OSU Graduate Assistant Health Insurance Group No.: G0021007 Balance PSN 100_10 VAR Effective: 10/01/2014 10/21/2014 3144143 PSGCC.OR.LG.0114 Welcome to your PacificSource group health plan. Your employer offers this coverage to help you and your family members stay well, and to protect you in case of illness, injury, or disease. Your plan includes a wide range of benefits and services, and we hope you will take the time to become familiar with them. Using this Handbook This handbook will help you understand how your plan works and how to use it. Please read it carefully and thoroughly. Within this handbook you’ll find Member Benefit Summaries for your medical plan and any other health benefits provided under your employer’s group health policy. The summaries work with this handbook to explain your plan benefits. The handbook explains the services covered by your plan; the benefit summaries tell you how much your plan pays toward expenses and how much you’re responsible for. If anything is unclear to you, the PacificSource Customer Service staff is available to answer your questions. Please give us a call, visit us on the Internet, or stop by our office. We look forward to serving you and your family. Governing Law This plan must comply with both state and federal law, including required changes occurring after the plan’s effective date. Therefore, coverage is subject to change as required by law. PacificSource Customer Service Department Phone (541) 684-5582 or (888) 977-9299 Email CONTENTS MEDICAL BENEFIT SUMMARY........................................................................................................................A PRESCRIPTION DRUG BENEFIT SUMMARY..................................................................................................E VISION BENEFIT SUMMARY...........................................................................................................................G ALTERNATIVE AND CHIROPRACTIC CARE SUMMARY................................................................................K BECOMING COVERED.....................................................................................................................................1 ELIGIBILITY................................................................................................................................................. 1 ENROLLING DURING THE INITIAL ENROLLMENT PERIOD.....................................................................1 ENROLLING NEW FAMILY MEMBERS.......................................................................................................2 ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD........................................................................3 PLAN SELECTION PERIOD.........................................................................................................................5 WHEN COVERAGE ENDS...........................................................................................................................5 CONTINUATION OF INSURANCE.................................................................................................................... 6 USERRA CONTINUATION...........................................................................................................................6 SURVIVING OR DIVORCED SPOUSES......................................................................................................7 COBRA CONTINUATION.............................................................................................................................7 WORK STOPPAGE......................................................................................................................................8 USING THE PROVIDER NETWORK.................................................................................................................8 PARTICIPATING PROVIDERS.................................................................................................................... 9 NON-PARTICIPATING PROVIDERS...........................................................................................................9 COVERAGE WHILE TRAVELING..............................................................................................................10 FINDING PARTICIPATING PROVIDER INFORMATION............................................................................11 TERMINATION OF PROVIDER CONTRACTS...........................................................................................11 COVERED EXPENSES....................................................................................................................................11 PLAN BENEFITS........................................................................................................................................12 PREVENTIVE CARE SERVICES............................................................................................................... 13 PEDIATRIC SERVICES..............................................................................................................................15 PROFESSIONAL SERVICES.....................................................................................................................15 HOSPITAL AND SKILLED NURSING FACILITY SERVICES.....................................................................16 OUTPATIENT SERVICES..........................................................................................................................17 EMERGENCY SERVICES..........................................................................................................................18 MATERNITY SERVICES............................................................................................................................19 MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES..............................................................19 HOME HEALTH AND HOSPICE SERVICES..............................................................................................20 DURABLE MEDICAL EQUIPMENT............................................................................................................21 TRANSPLANT SERVICES.........................................................................................................................22 PRESCRIPTION DRUGS...........................................................................................................................23 OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS............................................................25 MEDICAL EVACUATION AND REPATRIATION BENEFITS......................................................................28 Medical Evacuation.....................................................................................................................................29 BENEFIT LIMITATIONS AND EXCLUSIONS..................................................................................................29 EXCLUDED SERVICES.............................................................................................................................29 PREAUTHORIZATION...............................................................................................................................35 CASE MANAGEMENT................................................................................................................................36 INDIVIDUAL BENEFITS MANAGEMENT...................................................................................................36 UTILIZATION REVIEW...............................................................................................................................36 CLAIMS PAYMENT..........................................................................................................................................37 COORDINATION OF BENEFITS................................................................................................................39 THIRD PARTY LIABILITY...........................................................................................................................40 COMPLAINTS, GRIEVANCES, AND APPEALS..............................................................................................41 GRIEVANCE PROCEDURES.....................................................................................................................42 APPEAL PROCEDURES............................................................................................................................42 HOW TO SUBMIT GRIEVANCES OR APPEALS.......................................................................................43 RESOURCES FOR INFORMATION AND ASSISTANCE.................................................................................44 FEEDBACK AND SUGGESTIONS.............................................................................................................45 RIGHTS AND RESPONSIBILITIES..................................................................................................................45 PRIVACY AND CONFIDENTIALITY...........................................................................................................46 PLAN ADMINISTRATION................................................................................................................................46 EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA)................................................................47 DEFINITIONS...................................................................................................................................................48 Medical Benefit Summary Balance PSN 100_10 VAR POLICY INFORMATION Group Name: OSU Graduate Assistant Health Insurance Group Number: G0021007 Plan Name: Balance PSN 100_10 VAR Provider Network: PSN EMPLOYEE ELIGIBILITY REQUIREMENTS Minimum Hour Requirement: Per Employer Guidelines Waiting Period for New Employees: Per Employer Guidelines Annual Deductible Per Person, Per Contract Year Per Family, Per Contract Year All Providers $100 $300 Out-of-Pocket Limit Per Person, Per Contract Year Per Family, Per Contract Year Participating Providers $1,000 $12,700 Non-participating Providers $3,000 Not applicable The member is responsible for the above deductible and the following co-pays and co-insurance: Service Participating Providers: Non-participating Providers: Preventive Care Well baby/Well child care No charge* 30% co-insurance Routine physicals No charge* 30% co-insurance Well woman visits No charge* 30% co-insurance Routine mammograms No charge* 30% co-insurance Immunizations No charge* 30% co-insurance Routine colonoscopy, age 50-75 No charge* 30% co-insurance Professional Services Office and home visits 10% co-insurance 30% co-insurance Specialty office and home visits 10% co-insurance 30% co-insurance Office procedures and supplies 10% co-insurance 30% co-insurance Surgery 10% co-insurance 30% co-insurance Outpatient rehabilitation services 10% co-insurance 30% co-insurance Hospital Services Inpatient room and board 10% co-insurance 30% co-insurance Inpatient rehabilitation services 10% co-insurance 30% co-insurance Skilled nursing facility care 10% co-insurance 30% co-insurance Outpatient Services Outpatient surgery/services 10% co-insurance 30% co-insurance Advanced diagnostic imaging 10% co-insurance 30% co-insurance Diagnostic and therapeutic radiology and lab 10% co-insurance 30% co-insurance Urgent and Emergency Services 10/21/2014 3144143 PSGBS.OR.LG.MED.0114 A Urgent care center visits 10% co-insurance 30% co-insurance $50 co-pay/visit plus 10% $50 co-pay/visit plus 30% Emergency room visits co-insurance^ co-insurance^ Ambulance, ground 20% co-insurance 20% co-insurance Ambulance, air 50% co-insurance 50% co-insurance Maternity Services Physician/Provider services (global charge) 10% co-insurance 30% co-insurance Hospital/Facility services 10% co-insurance 30% co-insurance Mental Health/Chemical Dependency Services Office visits 10% co-insurance 30% co-insurance Inpatient care 10% co-insurance 30% co-insurance Residential programs 10% co-insurance 30% co-insurance Other Covered Services Allergy injections 10% co-insurance 30% co-insurance Durable medical equipment 10% co-insurance 30% co-insurance Home health care 10% co-insurance 30% co-insurance Alternative and chiropractic care 10% co-insurance 30% co-insurance Transplants No charge 30% co-insurance This is a brief summary of benefits. Refer to your handbook for additional information or a further explanation of benefits, limitations, and exclusions. ^ Co-pay applies to ER physician and facility charges only. Co-pay waived if admitted into hospital. For emergency medical conditions, non-participating providers are paid at the participating provider level. * Not subject to annual deductible. PSGBS.OR.LG.MED.0114 B Additional Information What is the annual deductible? Your plan’s deductible is the amount of money that you pay first, before your plan starts to pay. You’ll see on the Medical Benefit Summary that many services, particularly preventive care, are covered by the plan without you needing to meet the deductible. The individual deductible applies if you enroll without dependents. If you and one or more dependents enroll, individual deductibles apply only until the family deductible has been met. Deductible expense is applied to the out-of-pocket limit. Participating provider expense and non-participating provider expense apply together toward your deductibles. What is the out-of-pocket limit? The out-of-pocket limit is the most you’ll pay for approved medical expenses during the plan year. Once the out-of-pocket limit has been met, the plan will pay 100% of covered charges for the rest of that year. The individual out-of-pocket limit applies if you enroll without dependents. If you and one or more dependents enroll, individual out-of-pocket limits apply only until the family out-of-pocket limit has been met. Be sure to check your Member Handbook, as there are some charges, such as non-essential health benefits, penalties and balance billed amounts that do not count toward the out-of-pocket limit. Note that there is a separate category for participating and non-participating providers when it comes to meeting your out-of-pocket limit. Only participating provider expense applies to the participating provider out-of-pocket limit and only non-participating provider expense applies to the non-participating provider out-of-pocket limit. Annual change in deductible and/or out-of-pocket limit amounts This plan's deductible and/or out-of-pocket limit amounts may be automatically adjusted upward every January 1 based on the rules set forth by Health and Human Services (HHS). Payments to providers Payment to providers is based on the prevailing or contracted PacificSource fee allowance for covered services. Although participating providers accept the fee allowance as payment in full, non-participating providers may not. Services of non-participating providers could result in out-of-pocket expense in addition to the percentage indicated. PSGBS.OR.LG.MED.0114 C