the workplace, and emotional well-being.
• Adoption, pregnancy, and infertility
What else does the website offer?
• Adjusting to retirement
It includes dozens of locators that allow you to
search for health and wellness information, child
care providers, adoption services, schools and
colleges, daily living needs, older adult care, and
much more. The site also offers calculators that
can help you with everything from mortgage
payment calculations to how much to save for
your children’s college education.
• Locating services and care for older adults
• Pet care
• Finding schools
• Tutors and test prep
• Child development
• Recreational activities
• Consumer education
Humana.com
Your link to smart choices
For more information,
visit Humana.com.
Click “Register” on
the left side of the
page and follow the
instructions.
As a Humana member, you have powerful resources at your
fingertips to help when you’re making decisions that affect
your health.
At Humana.com, you can:
• Find in-network doctors, and hospitals
• FindoutaboutHumana’shealthand
wellness programs
• Viewandprintaletterofcoverageto
give the doctor as proof of coverage
AfteryoureceiveyourHumanaID
card, you can register for immediate
access to MyHumana – your secure
Website.
• Takeahealthassessmentandprintthe
results to share with your doctor
At MyHumana, you can:
• Createyourownhealthrecord,including
family history, immunizations, allergies,
and medications
• ViewandprintyourHumanaclaims
• OrderreplacementIDcards
• Viewandprintyourplancertificateand
a summary of your plan benefits
• Savemoneyonmedicines,supplements,
and other health and wellness products
withtheSavingsCenter
• VisitConditionCenterstoexplore
symptoms, treatments, and tests; track
your condition; and print reports to
discuss with your doctor
• UsePlanningToolstotrackyour
spending and estimate costs for a
procedure
Humana Plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana
Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas,
Inc. - A Health Maintenance Organization, or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana
Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, Humana Insurance of Puerto Rico, Inc. License # 00187-0009, or administered by Humana
Insurance Company or Humana Health Plan, Inc.
Statements in languages other than English contained in the advertisement do not necessarily reflect the exact contents of the policy written in English, because of possible linguistic differences.
In the event of a dispute, the policy as written in English is considered the controlling authority.
For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company.
Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on the company providing your benefits. Our health benefit
plans have limitations and exclusions.
Humana.com
GN14110HH_1112
GN14110HH_1112
Know where to get care
What’s the right level of care?
How do you decide where to seek medical care for yourself or a family member? The right
decision depends on your symptoms. Call HumanaFirst® Nurse Advice Line at
1-800-622-9529 for help in choosing the right level of care.
Home care
Minor health issues are often
easy to take care of at home.
Call HumanaFirst for advice.
Also, remember your out-of-pocket costs can vary significantly by the place of service.
Home Care
Care at home is an important consideration. You can visit the Conditions section under the
Get Healthy header on MyHumana, your secure website on Humana.com. You
also can call HumanaFirst for self-care advice. In addition, a variety of books provide selfcare guidelines.
Doctor’s Office
Your doctor should be your first call when you’re sick. Your doctor not only knows you,
but has all of your medical records in one place. Because of this, he or she can make an
informed decision about the care you need.
Retail Clinic
Put simply, these clinics make life easier when you need routine healthcare services for
common illnesses – like colds, flu, or sore throats – as well as screenings and vaccinations.
They usually cost less than an urgent care center or emergency room. Because they’re
in grocery stores, drugstores, and other retailers, you won’t have to make multiple trips
for medicine or supplies. Advanced Registered Nurse Practitioners (ARNPs) and Physician
Assistants (PAs) generally provide care at these facilities.
Urgent Care
Go to an urgent care center when your doctor isn’t available. Infections, injuries, cuts,
sprains, flu, fever, allergies, asthma, rash, and sore throat are some instances when you
should consider going to an urgent care center instead of an emergency room. Urgent
care centers have:
• Evening and weekend hours; usually a short wait
• Experienced, trained nurses and doctors
• Lower out-of-pocket costs for you than an emergency room
To find a location near you, visit your MyHumana.com page and click on the Find a Doctor
link, which will give you the option to choose urgent care providers close to you. You also
can call HumanaFirst for assistance.
Emergency Room
Use the “ER” for emergencies only. If you’re facing a serious situation – like uncontrolled
bleeding, chest pain, heart attack, difficulty breathing, possible stroke, or any threat to life
or limb – head straight to the ER. But the emergency room is not an appropriate place to
treat non-emergencies.
ERs aren’t “first come, first served.” Instead, a non-emergency must wait until all
emergencies are seen. At the ER, you could face:
• A long wait, and a crowded waiting area
• A hefty bill with high out-of-pocket costs
Doctor’s office
Your doctor knows the best
treatment for you.
$
Retail clinic
These clinics are usually in
retail stores, supermarkets,
and drugstores.
$
Urgent care center
Urgent care is a bridge
between your doctor and
the emergency room.
$$
Emergency room
When you think you’re having
an emergency, trust your
instincts and go to the ER.
$$$
Always be sure to check your plan details to confirm coverage.
Humana.com
GCA08DGHH 1013
ER or urgent care center?
How to know where to go
Emergency rooms treat serious or life-threatening conditions.
For non-emergency conditions, it’s better to go to your doctor or
an urgent care center.
When you can’t see your doctor right away, an urgent care center is a good medical
and financial alternative to an emergency room.
Here’s why:
• Your wait will probably be shorter.
• Urgent care centers are often open evenings and weekends.
• You don’t need an appointment.
• An urgent care center may be closer to your home or workplace.
• Your cost is usually lower than it would be at an emergency room. In fact, if you go to an
emergency room for non-emergency care, you may have to pay the entire bill yourself.
The choice is yours. But remember: For treatment of a minor illness or injury, an urgent
care center can save you time and money.
To find an urgent care center near you, log on to Humana.com and:
• Click “find a doctor”
• Select “Urgent Care Centers” under Provider Search at the right of the page
• Use your member ID or ZIP code on the pop-up window to find an urgent care center near you
Humana.com
Cost of care and out-of-pocket fees are dependent on facility charges. Health Plans are offered/administered by the Humana Family of
Insurance and Health Plan Companies. Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance) for more information
on the company providing your benefits. Our health plans have Limitations and Exclusions.
GN14455HH 513
Savings Center
One more reason to choose Humana
The Savings Center is a great place to find ways to lower the cost of staying healthy. Take advantage of these Humana
member discounts as often as you like:
Vision discount programs
• E
yeMed – 1-866-392-6056 Discounts on routine exams, eyeglass frames and lenses – including a wide range of lens
options – contact lenses, and laser correction.
To receive your EyeMed discount:
• Visit Physician Finder Plus on Humana.com to locate an EyeMed Vision provider near you
• Tell the EyeMed provider you’re a Humana member with EyeMed Vision benefits
• P
rint the discount ID card – you’ll find a link on the EyeMed, TruVision, and Alternative Medicine pages – or present your
Humana medical or dental ID card to your EyeMed provider
Your EyeMed provider will apply the discount directly to your purchase.
• T
ruVision – 1-877-580-2020 Traditional and custom LASIK to correct problems such as nearsightedness,
farsightedness, and astigmatism, offered at more than 200 TruVision centers nationwide for less than $1,000 per eye.
Services include:
• Telephone screening
• Comprehensive eye exam
• LASIK procedure on an FDA-approved excimer laser
• Postoperative care
• Retreatment warranty
To schedule an exam, determine price, find a location in your area, or get more information, call a Customer Care
specialist at 1-877-580-2020.
Cut out this card
and keep it in
your wallet for
handy reference.
Discount card
Subscriber name:
Subsciber ID:
ANSI/BIN#
610649
VISION:
EyeMed and TruVision
Alternative Medicine
HWHN
T hese discount programs are not part of your insurance.
Discounts are available only at participating providers.
Humana.com
GN20545HH 513
Page 1 of 2
Complementary and Alternative Medicine (CAM) discount program*
• Provided by Healthways WholeHealth Networks (HWHN), with more than 25,000 practitioners.
To access CAM services:
• Participating providers can be found at http://humana.wholehealthmd.com.
• Select a provider through the Health & Wellness link of the Savings Center or call the Customer Care number
on your member ID card.
• Present the Humana discount card below to receive the specified discount
It’s that easy!
You don’t need a referral to visit a participating massage therapist, acupuncturist, or chiropractor. However,
some Humana health plans offer coverage for some CAM services, so use your insured benefits whenever
possible.
*Not available in Arkansas, Tennessee, Oklahoma and where prohibited by law.
Stretch your health care dollars
Get special discounts just for Humana members on a wide variety of products and programs, from fitness facilities and
weight management programs to tobacco cessation and herbal teas and supplements. Check out the Health & Wellness
link for a complete list.
These discount programs are not part of your insurance product. Discounts are only available at participating providers.
Service providers are solely responsible for the provision of products and services. Humana and it’s affiliates are not liable
for product defects, provider negligence or other errors in the delivery of discount products or services. The insured/
administered benefits that make these discount services available are offered by Humana Medical Plan, Inc., Humana
Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana
Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health
Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. – A Health Maintenance Organization or insured
by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana,
Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, or Humana Insurance of Puerto Rico, Inc.
License # 00187-0009 or administered by Humana Insurance Company.
For Arizona Residents: Offered by Humana Health Plan, Inc. or insured or administered by Humana Insurance Company
Please refer to your Certificate of Coverage/Insurance or Summary Plan Description for more information on the company
providing your benefits.
Our health benefit plans have limitations and exclusions.
Humana.com
GN20545HH 513
Page 2 of 2
Explanation of Benefits
A savvy consumer’s guide
You want to get the most out of
your health plan.
Here’s a good place to start.
One of the most important plan documents you’ll see is
your Explanation of Benefits (EOB). It’s important to know
that an EOB isn’t a bill. It’s simply a form you receive from
Humana that explains the services and procedures you
received, what they cost, and what – if anything – you owe.
Get familiar with just a few sections on this form and you’ll be well on your way to a better healthcare experience.
Here’s what you need to know:
• Patient information shows which member of your health plan received care. All information on the EOB will
refer to this person.
• Servicing provider tells you the doctor, dentist, or healthcare facility you visited.
• Charge lists the total amount the provider charged for services received.
• Amount paid by Humana shows the amount your plan pays for services received. In many cases, Humana
has negotiated with providers to give you a discounted rate for certain services ... helping you save money.
• Estimated member responsibility tells you what you need to pay out-of-pocket. The provider will bill you
for this amount. Examples include your deductible or coinsurance amount, any denied service amount, or any
amount over the Maximum Allowable fee if you see a non-participating provider.
• Remark codes explain how your claim was processed or considered. You can find a description of the code on
page 2, which provides details on this process.
• Service code is a number used in the healthcare business to process claims more efficiently. The Service code
remarks section will tell you what this number means.
All information on your EOB should match the information that appears on statements you receive from your
healthcare provider. If it doesn’t, contact your provider immediately.
Keeping track
Once you understand how to read your EOB, you’ll be better prepared to track expenses, understand your
benefits, and avoid paying too much for your healthcare. It’s a good idea to keep your EOBs in a safe place should
you have questions later. You always can view your past 18 months of EOBs anytime on MyHumana, your secure
Website on Humana.com.
GH16646HH 509
Quick and easy
If you’d like your EOBs as quickly as possible, you can view or
download them online. Here’s what to do:
• Log in or register for MyHumana, your secure Website
on Humana.com
•
Select “Claims & Spending”
•
Click “Claims” for a list of all your claims
•
Select “Details” from the claim list
•
Select “(PDF) Download Explanation of Benefits” to view or
download your EOB
If you have questions, just give us a call at the number on the back
of your Humana ID card or visit us online at Humana.com.
GH16646HH 509
2017 Disclosure Notices
If you (and/or your dependents) have Medicare or will become eligible for Medicare in the
next 12 months, a Federal law gives you more choices about your prescription drug
coverage. Please see pages 6-7 for details.
Table of Contents
Special Enrollment
p. 2
Newborn Act Disclosure
p. 2
Women’s Health & Cancer Rights
p. 2
Choice of Healthcare Provider
p. 3
USERRA Continuation
p. 3
Medicaid & CHIP Offer Free or Low-Cost Health Coverage to Children & Families p. 4
Medicare part D Creditable Coverage
p. 6
SPECIAL ENROLLMENT NOTICE
This notice is being provided so that you understand your right to apply for group health insurance coverage
outside of Pflugerville ISD’s open enrollment period. You should read this notice regardless of whether or not you
are currently covered under Pflugerville ISD’s Group Health Plan. The Health Insurance Portability and
Accountability Act (HIPAA) requires that employees be allowed to enroll themselves and/or their dependent(s) in
an employer’s Group Health Plan under certain circumstances, described below, provided that the employee
notifies the employer within 60 days of the following events:

Loss of health coverage under another employer plan (including exhaustion of COBRA coverage);

Acquiring a spouse through marriage; or

Acquiring a dependent child through birth, adoption, placement for adoption or foster care placement.
Effective April 1, 2009, two new special enrollment rights were created under the Children’s Health Insurance
Program Reauthorization Act of 2009. All group health plans must also permit employees and dependents, who
are otherwise eligible for the group health plan, to enroll in the plan within 60 days of the following events:

Losing eligibility for coverage under a State Medicaid or CHIP program; or

Becoming eligible for State premium assistance under Medicaid or CHIP.
The employee or dependent must request coverage within 60 days of being terminated from Medicaid or CHIP
coverage or within 60 days of being determined to be eligible for premium assistance.
NEWBORN ACT DISCLOSURE
Under federal law, group health plans and health insurance issuers offering health insurance coverage generally
may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn
child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean
section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician,
nurse, midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn
earlier.
Also, under federal law, plan or issuers may not set the level of benefits or out-of-pocket costs so that the later
portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or the newborn than
the earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider
obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain
providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain pre-certification. For
information on pre-certification, contact your plan administrator.
WOMEN’S HEALTH & CANCER RIGHTS NOTICE
As required by the Women’s Health and Cancer Rights Act of 1998 (WHCRA), this medical plan provides
coverage for:
•
All stages of reconstruction of the breast of which the mastectomy was performed;
•
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
•
Prostheses and physical complications of mastectomy, including lymphedemas, in a manner determined
in consultation with the attending physician and the patient.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and
surgical benefits provided under this plan. If you would like more information of WHCRA benefits, call your plan
administrator.
2
CHOICE OF HEALTHCARE PROVIDER
If the group health plan in which you are enrolled requires the designation of a primary care provider, you have
the right to designate any participating primary care provider who is available to accept you or your family
members (for children, you may designate a pediatrician as the primary care provider). For information on how to
select a primary care provider and for a list of participating primary care providers, contact the Plan
Administrator. You do not need prior authorization from the group health plan or from any other person, including
your primary care provider, in order to obtain access to obstetrical or gynecological care from a health care
professional; however, you may be required to comply with certain procedures, including obtaining prior
authorization for certain services, following a pre-approved treatment plan, or procedures for making
referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact
the Plan Administrator.
USERRA CONTINUATION
Your right to continued participation in a group health plan during leaves of absence for active military duty is
protected by the Uniformed Services Employment and Reemployment Rights Act (USERRA). Accordingly, if you
are absent from work due to a period of active duty in the military for less than 31 days, your plan participation will
not be interrupted. If the absence is for more than 30 days and not more than 12 weeks, you may continue to
maintain your coverage under a group health plan by paying premiums in the manner specified by the Plan
Sponsor.
If you do not elect to continue to participate in a group health plan during an absence for military duty that is more
than 30 days, or if you revoke a prior election to continue to participate for up to 12 weeks after your military leave
began, you and your covered family members will have the opportunity to elect continuation coverage under a
group health plan for up to the 24-month period that begins on the first day of your leave of absence. You must
pay the premiums for continuation coverage with after-tax funds, subject to the rules that are set out in the
applicable Plan features.
USERRA continuation coverage is considered alternative coverage for purposes of COBRA. Therefore, if you
elect USERRA continuation coverage, COBRA coverage will generally not be available.
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your
employer, your state may have a premium assistance program that can help pay for coverage, using funds from
their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be
eligible for these premium assistance programs but you may be able to buy individual insurance coverage
through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact
your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial
1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a
program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under
your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled.
This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being
3
determined eligible for premium assistance. If you have questions about enrolling in your employer plan,
contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan
premiums. The following list of states is current as of January 31, 2016. Contact your State for more information
on eligibility –
ALABAMA – Medicaid
Website: http://myalhipp.com/
Phone: 1-855-692-5447
ALASKA – Medicaid
Website:
http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
COLORADO – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
FLORIDA – Medicaid
Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-877-357-3268
KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
LOUISIANA – Medicaid
Website:
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html
Phone: 1-800-442-6003
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
MINNESOTA – Medicaid
Website: http://mn.gov/dhs/ma/
Phone: 1-800-657-3739
MISSOURI – Medicaid
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
MONTANA – Medicaid
Website:
http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084
NEBRASKA – Medicaid
GEORGIA – Medicaid
Website: http://dch.georgia.gov/medicaid
- Click on Health Insurance Premium Payment (HIPP)
Phone: 404-656-4507
INDIANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.hip.in.gov
Phone: 1-877-438-4479
All other Medicaid
Website: http://www.indianamedicaid.com
Phone 1-800-403-0864
IOWA – Medicaid
Website: http://www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-785-296-3512
NEW HAMPSHIRE – Medicaid
Website:
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
NEW JERSEY – Medicaid and CHIP
Medicaid Website:
http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
NEW YORK – Medicaid
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
NORTH CAROLINA – Medicaid
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
NORTH DAKOTA – Medicaid
Website:
http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-844-854-4825
OKLAHOMA – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
OREGON – Medicaid
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid
4
Website:
http://dhhs.ne.gov/Children_Family_Services/AccessNebras
ka/Pages/accessnebraska_index.aspx
Phone: 1-855-632-7633
NEVADA – Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
SOUTH CAROLINA – Medicaid
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS – Medicaid
Website: http://gethipptexas.com/
Phone: 1-800-440-0493
UTAH – Medicaid and CHIP
Website:
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
Website: http://www.dhs.pa.gov/hipp
Phone: 1-800-692-7462
RHODE ISLAND – Medicaid
Website: http://www.eohhs.ri.gov/
Phone: 401-462-5300
VIRGINIA – Medicaid and CHIP
Medicaid Website:
http://www.coverva.org/programs_premium_assistance.cf
m
Medicaid Phone: 1-800-432-5924
CHIP Website:
http://www.coverva.org/programs_premium_assistance.cf
m
CHIP Phone: 1-855-242-8282
WASHINGTON – Medicaid
Website:
http://www.hca.wa.gov/medicaid/premiumpymt/pages/inde
x.aspx
Phone: 1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid
Website:
http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pag
es/default.aspx
Phone: 1-877-598-5820, HMS Third Party Liability
WISCONSIN – Medicaid and CHIP
Website:
https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002
WYOMING – Medicaid
Website: https://wyequalitycare.acs-inc.com/
Phone: 307-777-7531
To see if any other states have added a premium assistance program since January 31, 2016, or for more
information on special enrollment rights, contact either:
U.S. Department of Labor
U.S. Department of Health and Human Services
Employee Benefits Security Administration
Centers for Medicare & Medicaid Services
www.dol.gov/ebsa
www.cms.hhs.gov
1-866-444-EBSA (3272)
1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
5
Important Notice from Pflugerville ISD About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information
about your current prescription drug coverage with Pflugerville ISD and about your options
under Medicare’s prescription drug coverage. This information can help you decide whether or
not you want to join a Medicare drug plan. If you are considering joining, you should compare
your current coverage, including which drugs are covered at what cost, with the coverage and
costs of the plans offering Medicare prescription drug coverage in your area. Information about
where you can get help to make decisions about your prescription drug coverage is at the end of
this notice.
There are two important things you need to know about your current coverage and Medicare’s
prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare.
You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare
Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare
drug plans provide at least a standard level of coverage set by Medicare. Some plans may
also offer more coverage for a higher monthly premium.
2. Pflugerville ISD has determined that the prescription drug coverage offered by the Humana
is, on average for all plan participants, expected to pay out as much as standard Medicare
prescription drug coverage pays and is therefore considered Creditable Coverage. Because
your existing coverage is Creditable Coverage, you can keep this coverage and not pay a
higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from
October 15th through December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own,
you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug
plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug
Plan?
If you decide to join a Medicare drug plan, your current Pflugerville ISD coverage MAY be affected. If
you decide to join a Medicare drug plan, your current Humana plan coverage may be affected by the
coordination of benefits provision in the Humana plan. If you choose to drop Humana coverage to join a
Medicare drug plan, you may be able to get this plan back. However the Pflugerville ISD drug plan is
included in the Pflugerville ISD group health plan and is not available as a separate benefit.
If you do decide to join a Medicare drug plan and drop your current Pflugerville ISD coverage, be aware
that you and your dependents MAYbe able to get this coverage back.
6
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Pflugerville ISD and don’t join
a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher
premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly
premium may go up by at least 1% of the Medicare base beneficiary premium per month for every
month that you did not have that coverage. For example, if you go nineteen months without creditable
coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary
premium. You may have to pay this higher premium (a penalty) as long as you have Medicare
prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug
Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will
also get it before the next period you can join a Medicare drug plan, and if this coverage through
Pflugerville ISD changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug
Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare
& You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may
also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of
the “Medicare & You” handbook for their telephone number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is
available. For information about this extra help, visit Social Security on the web at
www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the
Medicare drug plans, you may be required to provide a copy of this notice when
you join to show whether or not you have maintained creditable coverage and,
therefore, whether or not you are required to pay a higher premium (a penalty).
Date:
Name of Entity/Sender:
Contact-Position/Office:
Address:
Phone Number:
08/01/2016
Pflugerville ISD
Benefits Department
1401 West Pecan Street
Pflugerville, TX 78660
512-594-0019
7
2017 Aviso Importante
Si usted (y/o sus dependientes) tienen Medicare o van a ser elegibles para
Medicare en los próximos 12 meses, la ley Federal le da más opciones sobre
su cobertura de prescripción. Por favor lea las paginas 7-8 para más detalles.
Indice
Aviso Especial de Inscripción
Información sobre la Ley de los Recién Nacidos
Aviso sobre los Derechos de la Mujer respecto a Salud Cáncer
Eleccion De Proveedor De Servicios Medicos
Continuacion De Cobertura Bajo USERRA
Asistencia con las primas bajo Medicaid y el Programa de Seguro de Salud
para Menores (CHIP)
Medicare parte D - Cobertura Acreditable
p. 2
p. 2
p. 2
p. 3
p. 3
p. 3
p. 5
1
AVISO ESPECIAL DE INSCRIPCIÓN
Este mensaje se envía para que usted entienda su derecho a solicitar una cobertura de seguro médico
colectivo fuera del período de inscripción abierta Pflugerville ISD. Usted debe leer este aviso esté o no
inscrito(a) actualmente en el Plan de Salud Colectivo Pflugerville ISD. La Ley de Portabilidad y
Responsabilidad de los Seguros de Salud (HIPAA, por sus siglas en inglés) dicta que los empleados
puedan inscribirse a sí mismos y/o a su(s) dependiente(s) en un Plan de Salud Colectivo de un empleador
bajo ciertas circunstancias descritas a continuación, siempre que el empleado notifique al empleador dentro
de 60 días de los siguientes eventos:

Pérdida de cobertura de salud en otro plan del empleador (incluyendo la terminación de la cobertura
COBRA);

Incorporación de un cónyuge por matrimonio; o

Incorporación de un(a) niño(a) dependiente por nacimiento, adopción, entrega en adopción o tutela
temporal.
A partir del 1º de abril de 2009 se crearon dos derechos especiales de inscripción según la Ley de
Reautorización del Programa de Seguro Médico para Niños (Children’s Health Insurance Program
Reauthorization Act o CHIP [por sus siglas en inglés]) del 2009. Todos los planes de salud colectivos
también deben permitir que los empleados y dependientes que de otra forma no tengan derecho al plan de
salud colectivo puedan inscribirse en el plan dentro de 60 días de los siguientes eventos:

Pérdida de elegibilidad para cobertura bajo un Medicaid estatal o un programa CHIP; o

Adquirir el derecho a asistencia de primas del estado por Medicaid o CHIP.
El empleado o dependiente debe solicitar la cobertura dentro de los 60 días posteriores a haber sido
desvinculado de la cobertura de Medicaid o CHIP o dentro de los 60 días de haber sido determinado
elegible para recibir ayuda para primas.
INFORMACIÓN SOBRE LA LEY DE LOS RECIÉN NACIDOS
Según la ley federal, los planes de salud colectivos y los emisores de seguros de salud que ofrecen
cobertura médica por lo general no pueden limitar los beneficios para estadías en hospitales relacionadas
con nacimientos para la madre o el recién nacido a menos de 48 horas tras un parto natural o menos de 96
horas tras un parto por cesárea. Sin embargo, el plan o el emisor puede pagar una estadía de menor
duración si el proveedor al cual se acude (por ej. su médico, enfermera, partera o asistente médico) tras ser
consultado con la madre, da de alta a la madre o al recién nacido antes.
Además, según la ley federal, el plan o los emisores no pueden determinar el nivel de beneficios o gastos
por cuenta propia para que la porción posterior de la estadía de 48 horas (o 96 horas) se considere de una
forma menos favorable a la madre o al recién nacido que la porción anterior de la estancia.
También, un plan o emisor no puede, según la ley federal, requerir que un médico u otro proveedor de
atención médica obtenga autorización para indicar una estadía de hasta 48 horas (o 96 horas). Sin
embargo, para usar ciertos proveedores o instalaciones, o reducir sus gastos por cuenta propia, puede que
usted deba obtener una precertificación. Para información sobre la precertificación contacte al administrador
de su plan.
AVISO SOBRE LOS DERECHOS DE LA MUJER RESPECTO A SALUD Y CÁNCER
Según dicta la Ley de Derechos sobre la Salud y el Cáncer de la Mujer de 1998 (Women’s Health and
Cancer Rights Act of 1998 o WHCRA, por sus siglas en inglés), este plan médico provee cobertura para:
•
Todos los niveles de reconstrucción del seno al que se le practicado una mastectomía;
•
Cirugía y reconstrucción del otro seno para crear una apariencia simétrica;
2
Prótesis y complicaciones físicas de la mastectomía, incluyendo linfoedemas, de la forma determinada en la
consulta con el médico responsable y la paciente.
Estos beneficios serán provistos y estarán sujetos a los mismos deducibles y coaseguro aplicables a otros
beneficios médicos y quirúrgicos brindados dentro de este plan. Si usted desea más información sobre los
beneficios de WHCRA, llame al administrador de su plan.
ELECCION DE PROVEEDOR DE SERVICIOS MEDICOS
Si el plan de salud de grupo en el que usted está inscrito requiere la designación de un proveedor principal
de servicios médicos, usted tiene el derecho de designar cualquier proveedor principal de servicios médicos
que sea participante y que esté disponible a aceptarlo a usted y a los miembros de su familia (para los
niños, puede designar a un pediatra como el proveedor principal). Usted no necesita autorización previa del
plan de salud de grupo o de ninguna otra persona, incluyendo su médico principal, para obtener acceso a
cuidados de un obstetra o de un ginecólogo; sin embargo, es posible que necesite cumplir ciertos
procedimientos, incluyendo el obtener autorización previa para ciertos servicios, seguir un tratamiento
previamente aprobado, o seguir procedimientos para obtener referencias. Contacte al Administrador del
Plan para recibir más información sobre como seleccionar a un proveedor principal de servicios médicos y
para pedir una lista de proveedores participantes, incluyendo otros proveedores profesionales como
obstetras y ginecólogos.
CONTINUACION DE COBERTURA BAJO USERRA
Usted tiene derecho a continuar participando en el plan de salud de grupo durante su permiso de ausencia
debido a servicio militar, el cual está protegido bajo la Ley de Derechos de Empleo y Reempleo para
Militares (USERRA). Consecuentemente, si usted está ausente en su trabajo debido a servicio activo militar
por más de 31 días, su participación en el plan de salud no será interrumpida. Si su ausencia es por más de
30 días pero no más de 12 semanas, usted puede mantener su cobertura bajo el plan de salud de grupo si
continua pagando las primas del seguro especificadas por su empresa (patrocinador del plan).
Si usted no elige continuar su participación en el plan de salud de grupo durante su ausencia debido a
servicio militar de más de 30 días, o si usted revoca su elección previa a continuar participando durante las
12 semanas después de que su ausencia empieza, usted y sus familiares cubiertos por el plan tendrán la
oportunidad de elegir la continuación de cobertura bajo el plan de salud de grupo por un máximo de 24
meses, el cual comienza el primer día de su permiso de ausencia. Usted debe pagar las primas de seguro
para continuar su cobertura con pagos después de los impuestos, las cuales están sujetas a las reglas
establecidas por el Plan.
La continuación de cobertura bajo USERRA es considerada una cobertura alternativa para propósitos de
COBRA (Ley de Continuación de Cobertura). Consecuentemente, si usted elige continuar su cobertura bajo
USERRA, la opción de cobertura bajo COBRA no estará disponible generalmente.
3
Asistencia con las primas bajo Medicaid y el Programa
de Seguro de Salud para Menores (CHIP)
Si usted o sus hijos son elegibles para Medicaid o CHIP y usted es elegible para cobertura médica de su
empleador, su estado puede tener un programa de asistencia con las primas que puede ayudar a pagar
por la cobertura, utilizando fondos de sus programas Medicaid o CHIP. Si usted o sus hijos no son
elegibles para Medicaid o CHIP, usted no será elegible para estos programas de asistencia con las
primas, pero es probable que pueda comprar cobertura de seguro individual a través del mercado de
seguros médicos. Para obtener más información, visite https://www.cuidadodesalud.gov/es/.
Si usted o sus dependientes ya están inscritos en Medicaid o CHIP y usted vive en uno de los estados
enumerados a continuación, comuníquese con la oficina de Medicaid o CHIP de su estado para saber si
hay asistencia con primas disponible.
Si usted o sus dependientes NO están inscritos actualmente en Medicaid o CHIP, y usted cree que
usted o cualquiera de sus dependientes puede ser elegible para cualquiera de estos programas,
comuníquese con la oficina de Medicaid o CHIP de su estado, llame al 1-877-KIDS NOW o visite
http://espanol.insurekidsnow.gov/ para información sobre como presentar su solicitud. Si usted es
elegible, pregunte a su estado si tiene un programa que pueda ayudarle a pagar las primas de un plan
patrocinado por el empleador.
Si usted o sus dependientes son elegibles para asistencia con primas bajo Medicaid o CHIP, y también
son elegibles bajo el plan de su empleador, su empleador debe permitirle inscribirse en el plan de su
empleador, si usted aún no está inscrito. Esto se llama oportunidad de “inscripción especial”, y usted
debe solicitar la cobertura dentro de los 60 días de haberse determinado que usted es elegible
para la asistencia con las primas. Si tiene preguntas sobre la inscripción en el plan de su empleador,
comuníquese con el Departamento del Trabajo electrónicamente a través
http://www.dol.gov/ebsa/contactEBSA/asistenciaalconsumidor.html o llame al servicio telefónico
gratuito 1-866-444-EBSA (3272).
Si usted vive en uno de los siguientes estados, tal vez sea elegible para asistencia para pagar las
primas del plan de salud de su empleador. La siguiente es una lista de estados actualizada al 31 de
enero de 2016. Comuníquese con su estado para obtener más información sobre la elegibilidad –
ALABAMA – Medicaid
Sitio web: http://www.myalhipp.com
Teléfono: 1-855-692-5447
ALASKA – Medicaid
Sitio web:
http://health.hss.state.ak.us/dpa/programs/medicaid/
Teléfono (Fuera de Anchorage): 1-888-318-8890
Teléfono (Anchorage): 907-269-6529
COLORADO – Medicaid
Sitio web de Medicaid: http://www.colorado.gov/hcpf
Medicaid Phone (fuera de estado): 1-800-221-3943
GEORGIA – Medicaid
Sitio web: http://dch.georgia.gov/medicaid
Haga clic en “Health Insurance Premium
Payment (HIPP)”
Teléfono: 404-656-4507
INDIANA – Medicaid
Healthy Indiana Plan for low-income – Plan de
Salud de Indiana de bajos ingresos
Sitio web: http://hip.in.gov
Telefono: 1-877-438-4479
All other Medicaid – Todos los demás
Medicaid
Sitio web: http//www.indianamedicaid.com
Teléfono: 1-800-403-0864
IOWA – Medicaid
Sitio web: www.dhs.state.ia.us/hipp/
Teléfono: 1-888-346-9562
4
FLORIDA – Medicaid
Sitio web: https://www.flmedicaidtplrecovery.com/
Teléfono: 1-877-357-3268
KANSAS – Medicaid
Sitio web: http://www.kdheks.gov/hcf/
Teléfono: 1-800-296-3512
KENTUCKY – Medicaid
Sitio web: http://chfs.ky.gov/dms/default.htm
Teléfono: 1-800-635-2570
NUEVO HAMPSHIRE – Medicaid
Sitio web:
http://www.dhhs.nh.gov/oii/documents/hippapp.
pdf
Teléfono: 603-271-5218
NUEVA JERSEY – Medicaid y CHIP
Sitio web de Medicaid:
http://www.state.nj.us/humanservices/dmahs/cli
ents/medicaid/
Teléfono de Medicaid: 609-631-2392
Sitio web de CHIP:
http://www.njfamilycare.org/index.html
Teléfono de CHIP: 1-800-701-0710
NUEVA YORK – Medicaid
Sitio web:
http://www.nyhealth.gov/health_care/medicaid/
Teléfono: 1-800-541-2831
LOUISIANA – Medicaid
Sitio web:
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Teléfono: 1-888-695-2447
MAINE – Medicaid
Sitio web: http://www.maine.gov/dhhs/ofi/publicassistance/index.html
Teléfono: 1-800-442-6003
TTY: Maine relay 711
MASSACHUSETTS – Medicaid y CHIP
Sitio web: http://www.mass.gov/MassHealth
Teléfono: 1-800-462-1120
MINNESOTA – Medicaid
Sitio web: http://www.mn.gov/dhs/ma
Teléfono: 1-800-657-3629
MISSOURI – Medicaid
Sitio web:
http://www.dss.mo.gov/mhd/participants/pages/hipp.
htm
Teléfono: 573-751-2005
MONTANA – Medicaid
Sitio web:
http://dphhs.mt.go/MontanaHealthcarePrograms/HI
P
Teléfono: 1-800-694-3084
NEBRASKA – Medicaid
CAROLINA DEL NORTE – Medicaid
Sitio web: http://www.ncdhhs.gov/dma
Teléfono: 919-855-4100
DAKOTA DEL NORTE – Medicaid
Sitio web:
http://www.nd.gov/dhs/services/medicalserv/me
dicaid/
Teléfono: 1-844-854-4825
OKLAHOMA – Medicaid y CHIP
Sitio web: http://www.insureoklahoma.org
Teléfono: 1-888-365-3742
OREGON – Medicaid
Sitio web: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Teléfono: 1-800-699-9075
PENSILVANIA – Medicaid
Sitio web:
http://dhhs.ne.gov/Children_Family_Services/Acces
sNebraska/Pages/accessnebraska_index.aspx
Teléfono: 1-855-632-7633
Sitio web: http://www.dhs.pa.us/hipp
Teléfono: 1-800-692-7462
NEVADA – Medicaid
Sitio web de Medicaid: http://dwss.nv.gov/
Teléfono de Medicaid: 1-800-992-0900
RHODE ISLAND – Medicaid
Sitio web: http://www.eohhs.ri.gov/
Teléfono: 401-462-5300
5
CAROLINA DEL SUR – Medicaid
Sitio web: http://www.scdhhs.gov
Teléfono: 1-888-549-0820
DAKOTA DEL SUR- Medicaid
Sitio web: http://dss.sd.gov
Teléfono: 1-888-828-0059
TEXAS – Medicaid
Sitio web: http://gethipptexas.com/
Teléfono: 1-800-440-0493
UTAH – Medicaid y CHIP
Sitio web de Medicaid:
http://health.utah.gov/medicaid
Sitio web de CHIP: http://health.utah.gov/chip
Teléfono: 1-866-543-7669
VERMONT– Medicaid
Sitio web: http://www.greenmountaincare.org/
Teléfono: 1-800-250-8427
VIRGINIA – Medicaid y CHIP
Sitio web de Medicaid:
http://www.coverva.org/programs_premium_ass
istance.cfm
Teléfono de Medicaid: 1-800-432-5924
Sitio web de CHIP:
http://www.coverva.org/programs_premium_ass
istance.cfm
Teléfono de CHIP: 1-855-242-8282
WASHINGTON – Medicaid
Sitio web:
http://www.hca.wa.gov/medicaid/premiumpymt/
pages/index.aspx
Teléfono: 1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid
Sitio web:
http://www.dhhr.wv.gov/bms/Medicaid%20Expa
nsion/Pages/default.aspx
Teléfono: 1-877-598-5820, HMS Third Party
Liability
WISCONSIN – Medicaid
Sitio web:
http://www.dhs.wisconsin.gov/publications/p1/p1
0095.pdf
Teléfono: 1-800-362-3002
WYOMING – Medicaid y CHIP
Sitio web: https://wyequalitycare.acs-inc.com/
Teléfono: 307-777-7531
Para saber si otros estados han agregado el programa de asistencia con primas desde el 31 de enero
de 2016, o para obtener más información sobre derechos de inscripción especial, comuníquese con
alguno de los siguientes:
Departamento del Trabajo de EE.UU.
Administración de Seguridad de Beneficios
de los Empleados
www.dol.gov/ebsa
1-866-444-EBSA (3272)
Departamento de Salud y Servicios
Humanos de EE.UU.
Centros para Servicios de Medicare y
Medicaid
www.cms.hhs.gov
1-877-267-2323, opción de menú 4, Ext.
6156
Número de Control de OMB 1210-0137
(vence al 31 de octubre de 2016)
6
Aviso Importante de Pflugerville ISD Sobre su Cobertura para Recetas Médicas y
Medicare
Por favor lea este aviso cuidadosamente y guárdelo donde pueda encontrarlo. Este aviso contiene
información sobre su cobertura actual para recetas médicas con Pflugerville ISD y sus opciones bajo la
cobertura de Medicare para medicamentos recetados. Además, le menciona dónde encontrar más
información que le ayude a tomar decisiones sobre su cobertura para medicinas. Si usted está considerando
inscribirse, debe comparar su cobertura actual, incluyendo los medicamentos que están cubiertos a qué
costo, con la cobertura y los costos de los planes que ofrecen cobertura de medicinas recetadas en su área.
Información sobre dónde puede obtener ayuda para tomar decisiones sobre su cobertura de medicamentos
recetados se encuentra al final de este aviso.
Hay dos cosas importantes que usted necesita saber sobre su cobertura actual de Medicare y la
cobertura de medicamentos recetados:
1. La nueva cobertura de Medicare para recetas médicas está disponible desde el 2006 para todas las
personas con Medicare. Usted puede obtener esta cobertura si se inscribe en un Plan de Medicare para
Recetas Médicas, o un Plan Medicare Advantage (como un PPO o HMO) que ofrece cobertura para
medicamentos recetados. Todos los planes de Medicare para recetas médicas proporcionan por lo menos
un nivel estándar de cobertura establecido por Medicare. Además, algunos planes pueden ofrecer más
cobertura por una prima mensual más alta.
2. Pflugerville ISD ha determinado que la cobertura para recetas médicas ofrecida por el Humana en
promedio se espera que pague tanto como lo hará la cobertura estándar de Medicare para recetas médicas
para todos los participantes del plan y por lo tanto es considerada Cobertura Acreditable. Debido a que su
cobertura actual es Acreditable, usted puede mantener esta cobertura y no pagar una prima más alta (una
penalidad), si más tarde decide inscribirse en un plan de Medicare.
¿Cuándo puede inscribirse en un plan de Medicare de medicamentos?
Usted puede inscribirse en un plan de Medicare de medicamentos la primera vez que es elegible para
Medicare y cada año del 15 de octubre al 7 de diciembre.
Sin embargo, si pierde su cobertura actual acreditable, y no es su culpa, usted será elegible para dos (2)
meses en el Período de Inscripción Especial (SEP) para subscribirse en un Plan Medicare de medicinas.
¿Qué sucede con su cobertura actual si decide inscribirse en un plan de Medicare de
medicamentos?
Si decide inscribirse en un plan de Medicare de medicamentos recetados, su cobertura actual con Pflugerville
ISD puede ser afectada.
Si decide inscribirse en un plan de Medicare de medicamentos recetados, su cobertura actual en el plan
Humana de Pflugerville ISD puede ser afectada debido a una provisión de coordinación de beneficios incluida
en el plan médico de Pflugerville ISD. Si decide dejar la cobertura del plan médico de Pflugerville ISD para
inscribirse en el plan de prescripción de Medicare, es posible que se le permita regresar a la misma cobertura
de su plan anterior. Sin embargo, el plan de prescripción de Pflugerville ISD está incluido en el plan médico
de Pflugerville ISD y no es un beneficio que está disponible fuera del plan.
Si cancela su cobertura actual con Pflugerville ISD y se inscribe en un plan de Medicare para recetas
médicas, puede ser que más adelante ni usted ni sus dependientes puedan obtener su cobertura de nuevo.
7
•
•
•
¿Cuándo usted pagará una prima más alta (penalidad) para inscribirse en un plan de
Medicare de medicamentos?
Usted debe saber también que si cancela o pierde su cobertura actual con Pflugerville ISD y deja de
inscribirse en una cobertura de Medicare para recetas médicas después de que su cobertura actual termine,
podría pagar más (una penalidad) por inscribirse más tarde en una cobertura de Medicare para recetas
médicas.
Si usted lleva 63 días o más sin cobertura acreditable para recetas médicas que sea por lo menos tan buena
como la cobertura de Medicare para recetas médicas, su prima mensual aumentará por lo menos un 1% al
mes por cada mes que usted no tuvo esa cobertura. Por ejemplo, si usted lleva diecinueve meses sin
cobertura acreditable, su prima siempre será por lo menos 19% más alta de lo que la mayoría de la gente
paga. Usted tendrá que pagar esta prima más alta (penalidad) mientras tenga la cobertura de Medicare. Además,
usted tendrá que esperar hasta el siguiente mes de octubre para inscribirse.
Para más información sobre este aviso o su cobertura actual para recetas médicas…
Llame a nuestra oficina para más información. NOTA: Usted recibirá este aviso cada año. Recibirá el aviso
antes del próximo período en el cual usted puede inscribirse en la cobertura de Medicare para recetas
médicas, y en caso de que esta cobertura con Pflugerville ISD cambie. Además, usted puede solicitar una
copia de este aviso en cualquier momento.
Para más información sobre sus opciones bajo la cobertura de Medicare para recetas
médicas…
Revise el manual “Medicare y Usted” para información más detallada sobre los planes de Medicare que
ofrecen cobertura para recetas médicas. Medicare le enviará por correo un ejemplar del manual. Tal vez los
planes de Medicare para recetas médicas le llamen directamente. Asimismo, usted puede obtener más
información sobre los planes de Medicare para recetas médicas de los siguientes lugares:
Visite www.medicare.gov por Internet para obtener ayuda personalizada,
Llame a su Programa Estatal de Asistencia sobre Seguros de Salud (consulte su manual Medicare y Usted
para obtener los números telefónicos)
Llame GRATIS al 1-800-MEDICARE (1-800-633-4227). Los usuarios con teléfono de texto (TTY) deben
llamar al 1-877-486-2048.
Para las personas con ingresos y recursos limitados, hay ayuda adicional que paga por un plan de Medicare
para recetas médicas. El Seguro Social (SSA, por sus siglas en inglés) tiene disponible información sobre
esta ayuda adicional. Para más información sobre esta ayuda adicional, visite la SSA en línea en
www.socialsecurity.gov por Internet, o llámeles al 1-800-772-1213 (Los usuarios con teléfono de texto (TTY)
deberán llamar al 1-800-325-0778.
Fecha:
Nombre de la Entidad/Remitente:
Contacto--Puesto/Oficina:
Dirección:
Número de Teléfono:
08/01/2016
Pflugerville ISD
Benefits Department
1401 West Pecan Street
Pflugerville, TX 78660
512-594-0019
8