8-Attachment A Current Medical Plan Summaries.pdf
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- Solicitation number
- LCSD10052026
- Issued by
- Utah
About this file
This is a Summary of Benefits and Coverage (SBC) document for medical plan summaries provided by MotivHealth Insurance Company for Logan City School District's employee benefits program. The document presents two Health Savings Account (HSA) plan options—HSA 2000 and HSA 4000—both PPO plans with coverage periods running from September 1, 2026, through August 31, 2027. The HSA 2000 plan features a $2,000 individual/$4,000 family deductible with a $6,000 individual/$6,850 family out-of-pocket limit for in-network providers, while the HSA 4000 plan offers a higher $4,000 individual/$8,000 family deductible with a $6,000 individual/$12,000 family out-of-pocket limit for in-network services. Both plans include preventive care coverage at no charge and require 20 percent coinsurance after deductible for most in-network services, with out-of-network costs at 40 percent coinsurance after higher deductibles. The plans cover a range of services including primary and specialist care, diagnostic testing, emergency services, mental health treatment, hospital stays, and rehabilitation services, with specific limitations on certain services such as chiropractic care (20 visits annually), skilled nursing care (30 days annually), and eye exams (one per year).
Both plans exclude coverage for long-term care, non-emergency international care, private-duty nursing, acupuncture, bariatric surgery, cosmetic surgery, dental care, hearing aids, and infertility treatment. The document includes coverage examples for three sample medical scenarios—maternity care (Peg), diabetes management (Joe), and emergency fracture treatment (Mia)—demonstrating cost-sharing responsibilities under each plan. Network providers are available through MotivHealth with referral information available at www.MotivHealth.com or by calling 1-844-234-4472. Both plans meet Minimum Value Standards and provide Minimum Essential Coverage under federal health insurance requirements. Participants have access to grievance and appeals procedures, language assistance services in multiple languages, and continuation coverage options through the Department of Labor's Employee Benefits Security Administration.
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ATTACHMENT A
CURRENT MEDICAL PLAN SUMMARIES
MotivHealth HSA 2000 and HSA 4000 - 2026-27 Plan Year
Logan City School District - Employee Benefits Consulting and Insurance Brokerage Services RFP
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services MotivHealth Insurance Company: HSA 2000
Logan City School District
Coverage for: Individual + Family | Plan Type: PPO
Coverage Period: 09/01/2026-08/31/2027
Will you pay less if you use a network provider?
Yes. See www.MotivHealth.com or call 1-844-234-4472 for a list of participating providers.
What is the out-of-pocket limit for this plan?
For participating providers
$6,000 person/ $6,850 family.
For non-particpating providers $12,000 person/$24,000 family
What is not included in the out-of-pocket limit?
Premiums, difference between billed and allowed amounts, healthcare this plan doesn’t cover, and ineligible expenses.
Are there services covered before you meet your deductible?
Yes. Preventive care.
Are there other deductibles for specific services?
No.
Important Questions Answers
What is the overall deductible?
$2,000 person/$4,000 family.
Doesn't apply to preventative care. For non-participating providers $4,000 person/
$8,000 family.
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.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-844-234-4472. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary.
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.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
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.
You don’t have to meet deductibles for specific services.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Why This Matters:
For more information about limitations and exceptions, see the plan or policy document at www.MotivHealth.com or call 1-844-234-4472. 1 of 5 https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ 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Network Provider
(You will pay the least)
20% After Deductible
20% After Deductible
No charge
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
40% After Deductible
40% After Deductible
No charge up to allowed amount
40% After Deductible
40% After Deductible
Not covered
Not covered
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Do you need a referral to see a specialist?
No.
Common Medical Event Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
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
Specialist visit
Preventive care/ screening/immunization
You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Not covered
Prior authorization applies
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.motivhealth.com
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
Specialty drugs Not covered
40% After Deductible
Facility fee (e.g., ambulatory surgery center) 40% After DeductibleIf you have outpatient surgery
20% After Deductible
20% After Deductible
Physician/surgeon fees
If you need immediate medical attention
Emergency room care
Out-of-network utilization of these benefits will apply to in network benefits up to allowed amount
Emergency medical transportation
Out-of-network utilization of these benefits will apply to in network benefits up to allowed amount
You can see the specialist you choose without a referral.
For more information about limitations and exceptions, see the plan or policy document at www.MotivHealth.com or call 1-844-234-4472. 2 of 5
Facility benefits must be preauthorized https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#diagnostic-test http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ https://www.healthcare.gov/sbc-glossary/#specialty-drug https://www.healthcare.gov/sbc-glossary/#specialty-drug https://www.healthcare.gov/sbc-glossary/#specialty-drug https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#diagnostic-test http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ https://www.healthcare.gov/sbc-glossary/#specialty-drug https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation
20% After Deductible
(You will pay the least)
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
No charge
20% After Deductible
Common Medical Event Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Out-of-Network
Provider (You will pay the most)
If you need immediate medical attention
Urgent care 40% After Deductible
If you need mental health, behavioral health, or substance abuse services
Outpatient services Facility charges require prior authorization.
Inpatient services
40% After Deductible
40% After Deductible
If you have a hospital stay
Facility fee (e.g., hospital room) Pre-cert is required except for maternity care.
Physician/surgeon fees
40% After Deductible
40% After Deductible
40% After Deductible
40% After Deductible
40% After Deductible Limited to 20 visits per year
Office visits
Childbirth/delivery professional services Home births are not covered.
Habilitation services 40% After Deductible
If you need eye care Eye exam Limited to one exam per year.
Children’s glasses Limited to one pair of glasses per year. Benefit not to exceed $150.
Skilled nursing care 40% After Deductible Limited to 30 days per year
Durable medical equipment 40% After Deductible
40% After Deductible
40% After Deductible
If you need help recovering or have other special health needs
Home health care 40% After Deductible
Rehabilitation services 40% After Deductible
Hospice services 40% After Deductible
Limited to 20 visits per year
Chiropractic services
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Long-term Care • Non-emergency care when traveling outside the U.S. • Private-duty nursing
• Acupuncture • Bariatric Surgery • Cosmetic Surgery
• Dental Care • Hearing Aids • Infertility Treatment
If you are pregnant
For more information about limitations and exceptions, see the plan or policy document at www.MotivHealth.com or call 1-844-234-4472. 3 of 5
Limited to 30 visits per year, up to 4 hours each
Limited to 20 visits per year
Limited to 6 months every 3 years https://www.healthcare.gov/sbc-glossary/#urgent-care https://www.healthcare.gov/sbc-glossary/#urgent-care https://www.healthcare.gov/sbc-glossary/#urgent-care https://www.healthcare.gov/sbc-glossary/#home-health-care https://www.healthcare.gov/sbc-glossary/#home-health-care https://www.healthcare.gov/sbc-glossary/#home-health-care https://www.healthcare.gov/sbc-glossary/#rehabilitation-services https://www.healthcare.gov/sbc-glossary/#rehabilitation-services https://www.healthcare.gov/sbc-glossary/#rehabilitation-services https://www.healthcare.gov/sbc-glossary/#habilitation-services https://www.healthcare.gov/sbc-glossary/#habilitation-services https://www.healthcare.gov/sbc-glossary/#habilitation-services https://www.healthcare.gov/sbc-glossary/#habilitation-services https://www.healthcare.gov/sbc-glossary/#habilitation-services https://www.healthcare.gov/sbc-glossary/#habilitation-services https://www.healthcare.gov/sbc-glossary/#skilled-nursing-care https://www.healthcare.gov/sbc-glossary/#skilled-nursing-care https://www.healthcare.gov/sbc-glossary/#skilled-nursing-care https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#hospice-services https://www.healthcare.gov/sbc-glossary/#hospice-services https://www.healthcare.gov/sbc-glossary/#hospice-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#urgent-care https://www.healthcare.gov/sbc-glossary/#habilitation-services https://www.healthcare.gov/sbc-glossary/#skilled-nursing-care https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#home-health-care https://www.healthcare.gov/sbc-glossary/#rehabilitation-services https://www.healthcare.gov/sbc-glossary/#hospice-services https://www.healthcare.gov/sbc-glossary/#habilitation-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#excluded-services
Does this plan meet the Minimum Value Standards? Yes
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Chiropractic care limited to 20 visits per year
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 the
Department of Labor’s Employee Benefits Security Administration is 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-801-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact MotivHealth at 1-844-234-4472 or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
• Routine eye care (Adult) • Routine foot care • Weight loss programs
[Spanish (Español): Para obtener asistencia en Español, llame al 1-844-234-4472.]
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-844-234-4472.]
[Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-844-234-4472.]
[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-844-234-4472.]
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––– –––––––––––
Language Access Services:
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.
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.
For more information about limitations and exceptions, see the plan or policy document at www.MotivHealth.com or call 1-844-234-4472. 4 of 5 https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/ http://www.healthcare.gov/ http://www.healthcare.gov/ http://www.healthcare.gov/ http://www.healthcare.gov/ http://www.healthcare.gov/ http://www.healthcare.gov/ http://www.healthcare.gov/ http://www.healthcare.gov/ http://www.healthcare.gov/ http://www.healthcare.gov/ https://www.healthcare.gov/sbc-glossary/ 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About these Coverage Examples:
$2,000 $2,000 n The plan’s overall deductible $2,000
20% 20% n Specialist 20%
20% 20% n Hospital (facility) 20%
20% 20% n Other 20%
This EXAMPLE event includes services like:
Total Example Cost $12,700 $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:
$2,000 Deductibles $2,000 Deductibles $2,000
$0 Copayments $0 Copayments $0
$2,140 Coinsurance $720 Coinsurance $160
$0 $0 Limits or exclusions $0
$4,140 $2,720 The total Mia would pay is $2,160 n The plan’s overall deductible n The plan’s overall deductible n Specialist n Specialist n Hospital (facility) n Hospital (facility)
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 would be responsible for the other costs of these EXAMPLE covered services.
Copayments
Coinsurance
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions Limits or exclusions
Total Example Cost
Cost Sharing Cost Sharing Cost Sharing
Deductibles
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)
Emergency room care (including medical
The total Peg would pay is The total Joe would pay is
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray) n Other n Other
This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including
For more information about limitations and exceptions, see the plan or policy document at www.MotivHealth.com or call 1-844-234-4472. 5 of 5 https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services MotivHealth Insurance Company: HSA 4000
Logan City School District
Coverage for: Individual + Family | Plan Type: PPO
Coverage Period: 09/01/2026-08/31/2027
Will you pay less if you use a network provider?
Yes. See www.MotivHealth.com or call 1-844-234-4472 for a list of participating providers.
What is the out-of-pocket limit for this plan?
For participating providers
$6,000 person/ $12,000 family. For non-particpating providers $12,000 person/$24,000 family
What is not included in the out-of-pocket limit?
Premiums, difference between billed and allowed amounts, healthcare this plan doesn’t cover, and ineligible expenses.
Are there services covered before you meet your deductible?
Yes. Preventive care.
Are there other deductibles for specific services?
No.
Important Questions Answers
What is the overall deductible?
$4,000 person/$8,000 family.
Doesn't apply to preventative care. For non-participating providers $8,000 person/
$16,000 family.
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.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-844-234-4472. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary.
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.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
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.
You don’t have to meet deductibles for specific services.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Why This Matters:
For more information about limitations and exceptions, see the plan or policy document at www.MotivHealth.com or call 1-844-234-4472. 1 of 5 https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/sbc-glossary/ 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(You will pay the least)
20% After Deductible
20% After Deductible
No charge
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
40% After Deductible
40% After Deductible
No charge up to allowed amount
40% After Deductible
40% After Deductible
Not covered
Not covered
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Do you need a referral to see a specialist?
No.
Common Medical Event Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
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
Specialist visit
Preventive care/ screening/immunization
You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Not covered
Prior authorization applies
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.motivhealth.com
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
Specialty drugs Not covered
40% After Deductible
Facility fee (e.g., ambulatory surgery center) 40% After DeductibleIf you have outpatient surgery
20% After Deductible
20% After Deductible
Physician/surgeon fees
If you need immediate medical attention
Emergency room care
Out-of-network utilization of these benefits will apply to in network benefits up to allowed amount
Emergency medical transportation
Out-of-network utilization of these benefits will apply to in network benefits up to allowed amount
You can see the specialist you choose without a referral.
For more information about limitations and exceptions, see the plan or policy document at www.MotivHealth.com or call 1-844-234-4472. 2 of 5
Facility benefits must be preauthorized https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#diagnostic-test http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ https://www.healthcare.gov/sbc-glossary/#specialty-drug https://www.healthcare.gov/sbc-glossary/#specialty-drug https://www.healthcare.gov/sbc-glossary/#specialty-drug https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#diagnostic-test http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ http://www.hsahealthplan.com/ https://www.healthcare.gov/sbc-glossary/#specialty-drug https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services
20% After Deductible
(You will pay the least)
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
20% After Deductible
No charge
20% After Deductible
Common Medical Event Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Out-of-Network
Provider (You will pay the most)
If you need immediate medical attention
Urgent care 40% After Deductible
If you need mental health, behavioral health, or substance abuse services
Outpatient services Facility charges require prior authorization.
Inpat…
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