SBC_PPO_Active___Final_FY_23-24.pdf

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 10/01/2023 – 09/30/2024

City of Edinburg: PPO Active Plan Coverage for: Individual / Family | Plan Type: PPO

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8

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, call 1-800-521-2227 or at

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 1-855-756-4448 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

For In-Network: $2,000 Individual / $4,000 Family For Out-of-Network: $4,000 Individual / $8,000 Family

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 services covered before you meet your deductible?

Yes. Services that charge a copayment, prescription drugs, emergency room services, inpatient hospital expenses, certain preventive care, and In-Network diagnostic tests, home health, skilled nursing, and hospice are covered before you meet your deductible.

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 www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

Yes. Per occurrence: $250 Out-of-Network inpatient admission. There are no other specific deductibles.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

What is the out-of-pocket limit for this plan?

For In-Network: $6,500 Individual / $13,000 Family For Out-of-Network: $19,500 Individual / $39,000 Family

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 www.bcbstx.com or call 1-800-810-2583 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.

https://policy-srv.box.com/s/g5df1kpa5wktp9ekvm5hjbmdzqhufzam.

http://www.healthcare.gov/sbc-glossary/ http://www.healthcare.gov/coverage/preventive-care-benefits/ http://www.bcbstx.com/

*For more information about limitations and exceptions, see the plan or policy document at Page 2 of 8

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

$35/visit;

deductible does not apply

30% coinsurance after deductible

Virtual visits are available, please refer to your plan policy for more details.

Specialist visit $50/visit;

deductible does not apply

30% coinsurance after deductible

None

Preventive care/screening/ immunization No Charge;

deductible does not apply

30% coinsurance after deductible

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.

No Charge for child immunizations Out-of- Network through the 6th birthday.

If you have a test

Diagnostic test (x-ray, blood work)

No Charge;

deductible does not apply

30% coinsurance after deductible

Office visit copayment may apply.

Imaging (CT/PET scans, MRIs)

20% coinsurance after deductible

50% coinsurance after deductible

None https://policy-srv.box.com/s/g5df1kpa5wktp9ekvm5hjbmdzqhufzam.

*For more information about limitations and exceptions, see the plan or policy document at Page 3 of 8

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 www.bcbstx.com

Generic drugs $15 retail/$37.50 mail order/prescription;

deductible does not apply

$15/prescription plus 30% coinsurance;

deductible does not apply

Retail covers a 30-day supply. With appropriate prescription, up to a 90-day supply is available. Mail order covers a 90-day supply.

Out-of-Network mail order is not covered.

Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available.

For Out-of-Network pharmacy, member must file claim.

Certain drugs require approval before they will be covered.

The cost-sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription.

Preferred brand drugs $35 retail/$87.50 mail order/prescription;

deductible does not apply

$35/prescription plus 30% coinsurance;

deductible does not apply

Non-preferred brand drugs $55 retail/$137.50 mail order/prescription;

deductible does not apply

$55/prescription plus 30% coinsurance;

deductible does not apply

Specialty drugs 35% coinsurance;

deductible does not apply

50% coinsurance;

deductible does not apply

For In-Network benefit, specialty drugs must be obtained from In-Network specialty pharmacy provider. Specialty retail limited to a 30-day supply. Mail order is not covered.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

20% coinsurance after deductible

50% coinsurance after deductible

None

Physician/surgeon fees 20% coinsurance after deductible

50% coinsurance after deductible

None

If you need immediate medical attention

Emergency room care $350/visit plus 20% coinsurance;

deductible does not apply

$350/visit plus 20% coinsurance;

deductible does not apply

Emergency room copayment waived if admitted.

Emergency medical transportation

20% coinsurance after deductible

20% coinsurance after deductible

Ground and air transportation covered.

Urgent care $100/visit;

deductible does not apply

30% coinsurance after deductible

You may have to pay for services that are not covered by the visit fee. For an example, see “If you have a test” on page 2.

*For more information about limitations and exceptions, see the plan or policy document at Page 4 of 8

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 a hospital stay

Facility fee (e.g., hospital room)

20% coinsurance;

deductible does not apply

50% coinsurance;

deductible does not apply

Plan deductible does not apply; a per-admission deductible of $250 does apply Out-of-Network.

Physician/surgeon fees 20% coinsurance;

deductible does not apply

50% coinsurance;

deductible does not apply

None

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

Outpatient services

$35/office visit;

deductible does not apply 20% coinsurance after deductible for other outpatient services

30% coinsurance after deductible office visit 50% coinsurance after deductible for other outpatient services

Certain services must be preauthorized;

refer to your benefit booklet* for details.

Virtual visits are available, please refer to your plan policy for more details.

Inpatient services 20% coinsurance;

deductible does not apply

50% coinsurance;

deductible does not apply

Plan deductible does not apply; a per-admission deductible of $250 does apply Out-of-Network.

If you are pregnant

Office visits

$35 PCP/

$50 SPC;

deductible does not apply

30% coinsurance after deductible

Copayment applies to first prenatal visit (per pregnancy).

Cost sharing does not apply for preventive services. Depending on the type of services, a copayment or coinsurance may apply.

Maternity care may include tests and service described elsewhere in the SBC (i.e.

ultrasound).

Childbirth/delivery professional services

20% coinsurance;

deductible does not apply

50% coinsurance;

deductible does not apply

Childbirth/delivery facility services

20% coinsurance;

deductible does not apply

50% coinsurance;

deductible does not apply

Plan deductible does not apply; a per-admission deductible of $250 does apply Out-of-Network.

*For more information about limitations and exceptions, see the plan or policy document at Page 5 of 8

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 20% coinsurance;

deductible does not apply

50% coinsurance after deductible

Limited to 60 visits per calendar year.

Preauthorization is required.

Rehabilitation services

$35 PCP/

$50 SPC/visit;

deductible does not apply 20% coinsurance after deductible for other outpatient services

30% coinsurance after deductible office visit 50% coinsurance after deductible for other outpatient services Limited to 35 visits combined for all therapies per calendar year. Includes, but is not limited to, occupational, physical, and manipulative therapy.

Habilitation services

$35 PCP/

$50 SPC/visit;

deductible does not apply 20% coinsurance after deductible for other outpatient services

30% coinsurance after deductible office visit 50% coinsurance after deductible for other outpatient services

Skilled nursing care 20% coinsurance;

deductible does not apply

50% coinsurance after deductible

Limited to 60 visits per calendar year.

Durable medical equipment 20% coinsurance after deductible

50% coinsurance after deductible

None

Hospice services 20% coinsurance;

deductible does not apply

50% coinsurance after deductible

None

*For more information about limitations and exceptions, see the plan or policy document at Page 6 of 8

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

$35 PCP/

$50 SPC;

deductible does not apply

30% coinsurance after deductible

None

Children’s glasses Not Covered Not Covered None

Children’s dental check-up Not Covered Not Covered None

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.)

• 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 foot 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 • Hearing aids (1 per ear per 36-month period) • Routine eye care (Adult) https://www.healthcare.gov/sbc-glossary/#plan

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: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. 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 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: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.

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 1-800-521-2227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-521-2227.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.

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.cciio.cms.gov/ http://www.healthcare.gov/ http://www.bcbstx.com/ http://www.dol.gov/ebsa/healthreform http://www.tdi.texas.gov/ http://www.bcbstx.com/ http://www.tdi.texas.gov/ http://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html https://www.healthcare.gov/sbc-glossary/#minimum-essential-coverage https://www.healthcare.gov/sbc-glossary/#minimum-value-standard https://www.healthcare.gov/sbc-glossary/#premium-tax-credits

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 8 of 8

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.

◼ The plan’s overall deductible $2,000 ◼ Specialist copayment $50 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20%

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)

Total Example Cost $12,700

In this example, Peg would pay:

Cost Sharing

Deductibles $2,000

Copayments $50

Coinsurance $1,900

What isn’t covered

Limits or exclusions $60

The total Peg would pay is $4,010

◼ 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:

Cost Sharing

Deductibles $800

Copayments $800

Coinsurance $0

What isn’t covered

Limits or exclusions $20

The total Joe would pay is $1,620

◼ 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:

Cost Sharing

Deductibles $1,300

Copayments $600

Coinsurance $80

What isn’t covered

Limits or exclusions $0

The total Mia would pay is $1,980

Mia’s Simple Fracture (in-network emergency room visit and follow up care)

Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition)

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) bcbstx.com

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, gender identity, age, sexual orientation, health status or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965

35th Floor Fax: 855-661-6960 Chicago, Illinois 60601

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697

Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html