14-Exhibit 4. Fort Bend ISD Surest Plan SBC 2025.pdf
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- Fort Bend County, Texas
About this file
This document is a Summary of Benefits and Coverage (SBC) for a health insurance plan offered by Surest to Fort Bend ISU for individual and family coverage, effective from January 1, 2025 to December 31, 2025. The plan is an Exclusive Provider Organization (EPO) with a $0 overall deductible and an out-of-pocket limit of $8,500 for individual and $17,000 for family coverage for in-network providers. The plan does not require referrals to see specialists and covers a wide range of medical services, including primary care visits, specialist consultations, preventive care, diagnostic tests, emergency services, hospital stays, mental health services, and prescription drugs.
The plan's cost-sharing structure includes copayments and coinsurance for various medical services, with costs varying depending on the type of service and provider. Prescription drugs are categorized into tiers with different coinsurance rates, and certain Tier 1 drugs like generic contraceptives are available at no charge. Out-of-network services are generally not covered. The plan provides language access services in multiple languages and offers free communication assistance. It meets Minimum Essential Coverage and Minimum Value Standards, potentially making members ineligible for premium tax credits. The document also outlines excluded services such as acupuncture, cosmetic surgery, dental care, and weight loss programs, while providing additional covered services like chiropractic care and hearing aids with certain limitations.
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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2025 – 12/31/2025 Fort Bend ISU: Surest Coverage for: Individual and Family | Plan Type: EPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit Join.Surest.com, Surest mobile app or call Surest
Member Services at 1-866-683-6440. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copay, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://healthcare.gov/sbc-glossary/ or call 1-866-487-2365 to request a copy.
Important Questions Answers Why This Matters What is the overall deductible? $0 See the Common Medical Events chart below for your costs for services this plan covers.
Are there services covered before you meet your deductible?
Yes.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copay or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?
No You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?
For network providers:
$8,500 individual / $17,000 family
For out-of-network providers:
Not covered
The out-of-pocket limit is the most you could pay in a year for covered services.
If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?
Premiums, balance billing charges and health care this plan doesn’t cover.
Even though you pay these expenses, they don't count toward the out-of-pocket limit.
Will you pay less if you use a network provider?
Yes. See Join.Surest.com or call 1-866-683-6440 for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?
No You can see the specialist you choose without a referral.
http://join.surest.com/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/coverage/preventive-care-benefits/
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important Information* In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
$50 - $150 copay/visit Not covered
Certain procedures performed in the office may have a higher office visit copay.
Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care.
*Cost share applies to any other Telehealth service based on provider type. If you receive services in addition to office visit, additional copays may apply.
Specialist visit $50 - $150 copay/visit Not covered
Preventive care/screening/ immunization
No charge Not covered You may have to pay for services that are not preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Routine diagnostic test (e.g., x-ray, blood work) Non-routine diagnostic test (e.g., sleep study, genetic testing)
Routine diagnostic test: No charge Non-routine diagnostic test:
$50 - $1,400 copay/visit
Routine diagnostic test:
Not covered Non-routine diagnostic test: Not covered
Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care.
Prior authorization is required for certain Non-routine diagnostic tests or there may be no coverage.
Imaging (CT/PET scans, MRIs)
$350 - $1,400 copay/visit Not covered
Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care.
Prior authorization is required for certain imaging tests or there may be no coverage.
*For more information about limitations and exceptions, see the plan or policy document at Join.Surest.com.
Common Medical Event Services You
May Need
What You Will Pay Limitations, Exceptions, & Other
Important Information In-Network Provider
(You will pay the least) Out-of-Network Provider (You will pay the most)
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at Caremark.com.
Tier 1 drugs
30-Day Supply 30% Coinsurance
90-Day Supply 25% Coinsurance
Not covered
Certain Tier 1 drugs are available with no charge, including prescribed generic contraceptives and tobacco cessation medications.
To learn more about drug tiers and about copays for specific drugs, visit Caremark.com website.
Prior authorization is required for certain drugs or there may be no coverage.
Tier 2 drugs
30-Day Supply 40% Coinsurance
90-Day Supply 35% Coinsurance
Not covered
Tier 3 drugs
30-Day Supply 50% Coinsurance
90-Day Supply 45% Coinsurance
Not covered
Specialty drugs 45% Coinsurance: $75 Max Not covered
Specialty drugs are not covered at a 90-day supply.
Prior authorization is required for certain specialty drugs or there may be no coverage.
http://www.caremark.com/ http://www.caremark.com/
Common Medical Event
Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information* In-Network Provider
(You will pay the least) Out-of-Network Provider (You will pay the most)
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center)
$75 - $5,500 copay/visit Not covered Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care.
Prior authorization is required for certain outpatient surgery or there may be no coverage.
Physician/surgeon fees
No charge Not covered
If you need immediate medical attention
Emergency room care
$1,000 copay/visit $1,000 copay/visit Copay is waived if admitted within 24 hours. Out-of-network emergency room care visit copay applies to the in-network out-of-pocket limit.
Emergency medical transportation
$500 copay/transport $500 copay/transport
Prior authorization is required for non-emergency medical transportation or there may be no coverage. Out-of-network emergency medical transportation copay applies to the in-network out-of-pocket limit.
Urgent care $75 copay/visit Not covered None
If you have a hospital stay
Facility fee (e.g., hospital room)
$400 - $5,500 copay/stay Not covered
Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care.
Prior authorization is required for non-emergency facility admissions and inpatient surgery or there may be no coverage.
Physician/surgeon fees
No charge Not covered
*For more information about limitations and exceptions, see the plan or policy document at Join.Surest.com.
Common Medical Event Services You
May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider
(You will pay the least) Out-of-Network Provider (You will pay the most)
If you need mental health, behavioral health, or substance abuse services
Outpatient services
Home/Office: $45 copay/visit Outpatient Facility: $170 copay/visit
Home/Office: Not covered Outpatient Facility: Not covered
Certain procedures/services in the outpatient setting may have a lower copay.
Prior authorization is required for certain outpatient services or there may be no coverage.
Inpatient services $4,500 copay/stay Not covered
Certain procedures/services in the inpatient setting may have a lower copay.
Prior authorization is required for certain inpatient services or there may be no coverage.
If you are pregnant
Office visits No charge Not covered
Cost sharing does not apply to preventive services with network providers.
Depending on the type of service, a copay may apply.
Childbirth/delivery professional services
No charge Not covered One copay for all covered services related to childbirth/delivery, including the newborn, unless discharged after mother.
Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care.
Prior authorization is required for inpatient stays beyond 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery or there may be no coverage.
Childbirth/delivery facility services
$2,400 - $4,500 copay/stay Not covered
Common Medical Event
Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information* In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most)
If you need help recovering or have other special health needs
Home health care $90 copay/visit Not covered
60 visit limit - combination of network providers and out-of-network providers per person per plan year.
Prior authorization is required for certain home health care services or there may be no coverage.
Rehabilitation services
$30 - $135 copay/visit Not covered
30 visit limit for occupational therapy
30 visit limit for physical therapy
30 visit limit for speech therapy
Visit limits are a combination of network providers and out-of-network providers per person per plan year.
Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care.
Habilitation services $30 - $135 copay/visit
Not covered
Skilled nursing care $3,500 copay/stay Not covered 60 day limit per person per plan year.
Prior authorization is required or there may be no coverage.
Durable medical equipment
$0 - $1,000 copay/equipment based on DME tier
Not covered
For durable medical equipment (DME) tiers and limitations, visit Join.Surest.com website.
Prior authorization is required for certain DME or there may be no coverage.
Hospice services Home: $90 copay/visit Inpatient: $4,500 copay/stay
Home: Not covered Inpatient: Not covered
None
If your child needs dental or eye care
Children’s eye exam Not covered Not covered None
Children’s glasses Not covered Not covered None
Children’s dental check-up
Not covered Not covered None
*For more information about limitations and exceptions, see the plan or policy document at Join.Surest.com.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your plan document for more information and a list of any other excluded services.)
• Acupuncture
• Bariatric surgery
• Cosmetic surgery
• Dental care (Adult)
• Infertility treatment
• Long term care
• Non-emergency care when traveling outside the U.S.
• Private duty nursing
• Routine eye care
• Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Chiropractic care (20 visit limit per person per plan year) • Hearing aids (limitations apply) • Routine foot care (for certain conditions)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:
the Department of Labor’s Employee Benefit Security Administration at 1-866-444-EBSA (3272) or dol.gov/ebsa/healthreform. You may also contact Surest Member Services at 1-866-683-6440. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace.
For more information about the Marketplace, visit HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Surest Member Services at 1-866-683-6440, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or dol.gov/ebsa/healthreform.
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-866-683-6440.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-683-6440.
Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 1-866-683-6440.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-683-6440.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
http://www.dol.gov/ebsa/healthreform http://www.healthcare.gov/ http://www.dol.gov/ebsa/healthreform https://www.healthcare.gov/sbc-glossary/#minimum-value-standard https://www.healthcare.gov/sbc-glossary/#plan
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments, and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)
Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition)
Mia’s Simple Fracture (in-network emergency room visit and follow up care)
■ The plan’s overall deductible $0 ■ The plan’s overall deductible $0 ■ The plan’s overall deductible $0
■ Specialist copayment $50 - $150 ■ Specialist copayment $50 - $150 ■ Specialist copayment $50 - $150
■ Hospital (facility) copayment $400 - $5,500
■ Hospital (facility) copayment $400 - $5,500
■ Hospital (facility) copayment $400 - $5,500
■ Other coinsurance $0 ■ Other coinsurance $0 ■ Other coinsurance $0
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Primary care physician office visits (including disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
Emergency room care (including medical supplies)
Diagnostic tests (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost sharing Cost sharing Cost sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $2,400 Copayments $1,600 Copayments $1,700
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $2,460 The total Joe would pay is $1,600 The total Mia would pay is $1,700
The plan would be responsible for the other costs of these EXAMPLE covered services.
https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#cost-sharing https://www.healthcare.gov/sbc-glossary/#cost-sharing
We do not treat members differently because of sex, age, race, color, disability or national origin.
If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.
Online: UHC_Civil_Rights@uhc.com Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130
You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again.
If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m.
to 8 p.m.
You can also file a complaint with the U.S. Dept. of Health and Human Services.
Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the number contained within this Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to 8 p.m.
mailto:UHC_Civil_Rights@uhc.com https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html
File details come from the government source that posted it. Updated .