Employee Health Plan (Retirees With Medicare) Clovis Unified School District
Summary of Benefits and Coverage:What this Plan Covers & What it Costs

Coverage Period: Beginning on or after 9/1/2016

Coverage for: Individual & 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.hnas.com or by calling 1-855-323-1124.(Note: the Uniform Glossary can be accessed at www.dol.gov/ebsa/healthreform).

Important Questions
	Answers
	Why this Matters:

What is the overall deductible?
	In-network & out-of-network combined:$300 person/$600 family. Applies to inpatient,outpatient & ambulatory surgery only.
	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.
	
Are there other deductibles forspecific services?
	
No.
	
You don’t 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 out–of–pocket limit on my expenses?
	Yes. In-network for medical: $1,550 person / $3,100 family; for prescription $5,300 person / $10,600 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.

What is not included in the out–of–pocket limit?
	Out-of-network deductible amounts, premiums,balance-billed charges, penalties for failure to obtain precertification & health care this plan doesn’t cover.

Even though you pay these expenses, they don’t 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.

Does this plan use a network of providers?
	
Yes. See www.blueshieldca.com or call 1-800-810-2583 for a list of in-network providers.
	If you use a participating doctor or other health care provider,this plan will pay some or all of the costs of covered services. Be aware, your participating doctor or hospital may use a non-participating 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 the plan.
	
Are thereservices this plan doesn’t cover?
	
Yes.
	Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excludedservices.

Questions: Call 1-855-323-1124 or visit us at www.hnas.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary	1 of 8 at www.hnas.com or call 1-855-323-1124 to request a copy.

Employee Health Plan (Retirees With Medicare) Clovis Unified School District
Summary of Benefits and Coverage:What this Plan Covers & What it Costs

Coverage Period: Beginning on or after 9/1/2016

Coverage for: Individual & Family | Plan Type: PPO

 Copayments are fixed dollar amounts (for example,$15) you pay for covered health care,usually when you receive the service.
 Coinsurance 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 plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t 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

Services You May Need
	
Your Cost If You Use a Participating Provider
	Your Cost If You Use a Non-Participating Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic
	Primary care visit to treat an injury or illness
	No charge
	50% coinsurance
	--none--
	
	Specialist visit
	No charge
	50% coinsurance
	--none--

Other practitioner office visit
	
No charge
	
50% coinsurance
	Chiropractic care from a non-participating provider is not covered.
	
	Preventive care/screening/immunization
	No charge
		50% coinsurance
	--none--

If you have a test
	Diagnostic test (x-ray,blood work) (Facility and Professional)
	
No charge
		
50% coinsurance
	
--none--
	
	Imaging (CT/PET scans,MRIs) (Facility and Professional)
	
No charge
		
50% coinsurance
	Precertification required for MRIs and CAT Scans.*

Questions: Call 1-855-323-1124 or visit us at www.hnas.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary	2 of 8 at www.hnas.com or call 1-855-323-1124 to request a copy.

Employee Health Plan (Retirees With Medicare) Clovis Unified School District
Summary of Benefits and Coverage:What this Plan Covers & What it Costs

Coverage Period: Beginning on or after 9/1/2016

Coverage for: Individual & Family | Plan Type: PPO

Common Medical Event

Services You May Need
	
Your Cost If You Use a Participating Provider
	Your Cost If You Use a Non-
Participating Provider

Limitations & Exceptions

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.caremark.com.

Generic drugs
	Retail -$9/prescription Mail -$18/prescription

Not Covered
	Limited to: 30 day supply – Retail 90 day supply – Mail
Mail order is required for maintenance prescriptions after the 2nd fill.

Preferred Brand Name drugs
	Retail -$24/prescription Mail -$48/prescription

Not Covered
	Limited to: 30 day supply – Retail 90 day supply – Mail
Mail order is required for maintenance prescriptions after the 2nd fill.

Non-Preferred Brand Name drugs
	Retail -$34/prescription Mail -$68/prescription

Not Covered
	Limited to: 30 day supply – Retail 90 day supply – Mail
Mail order is required for maintenance prescriptions after the 2nd fill.
	
If you have outpatientsurgery
	Facility fee (e.g., ambulatory surgery center)
	No charge**
		50% coinsurance**
	Precertification required.*
	
	Physician/surgeon fees
	No charge**
		50% coinsurance**
	Precertification required.*
	
If you need immediate medical attention
	Emergency room services
	$150/visit
		$150/visit
	--none--
	
	Emergency medical transportation
	No charge
	No charge
	--none--
	
	Urgent care
	$35/visit
	50% coinsurance
	--none--
	
If you have a hospital stay
	Facility fee (e.g., hospital room)
	No charge**
	50% coinsurance**
	Precertification required.*
	
	Physician/surgeon fee
	No charge**
	50% coinsurance**
	--none--
	
If you have mental health, behavioral health, or substance abuse needs
	Mental/Behavioral health outpatient services
	No charge
	50% coinsurance
	Precertification required.*
	
	Mental/Behavioral health inpatient services
	No charge**
	50% coinsurance**
	Precertification required.*
	
	Substance use disorder outpatient services
	No charge
	50% coinsurance
	Precertification required.*
	
	Substance use disorder inpatient services
	No charge**
		50% coinsurance**
	Precertification required.*

**Deductible applies

Questions: Call 1-855-323-1124 or visit us at www.hnas.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary	3 of 8 at www.hnas.com or call 1-855-323-1124 to request a copy.

Employee Health Plan (Retirees With Medicare) Clovis Unified School District
Summary of Benefits and Coverage:What this Plan Covers & What it Costs

Coverage Period: Beginning on or after 9/1/2016

Coverage for: Individual & Family | Plan Type: PPO

Common Medical Event

Services You May Need
	
Your Cost If You Use a Participating Provider
	Your Cost If You Use an Non-
Participating Provider

Limitations & Exceptions

If you are pregnant
	Prenatal and postnatal care - Physician
	No charge
	50% coinsurance
	--none--
	
	Delivery and all inpatient services
	No charge**
	50% coinsurance**
	--none--

If you need help recovering or have other special health needs

Home health care

No charge

50% coinsurance
	Covers up to 60 visits per calendar year – must be within 7 days of a hospital confinement.Precertification required.*
	
	Rehabilitation services
	No charge
	50% coinsurance
	--none--

Habilitation services
	
No charge
	
50% coinsurance
	Precertification required for skilled nursing facility confinement.*
	
	Skilled nursing care
	No charge
	50% coinsurance
	Precertification required.*
	
	Durable medical equipment
	No charge
	50% coinsurance
	Precertification required.*

Hospice service
	
No charge
	
No charge
	Case management must be involved. Precertification required.*

If your child needs dental oreye care
	
Eye exam
	
No charge
	
50% coinsurance
	Coverage as required by ACA under Preventive Care.
	
	Glasses
	Not Covered
	Not Covered
	--none--
	
	Dental check-up
	Not Covered
		Not Covered
	--none--

*	Precertification is required before certain medical services. Emergency admissions must be certified within 48 hours following the admission.To precertify services, call the phone number indicated on your ID card. Failure to precertify out-of-network services may result in a denial of your claim.
** Deductible applies.

Questions: Call 1-855-323-1124 or visit us at www.hnas.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary	4 of 8 at www.hnas.com or call 1-855-323-1124 to request a copy.

benefit
maximum benefit
Employee Health Plan (Retirees With Medicare) Clovis Unified School District
Summary of Benefits and Coverage:What this Plan Covers & What it Costs

Coverage Period: Beginning on or after 9/1/2016

Coverage for: Individual & Family | Plan Type: PPO

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excludedservices.)

	Acupuncture		Hearing aids		Private duty nursing 	Cochlear implants		Long-term care		Refractive eye surgery
	Cosmetic surgery		Non-emergency care when traveling outside		Routine eye care (adult) 	Dental care (adult)                                                the U.S.		Weight loss programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

	Bariatric surgery – limited to $5,000 maximum 	Infertility treatment– limited to $5,000		Treatment of TMJ

	Chiropractic care		Medically necessary treatment of sleep		Some routine foot care disorders

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending on your circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan.Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-855-323-1124. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Questions: Call 1-855-323-1124 or visit us at www.hnas.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary	5 of 8 at www.hnas.com or call 1-855-323-1124 to request a copy.

Employee Health Plan (Retirees With Medicare) Clovis Unified School District
Summary of Benefits and Coverage:What this Plan Covers & What it Costs

Coverage Period: Beginning on or after 9/1/2016

Coverage for: Individual & Family | Plan Type: PPO

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 HNAS at 1-855-323-1124,or the U.S.Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

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.

Language Access Services:

Spanish (Español):Para obtener asistencia en Español,llame al 1-855-323-1124.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-323-1124.

Chinese (中文):如果需要中文的帮助，请拨打这个号码 1-855-323-1124.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo,kwiijigo holne' 1-855-323-1124.

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

Questions: Call 1-855-323-1124 or visit us at www.hnas.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary	6 of 8 at www.hnas.com or call 1-855-323-1124 to request a copy.

Employee Health Plan (Retirees With Medicare) Clovis Unified School District
Summary of Benefits and Coverage:What this Plan Covers & What it Costs

Coverage Period: Beginning on or after 9/1/2016

Coverage for: Individual & Family | Plan Type: PPO

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.

Don’t 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 (normal delivery)

Amount owed to providers: $7,540 Plan pays $7,000 – Medicare payment Patient pays $460

Sample care costs:
	
Hospital charges (mother)
	$2,700
	
Routine obstetric care
	$2,100
	
Hospital charges (baby)
	$900
	
Anesthesia
	$900
	
Laboratory tests
	$500
	
Prescriptions
	$200
	
Radiology
	$200
	
Vaccines, other preventive
	$40
	
Total
	$7,540

Patient pays:
	
Deductibles
	$300
	
Copays
	$10
	
Coinsurance
	$0
	
Limits or exclusions
	$150
	
Total
	$460

Managing type 2 diabetes (routine maintenance of
a well-controlled condition)

Amount owed to providers: $5,400 Plan pays $4,760 – Medicare payment Patient pays $730

Sample care costs:

Prescriptions
	$2,900
	
Medical Equipment and Supplies
	$1,300
	
Office Visits and Procedures
	$700
	
Education
	$300
	
Laboratory tests
	$100
	
Vaccines, other preventive
	$100
	
Total
	$5,400

Patient pays:
Deductibles
	$0
	
Copays
	$650
	
Coinsurance
	$0
	
Limits or exclusions
	$80
	
Total
	$730

Questions: Call 1-855-323-1124 or visit us at www.hnas.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary	7 of 8 at www.hnas.com or call 1-855-323-1124 to request a copy.

Employee Health Plan (Retirees With Medicare) Clovis Unified School District
Summary of Benefits and Coverage:What this Plan Covers & What it Costs

Coverage Period: Beginning on or after 9/1/2016

Coverage for: Individual & Family | Plan Type: PPO

Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

	Costs don’t include premiums.
	Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services,and aren’t specific to a particular geographic area or health plan.
	The patient’s 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 in-network 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 isn’t 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 doctor’s 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 can’t 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, you’ll 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 you’ll 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.

Questions: Call 1-855-323-1124 or visit us at www.hnas.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary	8 of 8 at www.hnas.com or call 1-855-323-1124 to request a copy.