Chester Clinic

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OFFICE OF GROUP BENEFITS – MAGNOLIA LOCAL PLUS Coverage Period: 01/01/2016-12/31/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Plan Type: HMO
Coverage for: Active Employees and Retirees Without Medicare on or after March 1, 2015
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 atby calling 1-800-392-4089.
Important Questions
Why this Matters:
Network Providers: Employee Only:
You must pay al the costs up to the deductible amount before this plan
What is the overal
$400 Person; Employee + 1: $800;
begins to pay for covered services you use. Check your policy or plan deductible?
Family: $1,200; Per Calendar Year
document to see when the deductible starts over (usually, but not always,
January 1st). See the Common Medical Event chart for how much you pay Non-Network Providers: No Coverage for covered services after you meet the deductible.
Are there other deductibles
for specific services?
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.
Yes. Network Providers: Employee
Only: $2,500 Person; Employee + 1:
Is there an out–of–pocket
The out-of-pocket limit is the most you could pay during a coverage
$5,000; Family: $7,500; Per Calendar
limit on my expenses?
period (usual y one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Non-Network Providers: No Coverage
What is not included in
Premiums, Balance Bil ed Charges, and Even though you pay these expenses, they don't count toward the out-of-
the out–of–pocket limit?
Health Care this plan doesn't cover. pocket limit.
Is there an overall annual
limit on what the plan pays? No.
The Common Medical Event chart describes any limits on what the plan will pay for specific covered services, such as office visits.
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 Does this plan use a network Yes. For a full listing of network
doctor or hospital may use an out-of-network provider for some services.
of providers?
providers, seeor call 1-800-392-4089.
Plans use the term in-network, preferred, or participating for providers in
their network. See the Common Medical Event chart for how this plan
pays different kinds of providers.
Do I need a referral to see a No. You don't need a referral to see a
specialist?
You can see the specialist you choose without permission from this plan.
Questions: Call 1-800-392-4089 or visit us at
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atoor call 1-800-392-4089 to request a copy.

OFFICE OF GROUP BENEFITS – MAGNOLIA LOCAL PLUS Coverage Period: 01/01/2016-12/31/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Plan Type: HMO
Coverage for: Active Employees and Retirees Without Medicare on or after March 1, 2015
Are there services this plan
Some of the services this plan doesn't cover are listed in Excluded Services doesn't cover?
& Other Covered Services. See your policy or plan document for additional information about excluded services.
• Copayments are fixed dol ar 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 al owed amount for the service. For example, if
the plan's al owed 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
al owed 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 al owed amount is $1,000, you may have to pay the $500 difference. (This is called balance bil ing.)
• This plan may encourage you to use Preferred providers by waiving or charging you lower deductibles, copayments and coinsurance
Your Cost If You Use
Your Cost If You Use
Services You May Need
Limitations & Exceptions
Medical Event
In-network Provider
Provider
Primary care visit to treat an injury or illness $25 copayment per visit If you visit a health
Specialist visit $50 copayment per visit care provider's office
or clinic
Other practitioner office visit $25 copayment per visit Preventive care/screening Age and/or time restrictions apply Office, Free Standing Independent Diagnostic Testing Facility, or Contracted Reference Lab: If you have a test
Diagnostic test (x-ray, blood Outpatient Hospital: 0% coinsurance after Questions: Call 1-800-392-4089 or visit us at
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atoor call 1-800-392-4089 to request a copy. OFFICE OF GROUP BENEFITS – MAGNOLIA LOCAL PLUS Coverage Period: 01/01/2016-12/31/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Plan Type: HMO
Coverage for: Active Employees and Retirees Without Medicare on or after March 1, 2015
Your Cost If You Use
Your Cost If You Use
Services You May Need
Limitations & Exceptions
Medical Event
In-network Provider
Provider
Imaging (CT/PET scans, $50 copayment per visit Must obtain authorization. Generic Drugs ($30 $0 after Maximum Out-of- 50% coinsurance –In Appetite suppressant drugs; Dietary Maximum per 30 day supplements; Topical forms of prescription, up to the $1,500 80% coinsurance-Out of Minoxidil; Nutritional or parenteral If you need drugs to
Out-of-Pocket Maximum per therapy; Vitamins and minerals; treat your il ness or
Person per Plan Year) Drugs available over the counter; condition
Preferred Drugs ($55 $20 after Maximum Out-of- 50% coinsurance –In medical foods; bulk chemicals; any More information Maximum per 30 day federal legend drug with an over the about prescription
prescription, up to the $1,500 80% coinsurance-Out of counter equivalent available drug coverage is
Out-of-Pocket Maximum per Person per Plan Year) Utilization management criteria may apply to specific drugs or drug or by calling (800)910- Non-Preferred Drugs and $40 after Maximum Out-of- categories to be determined by PBM. Specialty Drugs ($80 Maximum per 30 day prescription, up to the $1,500 Out-of-Pocket Maximum per Person per Plan Year) Facility fee (e.g., ambulatory $100 copayment per visit If you have outpatient surgery center)
Must obtain authorization. Physician/surgeon fees 0% coinsurance after Facility - $150 copayment Facility - $150 copayment Non-Facility Charges – If you need
Emergency room services Non-Facility Charges – 0% 0% coinsurance after Facility copayment waived if admitted immediate medical
coinsurance after deductible deductible attention
Emergency medical Ground-$50 copayment per trip: Air-$250 copayment For emergency medical transportation Questions: Call 1-800-392-4089 or visit us at
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atoor call 1-800-392-4089 to request a copy. OFFICE OF GROUP BENEFITS – MAGNOLIA LOCAL PLUS Coverage Period: 01/01/2016-12/31/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Plan Type: HMO
Coverage for: Active Employees and Retirees Without Medicare on or after March 1, 2015
Your Cost If You Use
Your Cost If You Use
Services You May Need
Limitations & Exceptions
Medical Event
In-network Provider
Provider
$50 copayment per visit Facility fee (e.g., hospital $100 copayment per day; If you have a hospital room)
maximum of $300 per Must obtain authorization. Physician/surgeon fee 0% coinsurance after None Must obtain authorization for Mental/Behavioral health Intensive Outpatient Programs, outpatient services $25 copayment per visit Partial Hospitalization Programs, and services performed at Residential Treatment Centers. $100 copayment per day; If you have mental
Mental/Behavioral health Maximum of $300 per Must obtain authorization. health, behavioral
inpatient services health, or substance
Must obtain authorization for abuse needs
Substance use disorder Intensive Outpatient Programs, outpatient services $25 copayment per visit Partial Hospitalization Programs, and services performed at Residential Treatment Centers. Substance use disorder $100 copayment per day; inpatient services Maximum of $300 per Must obtain authorization. Prenatal and postnatal care $90 copayment per If you are pregnant
Authorization may be required if the Delivery and all inpatient $100 copayment per day; mother's length of stay exceeds 48 or Maximum of $300 per 96 hours following a vaginal or caesarean delivery, respectively. Questions: Call 1-800-392-4089 or visit us at
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atoor call 1-800-392-4089 to request a copy. OFFICE OF GROUP BENEFITS – MAGNOLIA LOCAL PLUS Coverage Period: 01/01/2016-12/31/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Plan Type: HMO
Coverage for: Active Employees and Retirees Without Medicare on or after March 1, 2015
Your Cost If You Use
Your Cost If You Use
Services You May Need
Limitations & Exceptions
Medical Event
In-network Provider
Provider
Must obtain authorization. Home health care Services limited to 60 visits per plan Physical & Occupational Therapy – Must obtain Authorization for $25 copayment per visit additional visits over the limit of 50 Rehabilitation services regardless of provider type visits combined per year. Services performed by Licensed Massage Therapists are not covered. $25 copayment per visit Physical & Occupational Therapy – regardless of provider type Must obtain Authorization for If you need help
additional visits over the limit of 50 recovering or have
visits combined per year. other special health
Habilitation services Services performed by Licensed Massage Therapists are not covered. $100 copayment per day; Must obtain authorization. Skilled nursing care Maximum of $300 per Services limited to 90 days per benefit 20% coinsurance of first $5,000 Allowable per year Must obtain authorization for durable Durable medical equipment (after deductible); 0% medical equipment, orthotic devices, coinsurance of Al owable in and prosthetics greater than $300. excess of $5,000 per year. Must obtain authorization. Services limited to 180 days per Questions: Call 1-800-392-4089 or visit us at
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atoor call 1-800-392-4089 to request a copy. OFFICE OF GROUP BENEFITS – MAGNOLIA LOCAL PLUS Coverage Period: 01/01/2016-12/31/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Plan Type: HMO
Coverage for: Active Employees and Retirees Without Medicare on or after March 1, 2015
Your Cost If You Use
Your Cost If You Use
Services You May Need
Limitations & Exceptions
Medical Event
In-network Provider
Provider
Purchased within 6 months following If your child needs
cataract surgery. dental or eye care
Frames limited to a maximum benefit of $50 Services are subject to plan year deductible and are available to all Questions: Call 1-800-392-4089 or visit us at
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atoor call 1-800-392-4089 to request a copy. OFFICE OF GROUP BENEFITS – MAGNOLIA LOCAL PLUS Coverage Period: 01/01/2016-12/31/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Plan Type: HMO
Coverage for: Active Employees and Retirees Without Medicare on or after March 1, 2015

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 excluded services.)
• Infertility Treatment Residential Treatment Centers Bariatric Surgery • Long-Term Care Routine Eye Care Cosmetic Surgery • Non-emergency care received outside the Routine Foot Care (except for Diabetes) Hearing Aids (Adult) United States, the Commonwealth of Puerto Weight Loss Programs Rico, and the U.S. Virgin Islands from a non- BlueCard Worldwide Provider • Private-Duty Nursing 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.)
• Chiropractic Care (Some restrictions apply) • Dental Care (Coverage is only available for Oral Surgery for Impacted Teeth) Questions: Call 1-800-392-4089 or visit us at
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atoor call 1-800-392-4089 to request a copy. OFFICE OF GROUP BENEFITS – MAGNOLIA LOCAL PLUS Coverage Period: 01/01/2016-12/31/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Plan Type: HMO
Coverage for: Active Employees and Retirees Without Medicare on or after March 1, 2015

Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that al ow you to keep health coverage. Any such rights may be limited in duration and wil 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 1-800-392-4089. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or

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: Blue Cross and BlueShield of Louisiana at 1-800-599-2583 orOR the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or

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.––––––––––– Questions: Call 1-800-392-4089 or visit us at
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atoor call 1-800-392-4089 to request a copy.

OFFICE OF GROUP BENEFITS – MAGNOLIA LOCAL PLUS Coverage Period: 01/01/2016-12/31/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Plan Type: HMO
Coverage for: Active Employees and Retirees Without Medicare on or after March 1, 2015
About these Coverage
Having a baby
Managing type 2 diabetes
(normal delivery) (routine maintenance of Examples:
a wel -controlled condition) These examples show how this plan might cover  Amount owed to providers: $7,540
 Amount owed to providers: $5,400
medical care in given situations. Use these  Plan pays $6,677
 Plan pays $3,278
examples to see, in general, how much financial  Patient pays $863
 Patient pays $2,122
protection a sample patient might get if they are Sample care costs:
covered under different plans. Hospital charges (mother) $2,700 Sample care costs:
Routine obstetric care Hospital charges (baby) Medical Equipment and Laboratory tests not a cost
Inpatient Medications estimator.
Don't use these examples to Vaccines, other preventive Laboratory tests estimate your actual costs Vaccines, other preventive under this plan. The actual care you receive wil be Patient pays:
different from these $400 Patient pays:
examples, and the cost of that care will also be Limits or exclusions See the next page for Limits or exclusions important information about Questions: Call 1-800-392-4089 or visit us at
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atoor call 1-800-392-4089 to request a copy. OFFICE OF GROUP BENEFITS – MAGNOLIA LOCAL PLUS Coverage Period: 01/01/2016-12/31/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Plan Type: HMO
Coverage for: Active Employees and Retirees Without Medicare on or after March 1, 2015
Questions and answers about the Coverage Examples:
What are some of the
What does a Coverage Example
Can I use Coverage Examples
assumptions behind the
to compare plans?
Coverage Examples?
For each treatment situation, the Coverage Example helps you see how deductibles,
When you look at the Summary of • Costs don't include premiums.
copayments, and coinsurance can add up. It
Benefits and Coverage for other plans, you'll find the same Coverage Examples. Sample care costs are based on national also helps you see what expenses might be left averages supplied by the U.S. up to you to pay because the service or When you compare plans, check the Department of Health and Human treatment isn't covered or payment is limited. "Patient Pays" box in each example. The Services, and aren't specific to a smaller that number, the more coverage particular geographic area or health plan. the plan provides. • The patient's condition was not an Does the Coverage Example
excluded or preexisting condition. predict my own care needs?
Are there other costs I should
• All services and treatments started and consider when comparing
ended in the same coverage period.  No. Treatments shown are just examples.
There are no other medical expenses for The care you would receive for this any member covered under this plan. condition could be different based on your Yes. An important cost is the premium
doctor's advice, your age, how serious your Out-of-pocket expenses are based only you pay. Generally, the lower your on treating the condition in the example. condition is, and many other factors. premium, the more you'l pay in out-of-
The patient received all care from in- pocket costs, such as copayments,
network providers. If the patient had
deductibles, and coinsurance.
received care from out-of-network Does the Coverage Example
providers, costs would have been higher.
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 wil be different depending on the care you receive, the prices your providers charge, and the reimbursement
your health plan allows. Questions: Call 1-800-392-4089 or visit us at
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atoor call 1-800-392-4089 to request a copy.

Source: http://www.ladelta.edu/Assets/HR/2016_Magnolia_Local_Plus_Active.pdf