94529WI0210035 Select Silver 3500 Deductible HSA (6067) Introducing The GHC Select Plan, a remarkable new insurance product from Group Health Cooperative of South Central Wisconsin (GHC-SCW). The GHC Select Plan gives individuals and employer groups of any size access to their choice of our six full-service, high-quality primary care clinics in and around Madison, plus access to specialty care close to home through our world-class specialty partners at UW Hospital and Clinics. Best of all, GHC-SCW offers an exclusive discount for using our exceptional network of primary care clinics. This brochure represents the Basic Plan Benefits for the plan indicated above. Click Here to see the bottom of page 3 to identify your specific plan variation. 94529WI0210035 Select Silver 3500 Deductible HSA (6067) 2015 INDIVIDUAL & FAMILY PLANS Best-In-Class Exceptional Primary Care ABOUT THIS HEALTH PLAN When you’re with GHC-SCW, you’re part of a team – a Care Team – of doctors, nurses, and others who are dedicated to meeting your health care needs. We’re committed to providing you with top-ranked1 quality care whenever you need it. PLAN NAME: Silver 3500 Deductible HSA Silver METAL LEVEL: DEDUCTIBLE: In-Network $3,500 That’s the GHC-SCW PROMISE. $7,000 Per Member Per Family CO-INSURANCE: After Deductible Complementary Medicine Mind. Body. Spirit. We complement conventional medicine with integrative therapies so you can reach your highest potential for well-being. And we’re the only area plan that includes massage, acupuncture, fitness classes, and more in your plan benefits.2 0% VISIT CO-PAYMENT: In-Network 0%* 0%* 0%* Primary Specialty ER * After deductible is met. MAXIMUM OUT-OF-POCKET (MOOP): In-Network Most of the Plan’s deductible, co-insurance, and co-payments apply to the Policy MOOP $3,500 $7,000 Per Member Per Family OUTPATIENT PRESCRIPTION DRUGS (RX): Your 24/7 online clinic Get a diagnosis and prescription in just a few minutes – anywhere, anytime. Plus, you get three visits for free per year. FOR FREE The care you need, when you need it. Specialty Care Close to Home 0%* 2 0%* 0%* Tier 2 Tier 3 Tier 4 * After deductible is met. For a complete description of covered services, please see your Member Certificate, Benefits Summary and any Amendments to your Benefits Plan. If you have questions regarding GHC-SCW Benefits, please call GHC-SCW Member Services at (608) 828-4853 or toll free at (800) 605-4327, press 0 and ask for Member Services. The best of both worlds. Best-in-class primary care from GHC-SCW and access to world-class specialty care through UW Health.3 Rankings according to the National Committee for Quality Assurance (NCQA; 2006-2013) Complementary Medicine services from a GHC-SCW provider are limited to benefits outlined in the GHC-SCW Benefits Summary. 3 Access to these specialists depends on a member’s selected Primary Care Provider or delivery system. Group Health Cooperative Of South Central Wisconsin (GHC-SCW) 1 Tier 1 0%* CLICK HERE You may be eligible for a Cost Sharing Plan. See available options on the next page. 94529WI0210035 Select Silver 3500 Deductible HSA (6067) 2015 INDIVIDUAL & FAMILY PLANS PLAN VARIATIONS CSR 02 - ZERO CSR 05 - 87% Cost-sharing reduction category #2 (CSR 02) applies to members of federally recognized American Indian tribes whose annual income level is below 300% of the Federal Poverty Level ($35,010 for a single person; $71,550 for a family of 4). Those who qualify will pay no out-of-pocket costs for copays, deductibles or coinsurance for any GHC-SCW Silver-level plan they purchase through the Health Insurance Marketplace at www.healthcare.gov. Persons whose annual income is between 151% and 200% of the Federal Poverty Level ($17,506 to $23,340 for a single person; $35,776 to $47,700 for a family of 4) are eligible for a GHC-SCW Health Plan that covers 87% of out-of-pocket costs when a Silver-level plan is purchased through the Health Insurance Marketplace at www.healthcare.gov. This means that the member pays 13% of out-of-pocket costs. This cost-sharing reduction is in addition to any Premium Tax Credit (often referred to as a “premium subsidy”) that an GHC-SCW member may receive to lower monthly insurance premium costs. CSR 03 - LIMITED Cost-sharing reduction category #3 (CSR 03) applies to members of federally recognized American Indian tribes whose annual income level is at or above 300% of the Federal Poverty Level ($35,010 for a single person; $71,550 for a family of 4). To be eligible for CSR 03, members must have a referral form from their healthcare provider. CSR 06 - 94% Persons whose annual income is between 100% and 150% of the Federal Poverty Level ($11,670 to $17,505 for a single person; $23,850 to $35,775 for a family of 4) are eligible for a GHC-SCW Health Plan that covers 94% of out-of-pocket costs when a Silver-level plan is purchased through the Health Insurance Marketplace at www.healthcare.gov. This means that the member pays 6% of out-of-pocket costs. This cost-sharing reduction is in addition to any Premium Tax Credit (often referred to as a “premium subsidy”) that an GHC-SCW member may receive to lower monthly insurance premium costs. CSR 04 - 73% Persons whose annual income is between 200% and 250% of the Federal Poverty Level ($23,341 to $29,175 for a single person; $47,701 to $59,625 for a family of 4) are eligible for an GHC-SCW Health Plan that covers 73% of out-of-pocket costs when a Silver-level plan is purchased through the Health Insurance Marketplace at www.healthcare.gov. This means that the member pays 27% of out-of-pocket costs. This cost-sharing reduction is in addition to any Premium Tax Credit (often referred to as a “premium subsidy”) that a GHC-SCW member may receive to lower monthly insurance premium costs. Note: persons whose annual income is below 100% of the Federal Poverty Level will qualify for Wisconsin’s Medicaid program, BadgerCare. BACK TO PLAN OVERVIEW Silver 3500 0035-01 CSR 02 - Zero 0035-02 CSR 03 - Limited 0035-03 CSR 04 - 73% 0035-04 CSR 05 - 87% 0035-05 CSR 06 - 94% 0035-06 $3,500 $0 $3,500 $2,750 $1,000 $500 CO-INSURANCE: 0% 0% 0% 0% 0% 0% MAXIMUM OUT-OF-POCKET: $3,500 $0 $3,500 $2,750 $1,000 $500 OFFICE VISIT CO-PAYS: 0%* 0%* 0%* 0%* 0%* 0%* PRESCRIPTION CO-PAYS: 0%* 0%* 0%* 0%* 0%* 0%* PLAN: DEDUCTIBLE: * After deductible is met. 94529WI0210035 Select Silver 3500 Deductible HSA (6067) PLAN LIMITATIONS & EXCLUSIONS This is an outline of the Limitations and Exclusions for the Group Health Cooperative of South Central Wisconsin (GHC-SCW) group and individual health plans. It is designed for reference only. Consult the Policy, Policy Amendments, Certificate of Coverage and Benefits Summary for a complete list of Limitations and Exclusions. The following services and expenses are not covered, and no benefits will be payable unless stated otherwise for expenses arising from: Medical care or services provided by a nonGHC-SCW Provider, whether or not under contract with GHC-SCW. Using a non-GHCSCW Provider or an Out-of-Plan Provider is not covered and the Member will be financially responsible for full payment of care and services unless: written approval for Out-of-Plan care and services has been obtained from GHC-SCW’s Care Management Department prior to obtaining the medical care or service; is for an Emergency Condition or an Urgent Condition when the Member is outside of the GHC-SCW Service Area; or, the plan provides for the use of nonGHC-SCW Providers Services that are not Medically Necessary, are experimental, investigative or for research purposes Billed amounts that are over and above the GHC-SCW Reasonable and Customary Fees and Charges for covered benefits Items or services required as a result of war or any act of war, insurrection, riot, terrorism, or sustained while performing military services Services provided at U.S. Government Health Facilities Services provided before the effective date or after the termination date of the Policy or Certificate of coverage Services related to an admission or confinement which occurs prior to and continues on or after the Member’s effective date when GHC-SCW coverage replaces other group coverage. Services while incarcerated, except as specifically required by state or federal law Charges for missed appointment(s) Services for injuries incurred during the commission of a crime Bilateral Cochlear Implants and Bilateral Bone Anchored Hearing Aid (BAHA) devices Blood donor services Common use supplies Complementary Medicine services not specifically covered under the Policy or Certificate of coverage Important: This plan summary provides only a general description of benefits and limitations. You can find a detailed description of coverage in the Individual Plan Certificate. Coverage is subject to all the terms and conditions of the certificate and any amendments. If there is ever a discrepancy between this plan summary and the Individual Certificate, the Individual Certificate has final authority. Benefit and Provider Information The GHC-SCW Individual Certificate requires the use of In-Network Providers. Benefits payments will be subject to the applicable Deductible, Co-insurance, annual Out-Of-Pocket Maximums, Co-payments, Lifetime Maximum Benefits, Exclusions and Limitations and other policy terms and conditions. A member’s coverage depends on his or her eligibility under the terms and conditions of the GHCSCW certificate. Complications, consultations, services and procedures related to a non-covered procedure Cosmetic services Custodial care Dental services not specifically covered under the Policy or Certificate of coverage Developmental delay (unless specifically included under the Policy or Certificate of coverage) including: nonmedical services for the evaluation, diagnosis, testing or treatment of educational problems, behavior modification or educational disorder services Drug screening, except as specifically covered under the Policy or Certificate of coverage Electrolysis services Emergency Outpatient Services when a Member leaves the emergency room prior to seeing a physician Keratorefractive surgery Surrogate maternity services and midwife services Medical Supplies, including durable and disposable medical equipment, supplies and prosthetic appliances not specifically covered under the Policy or Certificate of coverage Mental Health and Substance Use Disorder services beyond the services specified in the Policy or Certificate of coverage Coverage for medical problems which never would have occurred except through hospitalization, including but not limited to injuries or illnesses that could have been prevented such as certain infections, severe bedsores, fractures, and medical errors Obesity-related services Personal comfort items End of Life Services not specifically included under the Policy or Certificate of coverage Prescription drugs or contraceptive devices unless specifically included under the Policy or Certificate of coverage Food/Infant Formula and enteral nutritional products (medical foods) Private duty nursing services Functional capacity evaluations Gastro-intestinal surgical procedures for purposes of weight loss Growth Hormone for the treatment of idiopathic short stature Home modifications Housecleaning Hospital services for a Skilled Nursing Facility beyond the amount specified in the Policy or Certificate of coverage Hypnotherapy services Insulin injection pens not included in the GHC formulary. Infertility services not specifically covered under the Policy or Certificate of coverage, and services beyond the Benefit Maximum specified in the Benefits Summary Prior Authorization means advance authorization for specific medical services or treatment. Services requiring Prior Authorization are specified in the Covered Health Services section of the Certificate and in the Benefits Summary. Failure to obtain Prior Authorization may result in a reduction or declination of coverage. Premium Rates and Renewal Terms Your premium is based on a number of factors, including your age and the benefit option you select. Premium rates may change from time to time. You must submit the initial monthly premium, along with your completed application materials to us. All subsequent premium payments should be sent to us along with a copy of the premium invoice. This Policy will remain in force and will renew for future periods of coverage as long as you pay your premiums on time. We will notify you of a premium change at least 30 days prior to your renewal date. We will provide a 60-day notice of any premium increase of 25% or more. Prolotherapy Scar revisions Sex change operations Specialty medical care provided by a non-GHCSCW Provider, whether or not under contract with GHC-SCW, when the service requested may be provided by a GHC-SCW Specialty Provider Sperm banking or egg harvesting Supportive care Surgical Services and treatment to correct or reverse complications and/or dissatisfaction resulting from surgery, cosmetic treatment, or reconstruction when no functional impairment exists, as determined by GHC-SCW Tattoos: services for the removal of tattoos or complications related to tattoos Recreational and Educational therapy, therapy for congenital conditions (unless specifically included under the Policy or Certificate of coverage), telephonic mental health care therapy session, sexual dysfunction therapy, financial and occupational counseling, and therapies beyond the services specified in the Policy or Certificate of coverage Therapies for the diagnosis and treatment of chronic brain injury, including augmentative communication devices, and speech therapy for the treatment of stuttering, developmental delay, mental retardation or cerebral palsy, unless specifically included under the Policy or Certificate of coverage Third-party examinations Tobacco cessation products, except as specified in the Policy or Certificate of coverage Tongue thrust services or treatment Transplants, except for those specified in the Policy or Certificate of coverage and services, any organ or tissue which is sold rather than donated, involving non-human or artificial organs and tissues, and human to human organ or tissue transplant other than those specifically listed and specified within the Policy or Certificate of coverage Transportation services and costs, except Medically Necessary ambulance services Vocational Rehabilitation services Vision services, and eyewear for all Members (to include lenses, frames, contact lenses, contact lens prescriptions or contact lens fitting), unless specifically included under the Policy or Certificate of coverage Workers’ Compensation items and services incidental to an injury or conditions covered by any Workers’ Compensation law or occupational disease law Out-of-Area Dependents (who do not reside in the Service Area) are only eligible for Outof-Area Services as specified in the Policy or Certificate of coverage, unless the plan provides for the use of non-GHC-SCW Providers Transplant donor services when the recipient is not a current Member under this certificate. This Policy will become effective as of the date stated in your letter of acceptance. Renewal periods of coverage for this Policy are annually, and occur on January 1 for all policyholders. We will renew this Policy unless we discontinue offering this type of Individual Policy in Wisconsin. The Policy is guaranteed renewable except for the reasons stated in the Individual Certificate, Article II. Emergency Outpatient Care occurring at an Out-of-Network Provider or facility may be subject to applicable limitations to include reasonable and customary charges, medical necessity determination or other provisions, exclusions, or limitation of the policy. Grievance Procedure If a member has a question or concern that can’t be resolved by our Member Services Department, he or she can file a written grievance detailing the reason(s) for disagreeing with our benefit or claim payment decision. We define a “grievance” as meaning dissatisfaction with the provision of services or claims practices or administration of a health plan. This grievance is generally expressed to us in writing by a member or by a member’s representative. A member may file a grievance with us by sending their written grievance to: ATTN: Member Appeals GHC-SCW Member Services Department P.O. Box 44971 Madison, WI 53744-4971 Dependent Children The GHC-SCW Individual Policy includes coverage for eligible Dependent children through the end of the month they turn age 26. There may be tax consequences to individuals who enroll dependents who do not meet the IRS definitions of dependents/spouses. Individuals may want to consult with a tax advisor prior to enrolling Dependents for this coverage.
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