Att B1 - 2021 Choice Passport $3000 SBC Medica.PDF

MSI Medica Choice Passport ASO 3000-20% HSA Coverage Period: Beginning on or after 1/1/21 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family | Plan Type: PPO

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 thecost 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, go to www.medica.com or call 952-945-8000 (Minneapolis/St. Paul Metro area) or 1-800-952-3455. 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 or call Medica at 1-800-952-3455 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

$3,000 per person/ $6,000 per family in-network and $6,000 per person/ $12,000 per family for out-of-network services.

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.

Are there servicescovered before you meetyour deductible?

Yes. Preventive care and prenatal care from in-network providers.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment 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://www.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?

$6,000 per person/ $12,000 per family in-network. $12,000 per person/ $24,000 per family for out-of-network services.

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 inthe 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 youuse a network provider?

Yes. See www.medica.com or call 1-800-952-3455 or 711 (TTY users) for a list of Medica Choice with UnitedHealthcare 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 tosee a specialist? No. You don’t need a referral to see a specialist. You can see the specialist you choose without a referral.

COM Dunn County-1-00121 (202010271604) (163164)

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family | Plan Type: PPO

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 totreat an injury or illness

Primary care: 20% coinsurance Chiropractic: 20% coinsurance Convenience: 20% coinsurance Virtual: 20% coinsurance

Primary: 40% coinsurance Chiropractic: 40% coinsurance Convenience: 40% coinsurance Virtual: 40% coinsurance

Limited to 15 visits per member, per yearcombined for in-network and out-of-networkchiropractic care.

Specialist visit 20% coinsurance 40% coinsurance ---none--- Preventive care/ screening/ immunization

No charge. Deductible does not apply.

Well child care: 0% coinsuranceDeductible does not apply.

Other services: 40% coinsurance

You may have to pay for services that aren’t preventive. Ask your provider if the servicesneeded are preventive. Then check what your plan will pay for. Routine physicals are notcovered out-of-network.

If you have a test

Diagnostic test (x-ray,blood work) Lab: 20% coinsurance X-ray: 20% coinsurance 40% coinsurance ---none---

Imaging (CT/PETscans, MRIs) 20% coinsurance 40% coinsurance ---none---

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.medica.com/drugcost2

Generic drugs Retail: 20% coinsurance Mail order: 20% coinsurance 40% coinsurance

Up to a 31-day supply/ retail or 93-day supply/mail order prescription. Mail order drugs notcovered out-of-network.

Preferred brand drugs Retail: 20% coinsurance

Mail order: 20% coinsurance 40% coinsurance Non-preferred brand drugs Retail: 40% coinsurance

Mail order: 40% coinsurance 40% coinsurance Specialty drugs Preferred and Non-Preferred:20% coinsurance Not covered Up to a 31-day supply per prescription receivedfrom a designated specialty pharmacy.

If you have outpatient surgery

Facility fee (e.g.,ambulatory surgery center) 20% coinsurance 40% coinsurance ---none--- Physician/surgeon fees 20% coinsurance 40% coinsurance ---none---

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family | Plan Type: PPO

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 immediate medical attention

Emergency room care 20% coinsurance 20% coinsurance In-network deductible and out-of-pocket applies.

Emergency medical transportation 20% coinsurance 20% coinsurance In-network deductible and out-of-pocket applies.

Urgent care 20% coinsurance 20% coinsurance In-network deductible and out-of-pocket applies.

If you have a hospital stay

Facility fee (e.g.,hospital room) 20% coinsurance 40% coinsurance ---none--- Physician/surgeon fees 20% coinsurance 40% coinsurance ---none---

If you need mental health, behavioral health, or substance abuse services

Outpatient services 20% coinsurance 40% coinsurance ---none--- Inpatient services 20% coinsurance 40% coinsurance ---none---

If you are pregnant

Office visits Prenatal care: No charge. Deductible does not apply.

Postnatal care: 20% coinsurance

Prenatal care: 0% coinsurance. Deductible does not apply.

Postnatal care: 40% coinsurance

Cost sharing does not apply to in-network preventive services. Depending on the type ofservices, a copayment, coinsurance or deductible may apply. Maternity care mayinclude tests and services described elsewherein the SBC (i.e. certain ultrasounds.)

Childbirth/deliveryprofessional services 20% coinsurance 40% coinsurance Childbirth/deliveryfacility services 20% coinsurance 40% coinsurance

If you need help recovering or have other special health needs

Home health care 20% coinsurance 40% coinsurance ---none--- Rehabilitation services 20% coinsurance 40% coinsurance ---none--- Habilitation services 20% coinsurance 40% coinsurance ---none--- Skilled nursing care 20% coinsurance 40% coinsurance ---none--- Durable medical equipment 20% coinsurance 40% coinsurance ---none--- Hospice services 20% coinsurance 40% coinsurance ---none---

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family | Plan Type: PPO

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 your child needs dental or eye care

Children’s eye exam No charge. Deductible does not apply. 40% coinsurance ---none---

Children’s glasses Eyeglass & contact lenses: 20% coinsurance. Plan paymentmaximum of $200 everyconsecutive 2 years.

Frames: Not covered

Eyeglass & contact lenses: 40% coinsurance. Plan paymentmaximum of $200 everyconsecutive 2 years.

Frames: Not covered

Member responsible over $200. Limit combinedper member in- and out-of-network regardless of age.

Children’s dental check-up Not covered Not covered Dental check-ups are not covered by the plan.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family | Plan Type: PPO

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 other excluded services.)

Acupuncture exceeding 15 visits per memberper year for in-network and out-of-networkacupuncture services combined.Bariatric SurgeryChiropractic care exceeding 15 visits permember per year for out-of-network chiropractic care.Cosmetic Surgery

Dental Care (Adult)Dental check-upGlasses Hearing aids except for members 18 years ofage and younger for hearing loss that is notcorrectable by other covered procedures;coverage is limited to one hearing aid per earevery three years.

Infertility treatmentLong Term CarePrivate-duty nursingRoutine foot care except for specified conditionsWeight Loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Non-emergency care when traveling outside the U.S. Routine eye care (Adult)

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family | Plan Type: PPO

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 Minnesota Department of Commerce at(651) 539-1600 or 1-800-657-3602 or the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace.For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information aboutyour 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: your plan administrator or you may contact Medica at1-800-592-8202.

Does this Plan Provide Minimum Essential Coverage? YesMinimum 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 Standard? YesIf 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:

---------------------- To see examples of how this plan might cover costs for a sample medical situation, see the next section. ----------------------

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family | Plan Type: PPO

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 onthe 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. Pleasenote 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) The plan’s overall deductible: $3,000 Specialist coinsurance: 20% Hospital (facility) coinsurance: 20% Other coinsurance: 20%

This EXAMPLE event includes services like: Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia) Total Example Cost $12,700

In this example, Peg would pay:

Cost Sharing

Deductibles $3,000 Copayments $0 Coinsurance $1,400 What isn’t covered

Limits or exclusions $60 The total Peg would pay is $4,460

Managing Joe’s type 2 Diabetes(a year of routine in-network care of a well-controlled condition) The plan’s overall deductible: $3,000 Specialist coinsurance: 20% Hospital (facility) coinsurance: 20% Other coinsurance: 20%

This EXAMPLE event includes services like: Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600

In this example, Joe would pay:

Deductibles $2,200 Copayments $0 Coinsurance $0 What isn’t covered

Limits or exclusions $0 The total Joe would pay is $2,200

Mia’s Simple fracture(in-network emergency room visit and follow up care) The plan’s overall deductible: $3,000 Specialist coinsurance: 20% Hospital (facility) coinsurance: 20% Other coinsurance: 20%

This EXAMPLE event includes services like: Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy) Total Example Cost $2,800

In this example, Mia would pay:

Deductibles $2,800 Copayments $0 Coinsurance $0 What isn’t covered

Limits or exclusions $0 The total Mia would pay is $2,800

This plan is a self-funded group health plan administered by Medica Self Insured.The plan would be responsible for the other costs of these EXAMPLE covered services.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family | Plan Type: PPO