Centegra

Land of Lincoln Health: CENTEGRA LAND OF LINCOLN HEALTH PLAN PLATINUM
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2015 12/31/2015

Coverage for: Individual or Family | Plan Type: PPO
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 at www.landoflincolnhealth.org or by calling 1-844-674-3834.
Important Questions
Answers
Why this Matters:
What is the overall

deductible?
Integrated Preferred/In- network:

$250 individual / $500 family
Out-of-network: $5,000 individual /
$10,000
Doesnt apply to preventive care.
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.
Preferred/In-Network deductible is one integrated deductible. It is separate for the Outof-Network Deductible.
Are there other deductibles

for specific services?
No.
You dont have to meet deductibles for specific services but see the chart starting on page
2 for other costs for services this plan covers.
Is there an outofpocket
limit on my expenses?
Yes. For Preferred/In-network

providers: $2,500 individual /
$5,000 family
For out-of-network providers:
Unlimited individual and family
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. Preferred/In-Network Annual Out-of-Pocket limit are one integrated
Out-of-Pocket limit and is separate from Out-of-Network Annual Out-of-Pocket limit.
What is not included in the

outofpocket limit?
Premiums, balance-billed charges, and

health care this plan doesnt cover.
Even though you pay these expenses, they dont count toward the out-of-pocket limit.
Is there an overall annual

limit on what the plan
pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
www.landoflincolnhealth.org/finda-doctor/ or call 1-844-674-3834 for a
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

specialist?
No.
You can see the specialist you choose without permission from this plan.
Are there services this plan

doesnt cover?
Yes.
Some of the services this plan doesnt cover are listed on page 6. See your policy or plan
document for additional information about excluded services.
Does this plan use a

network of providers?
Yes. See
list of participating providers.
Questions: Call 1-844-674-3834 or visit us at www.landoflincolnhealth.org.

If you arent clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-844-674-3834 to request a copy.
I-048P-SBC
1 of 8
This Plan is a Qualified Health Plan in the Health Insurance Marketplace.
Coverage Period: 01/01/2015 12/31/2015

Copayments (copay) are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance (coins.) 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 plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may
change if you havent 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 in-network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health

care providers
office or clinic
If you have a test
Services You May

Need
Your Cost If You

Use a Preferred
Network
Provider
Your Cost If You

Use an
In-Network
Provider
Primary care visit to

treat an injury or illness
$5 copay/visit
$30 copay/visit
Specialist visit
$20 copay/visit
$40 copay/visit
Other practitioner office

$5 copay/visit
visit
Preventive care/
No charge
screening/immunization
$30 copay/visit
No charge
Your Cost If You

Use an
Out-of-Network
Provider
50% subject to
deductible
50% subject to
deductible
50% subject to
deductible
50% subject to
deductible
Diagnostic test (x-ray,

blood work)
$0 copay/visit
$40 copay/visit
50% subject to
deductible
Imaging (CT/PET
scans, MRIs)
$50 copay/service
$225 copay/service
50% subject to
deductible
Limitations & Exceptions
None
None
None
As determined by the U.S. Preventive
Services Task Force and CDC.
Includes Lab tests, x-ray, pathology,
imaging/diagnostic testing for both
inpatient and outpatient.
Precertification required.

I-048P-SBC
2 of 8
Coverage Period: 01/01/2015 12/31/2015

Common
Medical Event
Services You May

Need
Formulary Generic
drugs
If you need drugs

to treat your illness
or condition
Formulary Preferred
brand drugs
More information
about prescription
Formulary Nondrug coverage is
preferred brand drugs
available at
www.landoflincoln
health.org/shopfor-plans/formulary
If you have
outpatient surgery
If you need
immediate medical
Your Cost If You

Use a Preferred
Network
Provider
Your Cost If You

Use an
In-Network
Provider
Your Cost If You

Use an
Out-of-Network
Provider
$4
copay/prescription.
Mail-Order: $10
copay/prescription.
$20
copay/prescription.
Mail-Order: $50
copay/prescription.
$4
copay/prescription.
Mail-Order: $10
copay/prescription.
$20
copay/prescription.
Mail-Order: $50
copay/prescription.
50% subject to
deductible.
Mail-Order: 50%
subject to deductible.
50% subject to
deductible.
Mail-Order: 50%
$60
copay/prescription.
Mail-Order: $150
copay/prescription.
$60
copay/prescription.
Mail-Order: $150
copay/prescription.
50% subject to
deductible.
Mail-Order: 50%

Covers up to a 34-day supply (retail
prescription); 90-day supply (MailOrder prescription).
Prior Authorization, Step Therapy or
Quantity Limits may apply.
For a full list of covered drugs
(formulary prescriptions) and/or
services, please contact Member
Services, or refer to the formulary list
at
www.landoflincolnhealth.org/shopfor-plans/formulary.
Mandatory mail-order after first 3
retail fills.
Not all specialty drugs are covered
and prior authorization may be
required. Specialty drugs must be
filled through LLHs specialty drug
pharmacy Briova network. See your
policy documents for details.
Formulary Specialty
drugs
Retail and MailOrder: 10% subject

to deductible.
Retail and MailOrder: 10% subject

to deductible.
Retail and MailOrder: 50% subject to

deductible.
Facility fee (e.g.,

ambulatory surgery
center)
10% subject to
deductible
30% subject to
deductible
50% subject to
deductible
Physician/surgeon fees
10% subject to
deductible
30% subject to
deductible
50% subject to
deductible
Emergency room
services
$400 copay/visit
$400 copay/visit
$400 copay/visit
Notification required within 2

business days.

I-048P-SBC
3 of 8
Coverage Period: 01/01/2015 12/31/2015

Common
Medical Event
Services You May

Need
Your Cost If You

Use a Preferred
Network
Provider
Your Cost If You

Use an
In-Network
Provider
attention
Emergency medical
transportation
$500 copay/service
$500 copay/service
Urgent care
$40 copay/visit
$40 copay/visit
If you have a
hospital stay
Mental/Behavioral
health outpatient
services
If you have mental
Mental/Behavioral
health, behavioral
health inpatient services
health, or substance
Substance use disorder
abuse needs
outpatient services
Substance use disorder
inpatient services
Prenatal and postnatal
care
If you are pregnant
Delivery and all
inpatient services
Your Cost If You

Use an
Out-of-Network
Provider
50% subject to
deductible
50% subject to
deductible
None
None
$550 copay/day for

first 3 days
50% subject to
deductible
Based on the semi-private room rate.

Excludes patient convenience items.
10% subject to
deductible
30% subject to
deductible
50% subject to
deductible
$5 copay/visit
$5 copay/visit
50% subject to
deductible
10% subject to
deductible
30% subject to
deductible
$5 copay/visit
$5 copay/visit
10% subject to
deductible
30% subject to
deductible
$5 copay/visit
$30 copay/visit
$100 copay/day for

first 3 days
$550 copay/day for

first 3 days
Facility fee (e.g., hospital $100 copay/day for

room)
first 3 days
Physician/surgeon fee
50% subject to
deductible
50% subject to
deductible
50% subject to
deductible
50% subject to
deductible
50% subject to
deductible
None
None
Notification is required upon
confirmation of pregnancy.

I-048P-SBC
4 of 8
Coverage Period: 01/01/2015 12/31/2015

Common
Medical Event
If you need help

recovering or have
other special health
needs
Services You May

Need
Your Cost If You

Use a Preferred
Network
Provider
Your Cost If You

Use an
In-Network
Provider
Your Cost If You

Use an
Out-of-Network
Provider
Home health care
$25 copay/visit
$150 copay/visit
50% subject to
deductible
50% subject to
deductible
These services apply to Physical,

Occupational and Speech therapies.
Precertification and Periodic Review
required.
Rehabilitation services
$10 copay/visit
$50 copay/visit
Habilitation services
10% subject to
deductible
30% subject to
deductible
Skilled nursing care
$25 copay/day
$120 copay/day
Durable medical
equipment
10% subject to
deductible
10% subject to
deductible
30% subject to
deductible
30% subject to
deductible
Eye exam
No charge
No charge
Glasses
No charge
No charge
Dental check-up
No charge
No charge
Hospice service
If your child needs

dental or eye care
50% subject to
deductible
50% subject to
deductible
50% subject to
deductible
50% subject to
deductible
50% subject to
deductible
50% subject to
deductible
50% subject to
deductible
Limited to one exam per year for
children under age 19.
Limited to one pair of glasses per year
for children under age 19.
Limited to one check-up every six
months for children under age 19.
Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services.)
Abortions unless the mothers life is endangered

Acupuncture
Cosmetic surgery unless due to Illness or Injury
Dental care (Adult)
Hearing aids (except for children under age

19)
Long-term care
Non-medically necessary services
Routine eye care (Adult)

Routine foot care (Except for Diabetes)
Weight loss programs

I-048P-SBC
5 of 8
Coverage Period: 01/01/2015 12/31/2015

Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
Bariatric Surgery
Chiropractic Care
Infertility Treatment (see policy for details)

Private-duty nursing
Non-emergency care when traveling outside the

U.S.
Your Rights to Continue Coverage:

Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are
exceptions, however, such as if:
You commit fraud

The insurer stops offering services in the State
You move outside the coverage area
For more information on your rights to continue coverage, contact Land of Lincoln Health at 1-844-674-3834. You may also contact your state insurance
department at:
Illinois Department of Insurance
Office of Consumer Health Insurance
320 W. Washington Street
Springfield, IL 62767
Toll Free: 1 (877) 850-4740
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: Land of Lincoln Mutual Health Insurance Company, 222 S. Riverside Plaza, Suite
1900, Chicago, IL 60606 ATTN: APPEALS.
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.
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
6 of 8
I-048P-SBC
Coverage Period: 01/01/2015 12/31/2015

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.
Dont 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.
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
Amount owed to providers: $7,540.00

Plan pays $5,090.00
Patient pays $2,450.00
Amount owed to providers: $5,400.00

Plan pays $4,160.00
Patient pays $1,240.00
Sample care costs:

Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Sample care costs:

Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900.00
$1,300.00
$700.00
$300.00
$100.00
$100.00
$5,400.00
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$250.00
$600.00
$310.00
$80.00
$1,240.00
$2,700.00
$2,100.00
$900.00
$900.00
$500.00
$200.00
$200.00
$40.00
$7,540.00
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$250.00
$1,470.00
$580.00
$150.00
$2,450.00
Note: This example was calculated assuming

an individual deductible.
Note: This example was calculated assuming

an individual deductible.
I-048P-SBC
7 of 8
Coverage Period: 01/01/2015 12/31/2015

Questions and answers about the Coverage Examples:

What are some of the
assumptions behind the
Coverage Examples?
Costs dont include premiums.

Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and arent
specific to a particular geographic area or
health plan.
The patients 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?
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 isnt covered or payment is limited.
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 doctors
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 cant 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.
Can I use Coverage Examples to

compare plans?
Yes. When you look at the Summary of

Benefits and Coverage for other plans, youll
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 youll pay in out-of-pocket 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.

I-048P-SBC
8 of 8

Centegra

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Centegra

Загружено:

Авторское право:

Доступные форматы

Land of Lincoln Health: CENTEGRA LAND OF LINCOLN HEALTH PLAN PLATINUM

Coverage Period: 01/01/2015 12/31/2015

Why this Matters:

What is the overall

Integrated Preferred/In- network:

Are there other deductibles

Yes. For Preferred/In-network

What is not included in the

Premiums, balance-billed charges, and

Is there an overall annual

www.landoflincolnhealth.org/finda-doctor/ or call 1-844-674-3834 for a

Do I need a referral to see a

Are there services this plan

Does this plan use a

list of participating providers.

Questions: Call 1-844-674-3834 or visit us at www.landoflincolnhealth.org.

This Plan is a Qualified Health Plan in the Health Insurance Marketplace.

Coverage Period: 01/01/2015 12/31/2015

Land of Lincoln Health: CENTEGRA LAND OF LINCOLN HEALTH PLAN PLATINUM

Coverage for: Individual or Family | Plan Type: PPO

If you visit a health

If you have a test

Services You May

Your Cost If You

Your Cost If You

Primary care visit to

Other practitioner office

Your Cost If You

Diagnostic test (x-ray,

Limitations & Exceptions

Questions: Call 1-844-674-3834 or visit us at www.landoflincolnhealth.org.

Coverage Period: 01/01/2015 12/31/2015

Land of Lincoln Health: CENTEGRA LAND OF LINCOLN HEALTH PLAN PLATINUM

Services You May

If you need drugs

Coverage for: Individual or Family | Plan Type: PPO

Your Cost If You

Your Cost If You

Your Cost If You

Limitations & Exceptions

Retail and MailOrder: 10% subject

Retail and MailOrder: 10% subject

Retail and MailOrder: 50% subject to

Facility fee (e.g.,

Notification required within 2

Questions: Call 1-844-674-3834 or visit us at www.landoflincolnhealth.org.

Coverage Period: 01/01/2015 12/31/2015

Land of Lincoln Health: CENTEGRA LAND OF LINCOLN HEALTH PLAN PLATINUM

Services You May

Your Cost If You

Your Cost If You

Your Cost If You

Limitations & Exceptions

$550 copay/day for

Based on the semi-private room rate.

$100 copay/day for

$550 copay/day for

Facility fee (e.g., hospital $100 copay/day for

Coverage for: Individual or Family | Plan Type: PPO

Questions: Call 1-844-674-3834 or visit us at www.landoflincolnhealth.org.

Coverage Period: 01/01/2015 12/31/2015

Land of Lincoln Health: CENTEGRA LAND OF LINCOLN HEALTH PLAN PLATINUM

If you need help

Services You May