94529WI 0035 021

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.
`