Babson College
Benefits Guide
2014 Employee Benefits
TABLE OF CONTENTS
Overview of Benefits
Eligibility
Medical Coverage
3
4-5
6-10
Health Savings Account (HSA)
11
Dental Coverage
12
Vision Coverage
13
Flexible Spending Accounts (FSA)
14
HSA / FSA Comparison
15
Employee Contributions
16
Salary Continuation & Long Term Disability Coverage
17
Life and AD&D Insurance
18
Supplemental Life Insurance Rates
19
Retirement Plan
20
Tuition Benefits
21
Time-Off Benefits
22
Other Valuable Benefits
Benefit Resources
Compliance Notices
Appendix:
USERRA Notice
CHIP Notice
Summary of Benefits and Coverage
23-24
25
26-27
OVERVIEW OF BENEFITS
Welcome!
Babson College is proud to offer you a comprehensive benefit package to meet the needs
of you and your family.
The Babson College suite of benefits includes:

Medical coverage offered through Blue Cross Blue Shield of Massachusetts

A Health Savings Account administered by Wells Fargo

Dental coverage offered through Delta Dental of Massachusetts

Vision coverage offered through Vision Services Plan

Flexible Spending Accounts administered by Crosby Benefit Systems

Salary Continuation coverage self-administered by Babson College

Long Term Disability coverage administered through Cigna

Basic Life and AD&D Insurance administered through Cigna

Supplemental Life Insurance administered through Cigna

A 403(b) Defined Contribution Retirement Plan

Tuition Benefits

Time-Off Benefits

Additional programs, discounts and benefits
*Please note this guide is intended as a brief overview of benefits only. The policies,
contracts or certificate for each benefit plan will govern the benefits and include more details on how the benefit plan operates. See the next page for eligibility guidelines.
Page 3
ELIGIBILITY
Full-time Employees: You are eligible to participate in the Babson full-time benefits
program if you are a full-time faculty member or a member of the Babson staff regularly
scheduled to work a minimum of 1,456 hours per year (or 28 hours/week).
Part-time Employees: You are eligible for part-time benefits if you are a staff member
scheduled for at least 1,000 hours per year (or 20 hours/week), or if you are in a benefits
eligible part-time faculty role. See the chart on the following page for a listing of benefits
available for full-time and part-time employees.
COVERAGE LEVELS
You may choose from three coverage levels for medical, dental and vision care benefits:
 Employee
 Employee + 1 (spouse/domestic partner or child)
 Family
ELIGIBLE DEPENDENTS
Your eligible dependents for medical, dental and vision care coverage include:
 Your legal spouse
 Your eligible domestic partner
 A dependent child up to age 26 regardless of:
 their marital, student or employment status
 whether they are your tax dependent
 whether your home is their principal place of residence
 For this purpose, the term child is defined as:
 Your natural child
 A child for whom you are the legally appointed guardian with full financial
responsibility
 A child of a domestic partner, as long as you also cover your domestic partner
 Your stepchild
 Your child who is incapable of self-support because of a total physical or mental
disability
 Your legally adopted child or child placed with you for adoption
 A child named in a Qualified Medical Child Support Order
 Your child age 26 or older who is incapable of self-support because of a total
physical or mental disability that occurred while covered under the plan
 A child of a covered unmarried dependent . Please Contact Babson Human
Resources)
 An eligible domestic partner is a person of the same or opposite sex with whom you
have established a domestic partnership. To be considered domestic partners, both
partners must sign an affidavit of domestic partnership and meet certain requirements.
For more information, contact the Office of Human Resources, extension 5498 or
781-239-5498.
Page 4
ELIGIBILITY
The chart below lists the benefits that are included in Babson’s full-time and
part-time benefit programs. Eligibility requirements for each program are detailed
on the previous page of this booklet.
Comparison of Available Benefits - Full-Time vs. Part-Time
FULL-TIME BENEFITS
PART-TIME BENEFITS
Medical
Medical
Dental
Dental
Vision
Vision
Health Savings Account (PPO only)
Health Savings Account (PPO only)
Flexible Spending Accounts
Flexible Spending Accounts
Health Advocate
Health Advocate
Retirement Plan
Retirement Plan
Employee Assistance Program
Employee Assistance Program
Vacation Time
Vacation Time
Sick Time
Sick Time
Holiday Pay
Holiday Pay
Perks at Work
Perks at Work
HEALTHY YOU/Be Well Programs
HEALTHY YOU/Be Well Programs
Business Travel Accident
Business Travel Accident
Long Term Care
Long Term Care
529 Savings Plan
529 Savings Plan
WeCare+
WeCare+
Pet Insurance
Pet Insurance
Life Insurance
Salary Continuation
Long Term Disability
Floating Holidays
Tuition Remission
Tuition Reimbursement
Secure Travel
Medical Rebate
Dental Rebate
Page 5
MEDICAL COVERAGE
Babson College offers employees three medical plans through Blue Cross Blue
Shield of MA. Employees can choose between two HMO options: the High OptionHMO Blue New England Value Plus Plan, or the Low Option-HMO Blue New
England Enhanced Value Plan, or the PPO Blue Care Elect Saver Plan with a
Health Savings Account. You share the cost of medical coverage through pre-tax
payroll deductions.
Comparing Your Medical Options
HMO Options:
These plans cover services only when provided within the HMO provider network, except in
emergencies. You make a copayment for certain services, and other services including
preventive care, are covered in full. When you join one of the HMOs, you select a Primary
Care Physician (PCP). Your PCP will coordinate your overall health care and make
referrals to specialists, as necessary.
PPO and Health Savings Account:
The PPO is designed to work in conjunction with a Health Savings Account (HSA). This is
a consumer driven, high deductible health plan with a deductible that must be satisfied
before most services are covered, with the exception of preventive care. The PPO offers
the flexibility to use any provider in the extensive national PPO network. Out of network
benefits are available subject to the deductible and coinsurance.
Babson contributes a portion of the PPO deductible to a Health Savings Account for you.
You may also make tax-free contributions to the account to help pay for eligible
out-of-pocket health care expenses. See Health Savings Account section for more
information about the HSA.
Carefully review the comparison chart on the next page to see the differences among the
HMO and PPO options.
Summary of Benefits and Coverage (SBC)
As an employee, the health benefits available to you represent a significant component of
your compensation package. They also provide important protection for you and your
family in the case of illness or injury.
Your plan offers a series of health coverage options. Choosing a health coverage option is
an important decision. To help you make an informed choice, your plan makes available a
Summary of Benefits and Coverage (SBC), which summarizes important information about
any health coverage option in a standard format, to help you compare across options.
The SBC is located in the appendix section of this Benefits Guide. A paper copy is also
available, free of charge, by calling the HR Department at 781-239-5498 and Blue Cross
Blue Shield at 1-888-543-8770 to request a copy of the Glossary of terms.
Waive Coverage
Full-time faculty and full-time staff are eligible to receive a rebate when waiving medical
coverage and/or dental coverage. If you waive medical coverage and/or dental coverage,
you will not be able to enroll until the next open enrollment period, unless you have a
qualified life event.
Page 6
MEDICAL PLAN COMPARISON
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and state
mandates may apply.
Page 7
Additional BCBS Benefits
Value Based Benefits
Members with asthma, diabetes, coronary artery disease, or risk of cardiovascular disease (taking high blood
pressure medications in combination with high cholesterol medications), or depression associated with any of
these conditions, have coverage that helps to more affordably manage care.
For certain Tier 1 and Tier 2 medications used to treat these conditions, the member will pay the same
copayment for a three-month supply as the member would for a one-month supply from a retail pharmacy
when filling a prescription through the BCBS convenient, low-cost mail service
pharmacy. This is a savings of up to eight copayments per year for each medication.
Note: For members on the high deductible PPO, the RX deductible will not apply when using the mail order for
these specific medications.
This benefit also applies to covered spouses and dependents who are also eligible for these savings.
To access the medication list and learn more, visit www.bluecrossma.com/valuebased.
Women’s preventive health








Annual well-woman visits
Screening for gestational diabetes
Human papillomavirus (HPV) DNA testing
Counseling for sexually transmitted infections
Counseling and screening for human immunodeficiency virus (HIV) infections
Contraceptive methods and counseling
Breastfeeding support, supplies, and counseling
Domestic violence screening
MA mandates
Coverage is provided for a child under the age of 18 for treatment of cleft lip and cleft palate. This coverage
must include benefits for the following services, as long as they are prescribed by a physician or surgeon:







Medical, dental, oral and facial surgery
Surgical management and follow-up care by oral and plastic surgeons
Orthodontic treatment and management
Preventative and restorative dentistry
Speech therapy
Audiology
Nutrition services
Coverage is provided for any child 21 years of age or younger for the full cost of one hearing aid per hearingimpaired ear. The law requires coverage for up to $2,000 for each hearing aid every 36 months, upon
prescription from the minor’s treating physician that the hearing aids are medically necessary. Coverage must
include all related services prescribed by a licensed audiologist or hearing instrument specialist, including the
initial hearing aid evaluation, fitting and adjustments, and supplies (including ear molds).
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 8
New BCBS Benefits effective January 1, 2014
Benefits as required under the Affordable Care Act (ACA)

Fitness reimbursement—BCBS will reimburse the cost of membership fees up to 3 consecutive months for
one family or one individual for participation at a qualified fitness club

Weight Loss Benefit—BCBS will reimburse the cost for up to 3 months for participation in a qualified weight



Low Protein Foods— the $5000 per member per calendar year annual limit is removed; it is now unlimited
loss program each calendar year for any combination of members covered under the plan
Hair Prothesis—BCBS will reimburse the cost of one wig per calendar year with no dollar limit
Durable Medical Equipment—the per member per calendar year dollar limit will be removed; there will now
be a member coinsurance cost share
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 9
MEDICAL COVERAGE
Finding a Network Provider or Facility
You have several resources to find the right physician, specialist or facility in the
BCBS MA network.
BCBS Concierge Care Center:
 Call 888-543-8770, Monday - Friday, 8:00 am - 6:00 pm EST
Blue Cross Blue Shield Website:
 Log on to www.BCBSMA.com to view a provider directory
Prescription Drug Coverage
All three medical plans provide prescription drug coverage, which includes a mail
order program. When you fill your prescription at a participating retail pharmacy,
you may purchase up to a 30-day supply of covered drugs. At the pharmacy, you
will need to present your ID card and make the required copayment.
Mail-order Program: If you use a maintenance drug, you may use the mail order
program to receive a 90-day supply at a reduced cost. To start, ask your doctor to
provide a prescription for a 90-day supply of your medication, plus refills. Then
order your prescription refills online.
Health & Wellness
Healthy You
Babson is proud to join with other area colleges in the “Healthy You” initiative, dedicated to
a healthier and more productive workforce. You’ll be offered wellness programs through
bewell@babson.edu, Blue Cross Blue Shield, on-campus partners such as Athletics and
the CWEL with incentives to participate and become a healthier you! A healthier workforce
will also help Babson keep medical costs under control, which benefits both you and
Babson. Here’s to your health!
Health Advocate
Health Advocate is a free and confidential service for you and your family members that
serves as your lifeline to health care and insurance assistance. Save time and money by
having Health Advocate find you qualified specialists and hospitals, untangle your medical
bills, locate eldercare and support services, and help you and your loved ones with any
health or insurance related question. This service is available to you and your family,
whether or not you are covered by a Babson plan.
To Contact Health Advocate:
 Call 866-695-8622, Monday - Friday, 8:00 am - 9:00 pm EST
 Send an email to answer@HealthAdvocate.com
 Website: www.healthadvocate.com
Page 10
HEALTH SAVINGS ACCOUNT (HSA)
If you enroll in the Blue Care Elect Saver PPO Plan, Babson will establish a Health Savings
Account (HSA) for you through Wells Fargo. An HSA is an account that works in conjunction
with a high-deductible health insurance plan. You can use this account for qualified medical
expenses this year, or grow the account and use it for qualified medical expenses down the
road. When you participate in an HSA, Babson will make a tax-free contribution to your
account. You may only enroll in the HSA if you are enrolled in the PPO medical plan. Also,
you cannot enroll in the HSA if you are enrolled in the HMO, medical FSA or in Medicare.
2014 HSA Contributions
Health Savings Account
Coverage Level
Babson
Contribution
Your Maximum
Contributions*
Maximum Deposit to
HSA*
Employee Only
$250
$3,050
$3,300
Employee + 1
$500
$6,050
$6,550
Family
$500
$6,050
$6,550
* If you are 55 or older, you can make an additional catch-up contribution.
The maximum annual catch-up contribution is $1,000.
Highlights of the Wells Fargo HSA:

A debit card feature is included allowing you to pay for qualified health, dental and vision
expenses

Only the amount in the account can be spent

Triple Tax Advantage: Contributions are tax deductible, balances grow tax-free,
withdrawals are tax free when used for qualified medical expenses

Account balances earn interest

If you have $2,000

No penalty incurred if you do not spend the money; No use it or lose it provision. Funds
can grow to retirement

Portable – it is your money – for life

You are the administrator – no need to submit receipts – You just need to track your
expenses – debit card helps document transactions for the IRS in the event you are ever
audited
If you have additional questions, please call Wells Fargo HSA Customer Service
at 1-866-884-7374, Monday through Friday, 8:00 a.m. to 9:00 p.m. (EST).
More resources are available online at wellsfargo.com/hsa.
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 11
DENTAL PLAN COMPARISON
Babson offers the choice of two dental plans through Delta Dental of MA.
Employees can choose between the Delta Premier Plan and the DeltaCare Plan.
A rebate is available for full-time employees who elect to waive coverage.
Manage Your Dental Health
-Delta Dental provides easy access to your dental plan information. You can:
 Find a network dentist
 Verify plan eligibility and view benefit plan coverage
 View claims information
 Request an ID card
-Log on to www.deltadentalma.com
-Call Delta Premier at 800-872-0500 or DeltaCare at 800-327-6277
Monday - Thursday, 8:30 am - 8:00 pm EST; Friday, 8:30 am - 4:30 pm EST
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 12
VISION COVERAGE
Babson offers the option to purchase vision coverage through Vision Services Plan (VSP).
Employees pay for the full cost of this coverage through after-tax payroll deductions.
Vision exams
Lenses
Single vision, lined
bifocal and lined
trifocal lenses
Frames
Frame selections
VSP Provider
Out of Network
$10 copay - one every 12 months
Reimbursed up to $50
every 12 months
$10 copay combined with exam
Reimbursed up to:
Single vision: $50
Lined bifocal: $75
Lined trifocal: $100
every 24 months
$120 allowance for selection of frames
20% off the amount over allowance
Contact Lenses in
$120 allowance for contacts and the
Lieu of Eyeglasses contact lens exam (fitting and evaluation)
(every 12 months)
If you choose contact lenses you will be
eligible for frames 24 months from date
the contact lenses were obtained.
Reimbursed up to $70
Reimbursed up to $105
Note: current soft contact lens wearers
may qualify for a special program that
includes a contact lens exam and initial
supply of lenses.
$20 reimbursement for featured frame brands such as Bebe, Calvin Klein, Flexon, Lacoste, Michael
Kors, Nike, Nine West, and others.
Network now includes Costco, Visionworks and Cohen’s.
Need Additional Information or Have a Question?
For more information about the plan and discounts or to find a VSP provider, visit the VSP
website or call VSP customer service:
 Log on to www.vsp.com
 Call 800-877-7195, Monday - Friday, 8:00 am - 10:00 pm EST
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 13
FLEXIBLE SPENDING ACCOUNTS (FSA)
You have the opportunity to participate in a Flexible Spending Account (FSA) program
administered by Crosby Benefit Systems. Employees can contribute to two types of
accounts: the Medical Care FSA and the Dependent Care FSA. You need to plan
carefully before you participate in an FSA, because you forfeit any unused funds at
the end of the year, as legally required under the “use it or lose it” rule. You may
only change your FSA elections during the year if you have a qualified life event.
MEDICAL CARE FLEXIBLE SPENDING ACCOUNT
2014 Annual Contribution
Maximum
$2,500 - Maximum contribution amount
Note: The maximum amount you elect to contribute for the year is
available to you for expenses beginning January 1. You are
responsible for funding the total annual amount elected by the end
of the plan year (December 31).
Eligible Expenses
• Out-of-pocket medical costs, such as deductibles, copayments and
coinsurance
• Prescription drug copayments
• Over-the-counter medicine (prescription required )
• Non-covered dental, vision and other eligible health care expenses
Claims Period
Claims Deadline
Expenses must be incurred from January 1 through December 31
Claims must be submitted by March 31 of the following year
Eligible health care expenses can be paid for in one of two ways:


Medical Care FSA Debit Card: Use the debit card to pay for expenses at the point of service.
FSA Claim Process: Pay the health care provider directly and then file a claim for
reimbursement.
2014 Annual Contribution
Maximum
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
$5,000
Married, filing separate returns: $2,500
Eligible Expenses
• Pre-school or nursery school expenses
• Expenses for a babysitter in your home
• Day care center
• Summer day camp*
• Afterschool care
• Adult day care center or in-home care for an adult dependent
* Overnight summer camp is not eligible.
Claims Period
Expenses must be incurred from January 1 through December 31
Claims Deadline
Claims must be submitted by March 31 of the following year
Eligible dependent care expenses must be paid to your dependent care provider directly:





FSA Claim Process: Pay your dependent care provider directly and then file a claim for
reimbursement.
Contact Crosby Benefits For More Information
Log on to www.crosbybenefits.com
Call 866-918-9711,ext. 2, Monday - Thursday, 8:00 am - 6:00 pm and Friday, 8:00 am - 5:00 pm
Fax 978-367-9626
Crosby Benefit Systems, Inc. 27 Christina Street, Newton, MA 02461
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 14
FLEXIBLE SPENDING ACCOUNT/HEALTH SAVINGS ACCOUNT COMPARISON
Understanding the Differences Between Flexible Spending Accounts (FSAs) and
Health Savings Accounts (HSAs)
Medical FSA
Eligibility To
Contribute
Annual
Contribution Dollar
Limits
Account
Ownership
All benefits eligible employees may
participate, except those on the Blue Care
Elect Saver PPO. (Exception for PPO
members enrolled in Medicare).
HSA
You are eligible if you have a high deductible
health insurance plan that meets IRS
definitions, and you are not on Medicare. At
Babson, this is the Blue Care Elect Saver
PPO only. (Medicare participants in the PPO
will have an FSA instead).
HSAs have annual contribution limits.
In 2014, the contribution limit for single
coverage is $3,300. The contribution limit for
family coverage is $6,550. These limits
$2,500.
include contributions to your account made
by Babson ($250 for the year for single
coverage, $500 for the year for family).
The HSA account is a bank account owned
Your FSA account is set up and owned by
by you, regardless of where you work. Wells
Babson. The record keeper for these plans
Fargo is the bank for Babson’s Health
is Crosby Benefit Systems.
Savings Accounts.
The FSA has a maximum election limit.
You have access to what has actually been
deposited into your HSA to date, like any
other bank account.
Access To Your
Money
Use It or Lose It
You have access to your entire annual
election amount (as long as you continue
If you have an expense without sufficient
participating) any time during the plan year,
funds in your HSA to pay for it, you may pay
even if you have not had all of the money
for the cost out-of-pocket and reimburse
deducted yet from your check. Most
yourself later as more funds are deposited, or
employees use the Crosby debit card for
you may set up a payment plan with your
certain payments. Not all providers accept
provider. Most employees use the Wells
the debit card.
Fargo debit card to make payments.
Employees may also order checks from
Wells Fargo for a small fee.
Any money you do not spend in your FSA at “Use It or Lose It” does not apply to Health
the end of the year is forfeited. Be aware of Savings Accounts. Any unused funds in your
the annual deadline to submit requests for HSA at the end of the plan year are yours to
reimbursement for prior year expenses –
keep, and stay in your account indefinitely
March 31st of each year.
until you spend it.
The HSA can be used for the current year’s
The FSA is used to set aside pretax funds
medical expenses as well as to build medical
one
“plan
year”
at
a
time.
Each
year,
you
Time period for
savings for future plan years and retirement.
choose whether to participate and how much
If you are no longer employed at Babson and
eligible expenses
funds to set aside. Any unused funds stay
continue your HSA, you will be charged a
with your employer.
small account maintenance fee.
Substantiation
For Reimbursement Requests, you will be
required to submit or upload bills/receipts
showing the Provider, Person Receiving
Services, Date of Service, Nature of Service
and Expense Amount.
HSAs do not require receipts from you.
However, it is important that you keep all
receipts and documentation for your records
in the event of a personal IRS audit.
When using the Flex Debit Card, the FSA
Plan Provider may ask you to submit or
upload bills/receipts showing the items above
to verify that the expense is FSA eligible.
You can only change your election if you
You can change your election amount
Option to Change experience certain qualifying events such as
anytime, as long as it does not exceed IRS
marriage, divorce, birth of a child, etc. You
Contributions
limits.
are “locked in” until the next open enrollment.
Page 15
2014 EMPLOYEE CONTRIBUTIONS
Full-time Employee
Monthly
Part-time Employee
Bi-Weekly
Monthly
Bi-Weekly
Babson's Employee Babson's Employee's Babson's Employee Babson's Employee's
Cost
Cost
Cost
Cost
Cost
Cost
Cost
Cost
BCBS HMO Blue NE Value
Plus - High Option
Employee
$398.02
$244.47
$183.70
$112.83
$215.79
$426.70
$99.60
$196.94
Employee + 1
$816.08
$521.38
$376.65
$240.64
$442.48
$894.98
$204.22
$413.07
$1,190.15
$760.37
$549.30
$350.94
$645.31
$1,305.21
$297.83
$602.41
Employee
$398.01
$218.54
$183.70
$100.86
$215.79
$400.76
$99.60
$184.97
Employee + 1
$816.08
$448.15
$376.65
$206.84
$442.48
$821.75
$204.22
$379.27
$1,190.15
$653.59
$549.30
$301.66
$645.31
$1,198.43
$297.83
$553.12
Employee
$398.02
$132.67
$183.70
$61.23
$275.96
$254.73
$127.36
$117.57
Employee + 1
$816.08
$272.02
$376.65
$125.55
$565.81
$522.29
$261.14
$241.06
$1,190.14
$396.72
$549.30
$183.10
$825.16
$761.70
$380.84
$351.55
Family
BCBS HMO Blue NE
Enhanced Value - Low Option
Family
BCBS PPO Blue Care Elect
Family
Medical Rebate *
(Full-time Employee Only)
Employee
$84.00
$38.77
n/a
n/a
Delta Dental Premier
Employee
$32.18
$10.73
$14.85
$4.95
$17.16
$25.75
$7.92
$11.88
Employee + 1
$64.96
$21.65
$29.98
$9.99
$34.64
$51.97
$15.99
$23.98
Family
$121.49
$40.50
$56.07
$18.69
$64.79
$97.19
$29.90
$44.86
Employee
$25.85
$8.62
$11.93
$3.98
$13.78
$20.68
$6.36
$9.54
Employee + 1
$48.44
$16.15
$22.35
$7.45
$25.83
$38.75
$11.92
$17.88
Family
$72.94
$24.31
$33.66
$11.22
$38.90
$58.35
$17.95
$26.93
Delta Dental Care
Dental Rebate *
(Full-time Employee Only)
Employee
$12.00
$5.54
n/a
n/a
VSP Voluntary Vision
(100% employee paid)
Employee
$10.57
$4.88
$10.57
$4.88
Employee + 1
$15.32
$7.07
$15.32
$7.07
Family
$27.48
$12.68
$27.48
$12.68
*Rebate provided each pay when you waive this benefit.
Domestic Partner benefits: The value of the premium for medical and dental coverage may be imputed as income and
added to your W-2 form for tax purposes. Please consult with your tax advisor.
Page 16
DISABILITY COVERAGE
Babson provides full-time employees with both Salary Continuation and Long Term
Disability coverage at no cost. These plans are designed to replace all or a portion
of your income if you become disabled due to a non-work related injury or illness.
Salary Continuation
If you are benefits eligible and actively employed for a minimum of one year and become disabled for
2 consecutive weeks or more, you may apply for Salary Continuation. Babson may continue up to
100% of your income for an approved period for up to and not to exceed 6 months of disability.
Long Term Disability
Long term disability coverage is provided by Cigna. In the event you become
disabled and are unable to perform the essential functions of your job, LTD benefits
will replace 60% of your salary, up to a maximum of $10,000 per month. Benefits
begin after 180 days of continuous disability.
Pre-existing Condition: If your disability is related to a condition for which you
received treatment within the past three months, you may not be eligible for
benefits until you have been covered under this plan for 12 months.
Union employees, please refer to your collective bargaining
agreement for specific information about your benefits.
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 17
LIFE AND AD&D INSURANCE
Babson provides full-time employees Life and Accidental Death & Dismemberment
(AD&D) insurance through Cigna to provide financial security to your dependents if
you die or are severely injured in an accident. Babson provides coverage at no cost
to you and gives you the opportunity to purchase additional life coverage for
yourself and your dependents.
Basic Life and AD&D
Babson provides eligible faculty and staff with Basic Life Insurance equal to one times your
base salary rounded to the next $1,000, up to $400,000, at no cost to you. An equal amount
of Accidental Death and Dismemberment (AD&D) Insurance is also provided.
AD&D Insurance protects you in case of accidental death or injury (loss of a limb, eyesight or
hearing). Benefits are reduced for employees age 65 or older.
Supplemental Life
You may elect to purchase additional life insurance coverage in $10,000 increments, not to
exceed five times your annual salary or $700,000, whichever is smaller. Benefits are
reduced for employees age 65 or older.
Evidence of Insurability: If you enroll in Supplemental Life Insurance within 31 days of
when you first become eligible, you do not need to provide evidence of good health.
Evidence of insurability is required when:
 You enroll late (after the 31-day enrollment period)
 You want to increase your Supplemental Life Insurance coverage at any time throughout
the year
 You elect coverage above the guarantee issue of $250,000 under age 70
($20,000 ages 70-74)
In these cases, approval for Supplemental Life Insurance is based on medical evidence of
insurability.
Dependent Life
You may also purchase life insurance coverage for your spouse and eligible dependent
children.
Spousal Life Insurance: As long as you elect Supplemental Life Insurance coverage for
yourself, you may purchase coverage for your spouse. You may elect coverage of up to
$150,000, in $5,000 increments, provided coverage does not exceed 50% of your elected
coverage amount. Your spouse will be required to provide evidence of insurability if
requesting more the $50,000 in coverage or enrolling after first becoming eligible. Benefits
are reduced when the spouse reaches his/her age of 65. Benefits for the spouse terminate at
the spouse’s age of 80.
Dependent Life Insurance: Provided you elect Supplemental Life Insurance coverage for
yourself, you may purchase life insurance coverage for your eligible dependent children. You
may elect coverage of $500 per child from 14 days to six months and $10,000 per child from
six months to age 25. All of your eligible children are covered at one rate and are not
required to provide evidence of insurability.
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 18
SUPPLEMENTAL LIFE INSURANCE RATES
Supplemental Life Insurance
*Must have own coverage to elect spousal coverage
Employee/
Spouse Age
Employee Monthly Cost
per $10,000 Unit
Spouse Monthly Cost
per $5,000 Unit
Under 30
0.60
0.30
30 to 34
0.80
0.40
35 to 39
1.00
0.50
40 to 44
1.50
0.75
45 to 49
2.50
1.25
50 to 54
4.00
2.00
55 to 59
7.10
3.55
60 to 64
10.70
5.35
65 to 69
16.30
8.15
70 to 74
32.40
16.20
75 to 79
55.50
27.75
80 & Over
55.50
XXX
Note: Benefits are reduced starting at age 65. Employee coverage is in $10,000
increments. Spousal coverage is in $5,000 increments and cannot exceed 50% of
the employee’s coverage amount. Benefits terminate for the spouse at the
spouse’s age of 80. The monthly cost for children is $2.20 for $10,000 of
coverage. One premium will insure all your eligible children, regardless of the
number of children you have.
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 19
RETIREMENT PLAN
The Babson College Retirement Plan helps prepare you financially for retirement.
The plan is a 403(b) defined contribution plan. As a condition of employment, you
must participate in the Retirement Plan, following four full months of employment.
Both you and Babson contribute to the plan. The contribution amount is based on
your base earnings.
You direct the investment of your Retirement Plan contributions to TIAA-CREF and/
or Fidelity, and are immediately vested in your account balance (all contributions
and investment earnings). Both companies offer an array of funds and a brokerage
option. When you retire or leave Babson, you take your entire account balance with
you.
Your Contributions
If your base salary is $58,850 or less,
your annual contribution to the plan is
2% of your base salary.
If your base salary is more than
$58,850, you contribute 2% of your first
Babson’s Contributions
Babson contributes an amount equal to
four times your contributions to the plan:
 8% of base salary up to $58,850
 12% of base salary above $58,850,
up to the 403(b) earnings limit
$58,850 ($1,137) of salary and 3% of
any amount over $58,850.
*The amount of $58,850 is based on 2014.
Manage Your Retirement Plan Account
You may enroll online, review your account balances and activities, make election
changes, and access information, tools and resources through Fidelity Investments
and/or TIAA-CREF.
Fidelity Investments
 www.NetBenefits.com
 800-343-0860, Monday - Friday, 8:00 am - midnight EST
TIAA-CREF
 www.TIAA-CREF.org/Babson
 800-842-2776, Monday - Friday, 8:00 am - 6:00 pm EST and
Saturday, 9:00 am - 6:00 pm EST
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 20
TUITION BENEFITS
Babson supports your professional growth and the education of your family through
tuition remission benefits. Full-time faculty and full-time regular benefits eligible
staff, their spouses and dependent children may be eligible for tuition remission for
graduate and undergraduate courses taken at Babson.
Benefits cover tuition charges (excluding books, room, board, supplies and other
fees) based on the following guidelines:
Babson College Undergraduate and Graduate Schools
Employee
100% remission for graduate evening programs beginning the next
semester falling on or after your four-month anniversary.
You may take up to a maximum of 18 credits per calendar year
(unless otherwise approved by your President’s Cabinet member).
Note: Federal law requires that tuition remission granted in each calendar
year in excess of $5,250 be reported as taxable income on the employee’s
W2. Some courses may be considered tax exempt, contact HR for more
information.
Spouse or Dependent
Child
For Fast Track, undergraduate, and evening, one-year and two-year graduate
programs, beginning the next semester falling on or after the employee’s
anniversary of full-time employment as follows:
• Second anniversary …….50%
• Third anniversary …….....80%
• Fourth anniversary …....100%
Note: Tuition remission is not available for post-graduate MBA degree
programs or for post-baccalaureate studies in the undergraduate program.
Tuition remission received for undergraduate programs is tax exempt.
Federal law requires that the full amount of the tuition remission granted in
each calendar year for graduate programs be reported as taxable income on
the employee’s W2.
Benefit Requirement
Users of the tuition remission benefit must be admitted according to the general standards
expected of all applicants to the College. Tuition remission is not available to non-admitted
students taking courses at the College. Users of the tuition remission benefit must notify
Human Resources prior to the start of each semester. Users of the tuition remission benefit
are encouraged to apply for all federal, state, local and private scholarships or grants to
which they may be entitled. If other funds are received, appropriate adjustments will be
made.
End of Full-Time Employment
If you end full-time employment at Babson tuition benefits end immediately and a prorated
tuition charge is made for the course(s) you and/or your spouse are taking. Dependent
children taking courses will receive the tuition benefit until the end of the semester currently
in session.
Off-Campus Education
Babson may provide up to $5,250 per calendar year of tax-exempt financial support for fulltime regular benefits eligible staff members pursuing degree programs or specific
coursework at other appropriate educational institutions, provided study is related to the
staff member’s present position, professional area or career path at Babson.
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 21
TIME-OFF BENEFITS
Babson offers a comprehensive time-off program that provides financial support
when you are sick and for time away from your regular job responsibilities.
The program includes vacation time, sick time and holidays.
Vacation Time
You earn vacation time based on your job category and length of employment. Parttime employees accrue vacation on a prorated basis based upon your standard
hours. When you leave Babson, any accrued and unused vacation time is paid out
to you. Your accrual will be prorated based on your hire date.
Sick Time
During the first full 12 months of employment, full-time faculty and staff have 3 weeks
of sick time. After 1 full year of employment, you may have an unspecified amount of
time. Documentation of your illness or injury may be required in order to continue
to be paid. Salary Continuation, Long-Term Disability and Family and Medical Leave
Act (FMLA) may apply for extended illnesses.
Holidays
Babson celebrates 17 holidays each year, including national, state and floating
holidays and special holidays determined annually by the President. The schedule
is posted on hrinfo, accessible from the Babson portal.
Leaves of Absence
Babson complies with all federal and state laws regarding leaves of absence.
Family illness and parental leaves are also available.
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 22
OTHER VALUABLE BENEFITS
Babson offers several additional programs, discounts and benefits that you may want
to take advantage of.
Employer Paid
Employee Assistance Program
Travel Benefits
The Employee Assistance Program (EAP)
is offered through Kathleen Greer
Associates (KGA) and is designed to help
you or your household members address
personal concerns or life issues you may be
facing – at home or at work. The
confidential and free service provides
professional counseling and referral
networks. The EAP counselors provide
assessments services and short-term
counseling on items such as legal
consultation, financial consultation, child
and elder care resources, nutrition
consultation, work life resources, career
assessment, parenting resources and
stress reduction. You have access to the
EAP, 24 hours a day, 7 days a week.
Secure Travel is a free benefits for full-time
employees through Cigna, administrator of
our life insurance and disability plans. Secure Travel provides emergency medical
evacuation assistance and travel services,
as well as helpful pre-trip planning assistance, when traveling 100 miles or more
away from home on college business or on
vacation. The toll-free customer service
center is available 24 hours a day, 365 days
a year. And, in an emergency, the customer service center can even accept collect
calls.
Access EAP Services
Website:
www.kgreer.com
User Name: Babson
Password: 9557
Phone:
800-648-9557
U.S. & Canada: 888-226-4567
Other Locations, Call Collect: 202-331-7635
www.cigna.com
Business Travel Accident Insurance,
administered by AIG/Chartis, is free and
provides you and your family with a degree
of financial security should you die or suffer
a loss resulting from an accident while
traveling on business for Babson College.
The benefit amount is based on your base
salary and contingent on the type of loss
incurred. This plan also provides
business-related travel services, such as
pre-travel assistance, support during your
trip, medical emergency services and legal
assistance.
When within U.S., call 877-244-6871; When outside
the U.S., call +1 715-346-0859
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 23
OTHER VALUABLE BENEFITS
Voluntary
Long-Term Care (LTC) Insurance
Long-term Care Insurance, offered through CNA, provides financial assistance when you are no
longer able to perform basic activities of daily living without help. This optional plan provides a daily benefit amount for nursing home care and community based care (i.e., care outside of a nursing
home, such as home healthcare, adult day care, foster care or assisted living facility). You choose
the level of care, which determines your cost. You may elect LTC coverage for yourself, your spouse
(including same sex or opposite sex domestic partner), parents, parents-in-law, grandparents or
grandparents-in-law who are under age 90. You may enroll within 30 days of your date of hire without providing evidence of insurability. If you enroll outside this period, you will need to provide proof
of good health. Family members are subject to approval. This plan is portable when you leave
Babson.
 877-777-9072
www.ltcbenefits.com
529 Savings Plan
The 529 Savings Plan, offered through Fidelity Investment Advisors, allows you to make after-tax
contributions to save for college expenses. The contributions are made through direct deposit and
are allowed to grow on a tax-deferred basis. There is no commission fee or monthly maintenance
cost when you join the plan through Babson. Distributions from the plan are tax-exempt provided
they are used for qualified higher education expenses.




Fidelity/800-343-0860, www.advisor.fidelity.com
M-F, 8:00 am-midnight EST
TIAA-CREF/800-842-2776, www.TIAA-CREF.org/Babson
M-F, 8:00 am-6:00 pm EST & Saturday, 9:00 am-6:00 pm EST
Pet Health Insurance
This optional benefit, offered through Blue Cross Blue Shield of MA, helps protect the non-human
members of your family. Petplan Pet Insurance covers dogs and cats, and offers comprehensive
coverage for most illnesses and injuries. You choose the annual deductible level you want and pay
for this insurance at favorable group rates.
Visit hrinfo on the Babson portal for enrollment information.
 www.petplanbenefit.com
 800-809-9200
 Monday - Friday, 8:00 a.m. - 10:30 p.m. (EST)
 Saturday,8:30 am - 8:30 pm
(EST)
 Sunday, 10:00 am - 6:00 pm
(EST)
Perks@Work
Through Perks@Work, Babson offers many different discounts related to sports and recreation,
insurance, entertainment, transportation, flowers, food, personal care and more. For more
information, visit hrinfo from the Babson portal.
WeCare + Eldercare Support
This employee paid program is designed to assist you throughout the complex process of caring and
arranging care of an aging or ailing loved one whether the care is delivered in or out of state. The
service includes a comprehensive in-home needs and safety assessment, a personalized plan of
care, rich resources on care providers, access to geriatric specialists and care coordination.
For more information, visit hrinfo from the Babson portal.
 To enroll call: 855-570-CARE (2273)
 Email wecareplus@longtermsol.com
* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and
state mandates may apply.
Page 24
BENEFIT RESOURCES
FOR INFORMATION ABOUT…
CONTACT...
GO TO…
Concierge Care Center
888-543-8770,
M-F, 8:00 am-6:00 pm EST
www.bcbsma.com
866-695-8622, M-F,
8:00 am-9:00 pm EST
www.healthadvocate.com
Wells Fargo Health Account
Manager: 866-884-7374,
M-F, 8:00 am-7:00 pm EST
www.wellsfargo.com/hsa
Delta Premier: 800-872-0500
DeltaCare: 800-327-6277
M-Th, 8:30 am-8:00 pm EST &
Friday, 8:30 am-4:30 pm EST
www.deltadentalma.com
Vision Care Benefits
Vision Services Plan (VSP)
800-877-7195,
M-F, 8:00 am-10:00 pm EST
www.vsp.com
Flexible Spending Accounts
Crosby Benefits
866-918-9711, ext. 2,
M-Th, 8:00 am-6:00 pm &
Friday, 8:00 am-5:00 pm EST
www.mycrosbybenefits.com
617-630-4300
www.cigna.com
877-208-0098
M-F, 8:00 am-midnight EST
800-842-2776,
M-F, 8:00 am-6:00 pm EST &
Saturday, 9:00 am-6:00 pm EST
advisor.fidelity.com
www.TIAA-CREF.org/Babson
781-239-4128
hrinfo through the
Babson portal
Employee Assistance Program
KGA
800-648-9557,
M-Th, 8:30 am-5:30 pm EST & Friday, 8:30 am-5:00 pm EST,
Hotline 24/7
www.kgreer.com
User Name: Babson
Password: 9557
Secure Travel
Cigna
U.S. & Canada: 888-226-4567
Other Locations, Call Collect: 202331-7635
www.cigna.com
When within U.S., call 877-244-6871;
When outside the U.S., call +1 715346-0859
www.chartisinsurance.com/
_1247_296622.html
Long-Term Care Benefits
CNA Insurance
877-777-9072
www.ltcbenefits.com
Password: babsonolin
529 Savings Plan
Fidelity Advisor 529 Plan
800-522-7297
www.fidelity.com
Medical Benefits
Blue Cross Blue Shield
Health Advocate
Health Savings Account
Wells Fargo Customer Service
Dental Benefits
Delta Dental
Disability Benefits
Life Insurance Benefits
AD&D Insurance Benefits
Cigna
Retirement Benefits
Fidelity
TIAA-CREF
Tuition Benefits
Human Resources
Business Travel Accident Benefit
AIG/Chartis Insurance
Pet Health Insurance
Perks@Work
WeCare+ Eldercare Support
Human Resources
General Benefits Information
800-809-9200
M-F, 8:00 am-10:30 pm (EST)
www.petplanbenefits.com
Saturday,8:30 am –8:30 pm (EST
Sunday,10:00 am-6:pm (EST)
Babson Portal – Click “hrinfo” under Human Resources,
then select Perks@Work under company info
855-570-CARE (2273)
wecareplus@longtermsol.com
781-239-5498
hrinfo through the
Babson portal
Page 25
Special Notices
Notice of HIPAA Special Enrollment Rights
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health
insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or
your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your
dependents' other coverage). However, you must request enrollment within [insert “30 days'' or any longer period that
applies under the plan] after your or your dependents' other coverage ends (or after the employer stops contributing
toward the other coverage).
If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to
enroll yourself and your dependents. However, you must request enrollment within [insert “30 days'' or any longer
period that applies under the plan] after the marriage, birth, adoption, or placement for adoption.
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or
coverage under a state children's health insurance program is in effect, you may be able to enroll yourself and your
dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request
enrollment within 60 days after your or your dependents' coverage ends under Medicaid or a state children's health
insurance program.
If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children's health insurance program with respect to coverage under this plan, you may be able
to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or
your dependents' determination of eligibility for such assistance.
To request special enrollment or obtain more information, contact Human Resources at (781) 239-5498.
Newborns’ and Mothers’ Health Protection Act
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any
hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a
vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit
the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her
newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law,
require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in
excess of 48 hours (or 96 hours).
Women’s Health and Cancer Rights Act
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health
and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:



all stages of reconstruction of the breast on which the mastectomy was performed;
surgery and reconstruction of the other breast to produce a symmetrical appearance;
prostheses; and
treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.
Page 26
Patient Protection Notice
Blue Cross Blue Shield generally requires the designation of a primary care provider. You have the right
to designate any primary care provider who participates in our network and who is available to accept
you or your family members. For information on how to select a primary care provider, and for a list of
the participating primary care providers, contact Human Resources at (781) 239-5498.
For children, you may designate a pediatrician as the primary care provider.
You do not need prior authorization from Blue Cross Blue Shield or from any other person (including a
primary care provider) in order to obtain access to obstetrical or gynecological care from a health care
professional in our network who specializes in obstetrics or gynecology. The health care professional,
however, may be required to comply with certain procedures, including obtaining prior authorization for
certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list
of participating health care professionals who specialize in obstetrics or gynecology, contact Human
Resources at (781) 239-5498.
Page 27
Your Rights Under USERRA
USERRA: The Uniformed Services Employment and Reemployment Rights Act
USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military
service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from
discriminating against past and present members of the uniformed services, and applicants to the uniformed services.
Reemployment Rights
You have the right to be reemployed in your civilian job if you leave that job to perform service in the uniformed service and:
 You ensure that your employer receives advance written or verbal notice of your service;
 You have five years or less of cumulative service in the uniformed services while with that particular employer;
 You return to work or apply for reemployment in a timely manner after conclusion of service; and
You have not been separated from service with a disqualifying discharge or under other than honorable conditions.
If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if you had not been
absent due to military service or, in some cases, a comparable job.
Right to be Free from Discrimination and Retaliation
If you:
 Are a past or present member of the uniformed service
 Have applied for membership in the uniformed service; or
 Are obligated to serve in the uniformed service; then an employer may not deny you:
 Initial employment;
 Reemployment;
 Retention in employment;
 Promotion; or
Any benefit of employment because of this status
In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights, including testifying
or making a statement in connection with a proceeding under USERRA, even if that person has no service connection.
Health Insurance Protection
 If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health
plan coverage for you and your dependents for up to 24 months while in the military.
Even if you don’t elect to continue coverage during your military service, you have the right to be reinstated in your employer’s
health plan when you are reemployed, generally without any waiting periods or exclusions (e.g., pre-existing condition
exclusions) except for service-connected illnesses or injuries.
Enforcement
 The U.S. Department of Labor, Veterans Employment and Training Service (VETS) is authorized to investigate and
resolve complaints of USERRA violations.
 For other assistance in filing a complaint, or for any other information on USERRA, contact VETS at 1-866-4-USA-DOL or
visit its website at http://www.dol.gov/vets. An interactive online USERRA Advisor can be viewed at http://www.dol.gov/elaws/
userra.htm.
 If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referred to the
Department of Justice or the Office of Special Counsel, as applicable, for representation.
You may also bypass the VETS process and bring a civil action against an employer for violations of USERRA.
Page 28
IDAHO – Medicaid and CHIP
MONTANA – Medicaid
Medicaid Website: www.accesstohealthinsurance.idaho.gov
Website: http://medicaidprovider.hhs.mt.gov/clientpages/
clientindex.shtml
Medicaid Phone: 1-800-926-2588
Phone: 1-800-694-3084
CHIP Website: www.medicaid.idaho.gov
CHIP Phone: 1-800-926-2588
INDIANA – Medicaid
Website: http://www.in.gov/fssa
NEBRASKA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-889-9949
Phone: 1-800-383-4278
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/
NEVADA – Medicaid
Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562
KANSAS – Medicaid
Medicaid Phone: 1-800-992-0900
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY – Medicaid
NEW HAMPSHIRE – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 1-800-635-2570
Phone: 603-271-5218
LOUISIANA – Medicaid
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/
index.html
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
Phone: 1-800-977-6740
TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP
NEW YORK – Medicaid
Website: http://www.mass.gov/MassHealth
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-462-1120
Phone: 1-800-541-2831
MINNESOTA – Medicaid
Website: http://www.dhs.state.mn.us/
Click on Health Care, then Medical Assistance
NORTH CAROLINA – Medicaid
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
Phone: 1-800-657-3629
MISSOURI – Medicaid
NORTH DAKOTA – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/
hipp.htm
Website: http://www.nd.gov/dhs/services/medicalserv/
medicaid/
Phone: 573-751-2005
Phone: 1-800-755-2604
Page 29
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a
premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people
who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible
for Medicaid or CHIP, you will not be eligible for these premium assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid
or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for
either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find
out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored
plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your
employer plan, your employer must permit you to enroll in your employer plan if you are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have
questions about enrolling in your employer plan, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling
toll-free 1-866-444-EBSA (3272).
If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums.
The following list of States is current as of July 31, 2013. You should contact your State for further information on eligibility.
ALABAMA – Medicaid
COLORADO – Medicaid
Website: http://www.medicaid.alabama.gov
Medicaid Website: http://www.colorado.gov/
Phone: 1-855-692-5447
Medicaid Phone (In state): 1-800-866-3513
Medicaid Phone (Out of state): 1-800-221-3943
ALASKA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA – CHIP
Website: http://www.azahcccs.gov/applicants
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
Phone (Outside of Maricopa County): 1-877-764-5437
Phone (Maricopa County): 602-417-5437
GEORGIA – Medicaid
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid, then Health Insurance
Premium Payment (HIPP)
Phone: 1-800-869-1150
Page 30
OKLAHOMA – Medicaid and CHIP
UTAH – Medicaid and CHIP
Website: http://health.utah.gov/upp
Website: http://www.insureoklahoma.org
Phone: 1-866-435-7414
Phone: 1-888-365-3742
OREGON – Medicaid and CHIP
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Phone: 1-800-250-8427
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
VIRGINIA – Medicaid and CHIP
Medicaid Website: http://www.dmas.virginia.gov/rcpHIPP.htm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
RHODE ISLAND – Medicaid
WASHINGTON – Medicaid
Website: www.ohhs.ri.gov
Website: http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone: 401-462-5300
SOUTH CAROLINA – Medicaid
Website: http://www.scdhhs.gov
Phone: 1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820, HMS Third Party Liability
Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
WISCONSIN – Medicaid
Website: http://www.badgercareplus.org/pubs/p-10095.htm
Phone: 1-800-362-3002
TEXAS – Medicaid
WYOMING – Medicaid
Website: https://www.gethipptexas.com/
Website: http://health.wyo.gov/healthcarefin/equalitycare
Phone: 1-800-440-0493
Phone: 307-777-7531
To see if any more States have added a premium assistance program since July 31, 2013, or for more information on special
enrollment rights, you can contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 09/30/2013)
Page 31
Babson College
Coverage Period: 01/01/2014 -12/31/2014
Coverage for: Individual and Family | Plan Type: PPO
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.
No.
1 of 9
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan document
for additional information about excluded services.
Yes.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association
You can see the specialist you choose without permission from this plan.
No.
Yes. $5,000 individual contract /
The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for
$10,000 family contract
your share of the cost of covered services. This limit helps you plan for health care expenses.
Premiums, balance-billed charges, and
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
health care this plan doesn’t cover.
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 doctor or hospital may use an out-ofYes. See www.bluecrossma.com/
findadoctor or call 1-800-821-1388 for network 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
a list of preferred providers.
of providers.
Why this Matters:
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.
Answers
$1,500 individual contract / $3,000
family contract. Does not apply to
preventive care, in-network prenatal
care
Questions: Call 1-888-543-8770 or visit us at www.bluecrossma.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.bluecrossma.com/sbcglossary or call 1-888-543-8770 to request a copy.
Do I need a referral to see
a specialist?
Are there services this
plan doesn’t cover?
Does this plan use a
network of providers?
Are there other
deductibles for specific
services?
Is there an out-of-pocket
limit on my expenses?
What is not included in the
out-of-pocket limit?
What is the overall
deductible?
Important Questions
www.bluecrossma.com or by calling 1-888-543-8770.
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
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Blue Care Elect Saver
If you have a test
If you visit a health care
provider’s office or clinic
Common
Medical Event
No charge
No charge
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
No charge
No charge
No charge
No charge /
chiropractor visit
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance /
chiropractor visit
Your cost if you use
In-Network
Out-of-Network
Preventive care/screening/immunization
Other practitioner office visit
Primary care visit to treat an injury or illness
Specialist visit
Services You May Need
Deductible applies first
Deductible applies first
2 of 9
Deductible applies first for out-ofnetwork; limited to age based schedule
and / or frequency
Deductible applies first
Deductible applies first
Deductible applies first
Limitations & Exceptions
•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 (or provider’s charge if it is less than the allowed
amount) for the service. For example, if the plan’s allowed amount for an overnight stay is $1,000 (and it is less than the provider’s charge), 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. (If you are eligible
to elect a Health Reimbursement Account (HRA), Flexible Spending Account (FSA) or you have elected a Health Savings Account (HSA), you may have
access to additional funds to help cover certain out-of-pocket expenses such as copayments, coinsurance, deductibles and costs related to services not
otherwise covered.)
If you need immediate
medical attention
If you have outpatient
surgery
More information about
prescription drug
coverage is available at
www.bluecrossma.com.
If you need drugs to treat
your illness or condition
Common
Medical Event
$150 / visit
No charge
No charge
Emergency room services
Emergency medical transportation
Urgent care
No charge
20% coinsurance
$150 / visit
20% coinsurance
20% coinsurance
Specialty drugs
No charge
No charge
Not covered
Applicable cost share
(generic, preferred,
non-preferred
Facility fee (e.g., ambulatory surgery center)
Physician/surgeon fees
$90 / retail
$45 / retail or $90 /
mail service supply
Non-preferred brand drugs
$50 / retail
$20 / retail
Preferred brand drugs
$10 / retail or $20
($10 for value drugs)
/ mail service supply
Your cost if you use
In-Network
Out-of-Network
$25 / retail or $50
($25 for value drugs)
/ mail service supply
Generic drugs
Services You May Need
3 of 9
Deductible applies first; copayment
waived if admitted or for observation stay
Deductible applies first
Deductible applies first
Deductible applies first
Deductible applies first
Up to 30-day retail (90-day mail service)
supply; deductible applies first; cost
share waived for birth control, smoking
cessation and certain orally administered
anticancer drugs; pre-authorization
required for certain drugs
Up to 30-day retail (90-day mail service)
supply; deductible applies first; cost
share waived for smoking cessation and
certain orally administered anticancer
drugs; pre-authorization required for
certain drugs
Up to 30-day retail (90-day mail
service) supply; deductible applies first;
cost share waived for certain orally
administered anticancer drugs;
pre-authorization required fo
certain drugs
When obtained from a designated
specialty pharmacy; pre-authorization
required for certain drugs
Limitations & Exceptions
If you are pregnant
If you have mental health,
behavioral health, or
substance abuse needs
If you have a hospital stay
Common
Medical Event
No charge
No charge
No charge
No charge
Mental/Behavioral health outpatient services
Mental/Behavioral health inpatient services
Substance use disorder outpatient services
Substance use disorder inpatient services
Delivery and all inpatient services
Prenatal and postnatal care
No charge
Physician/surgeon fee
No charge for
prenatal care;
no charge after
deductible for
postnatal care
No charge
No charge
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
Your cost if you use
In-Network
Out-of-Network
Facility fee (e.g., hospital room)
Services You May Need
Deductible applies first
4 of 9
Deductible applies first for in-network
postnatal care and out-of-network for
prenatal and postnatal care
Deductible applies first
Deductible applies first; pre-authorization
required
Deductible applies first
Deductible applies first; pre-authorization
required
Deductible applies first; pre-authorization
required
Deductible applies first; pre-authorization
required
Limitations & Exceptions
If your child needs dental
or eye care
If you need help
recovering or have other
special health needs
Common
Medical Event
Dental check-up
Not covered
No charge for
members with a
cleft palate / cleft lip
condition
No charge
Eye exam
Glasses
No charge
Hospice service
20% coinsurance
No charge
Skilled nursing care
Durable medical equipment
No charge
No charge
Rehabilitation services
Habilitation services
No charge
Not covered
20% coinsurance
for members with a
cleft palate / cleft lip
condition
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
Your cost if you use
In-Network
Out-of-Network
Home health care
Services You May Need
5 of 9
Limited to members under age 18;
deductible applies first out-of-network
Deductible applies first for out-ofnetwork; limited to one exam every 24
months
——— none ———
Deductible applies first; pre-authorization
required
Deductible applies first; limited to 100
visits per calendar year (other than for
autism, home health care, and speech
therapy)
Deductible applies first; rehabilitation
therapy coverage limits apply; cost share
and coverage limits waived for early
intervention services for eligible children
Deductible applies first; limited to 100
days per calendar year; pre-authorization
required
Deductible applies first; in-network cost
share waived for one breast pump per
birth
Deductible applies first
Limitations & Exceptions
•Dental care (adult)
•Children’s glasses
•Private-duty nursing
•Long-term care
•Infertility treatment
•Non-emergency care when traveling outside the U.S.
•Routine eye care - adult (limited to one exam every
24 months)
•Bariatric surgery
•Chiropractic care
•Hearing aids ($2,000 per ear every 36 months for
members age 21 or younger)
•Weight loss programs (three months in qualified
program(s) per contract per calendar year)
•Routine foot care (only for patients with systemic
circulatory disease)
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.)
•Cosmetic surgery
•Acupuncture
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Excluded Services & Other Covered Services:
6 of 9
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
7 of 9
This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview
only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and
the policy, the terms and conditions of the policy will govern.
Disclaimer:
Language Assistance
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.
Does this Coverage Meet the Minimum Value Standard?
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 Provide Minimum Essential Coverage?
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 the Member Service number listed on your ID card or contact your plan sponsor. Note: A plan sponsor is usually the
member’s employer or organization that provides group health coverage to the member. .
Your Grievance and Appeals Rights:
If you lose coverage under the plan, then, depending upon the 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 your plan sponsor. Note: A plan sponsor is usually the member’s employer or organization that provides
group health coverage to the member. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at
1-866-444-3272 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.
Your Rights to Continue Coverage:
See the next page for important
information about these examples.
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 also will be
different.
This is
not a cost
estimator.
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.
About these Coverage
Examples:
$3,000
$880
$0
$80
$3,960
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
Patient Pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$3,000
$20
$0
$150
$3,170
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Patient Pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
8 of 9
$2,900
$1,300
$700
$300
$100
$100
$5,400
n Amount owed to providers: $5,400
n Plan pays $1,440
n Patient Pays $3,960
Managing type 2 diabetes
(routine maintenance of a well-controlled
condition)
n Amount owed to providers: $7,540
n Plan pays $4,370
n Patient Pays $3,170
(normal delivery)
Having a baby
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.
•Costs don’t include premiums.
•Sample care costs are based on national averages
supplied to 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.
•The patient is enrolled in a family plan.
Questions: Call 1-888-543-8770 or visit us at www.bluecrossma.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.bluecrossma.com/sbcglossary or call 1-888-543-8770 to request a copy.
1130234BS (9/13) 4C JI
9 of 9
pay. Generally, the lower your premium, the
more you’ll pay in out-of-pocket costs, such as
copayments, deductibles, and coinsurance.
You also should 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.
üYes. An important cost is the premium you
Are there other costs I should consider
when comparing plans?
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.
üYes. When you look at the Summary of Benefits
Can I use Coverage Examples to
compare plans?
® Registered Marks of the Blue Cross and Blue Shield Association.© 2013 Blue Cross and Blue Shield of Massachusetts, Inc., and
Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
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.
û No. Coverage Examples are not cost
Does the Coverage Example predict my
future expenses?
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.
û No. Treatments shown are just examples. The
Does the Coverage Example predict my
own care needs?
What does a Coverage Example
show?
What are some of the assumptions
behind the Coverage Examples?
Questions and answers about the Coverage Examples:
MCC Compliance
This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that
went into effect as of January 1, 2014, as part of the Massachusetts Health Care Reform Law.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross
and Blue Shield Association. © 2013 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
129108
55-0647 (7/13) 150M
Coverage Period: 01/01/2014 - 12/31/2014
Coverage for: Individual and Family | Plan Type: HMO
Why this Matters:
See the chart starting on page 2 for your costs for services this plan covers.
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.
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.
Answers
$0
No.
Yes. $1,000 member / $2,000 family
Questions: Call 1-888-543-8770 or visit us at www.bluecrossma.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.bluecrossma.com/sbcglossary or call 1-888-543-8770 to request a copy.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association
1 of 9
Premiums, prescription drugs, balanceWhat is not included in the
billed charges, and health care this plan Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
out-of-pocket limit?
doesn’t cover.
If you use an in-network doctor or other health care provider, this plan will pay some or all of
Yes. See www.bluecrossma.com/
the costs of covered services. Be aware, your in-network doctor or hospital may use an out-ofDoes this plan use a
findadoctor or call 1-800-821-1388 for network provider for some services. Plans use the term in-network, preferred, or participating for
network of providers?
a list of network providers.
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
This plan will pay some or all of the costs to see a specialist for covered services but only if you
Yes.
a specialist?
have the plan’s permission before you see the specialist.
Are there services this
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan document
Yes.
plan doesn’t cover?
for additional information about excluded services.
Important Questions
What is the overall
deductible?
Are there other
deductibles for specific
services?
Is there an out-of-pocket
limit on my expenses?
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.bluecrossma.com or by calling 1-888-543-8770 .
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
HMO Blue New England Value Plus Babson College High Option
If you have a test
If you visit a health care
provider’s office or clinic
Common
Medical Event
$75
No charge
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
No charge
$20 / visit
$20 / visit
$20 / chiropractor visit
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Your cost if you use
In-Network
Out-of-Network
Preventive care/screening/immunization
Primary care visit to treat an injury or illness
Specialist visit
Other practitioner office visit
Services You May Need
2 of 9
——— none ———
Copayment limited to $375 per calendar
year; copayment applies per category of
test / day; pre-authorization required for
certain services
——— none ———
——— none ———
——— none ———
GYN exam limited to one exam per
calendar year
Limitations & Exceptions
•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 (or provider’s charge if it is less than the allowed
amount) for the service. For example, if the plan’s allowed amount for an overnight stay is $1,000 (and it is less than the provider’s charge), 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. (If you are eligible
to elect a Health Reimbursement Account (HRA), Flexible Spending Account (FSA) or you have elected a Health Savings Account (HSA), you may have
access to additional funds to help cover certain out-of-pocket expenses such as copayments, coinsurance, deductibles and costs related to services not
otherwise covered.)
If you need immediate
medical attention
If you have outpatient
surgery
More information about
prescription drug
coverage is available at
www.bluecrossma.com.
If you need drugs to treat
your illness or condition
Common
Medical Event
Specialty drugs
No charge
$150 / visit
No charge
$20 / visit
Physician/surgeon fees
Emergency room services
Emergency medical transportation
Urgent care
$20 / visit
No charge
$150 / visit
Not covered
Not covered
Not covered
Applicable cost share
(generic, preferred,
non-preferred)
$150 / admisison
Not covered
$45 / retail or $90 /
mail service supply
Non-preferred brand drugs
Facility fee (e.g., ambulatory surgery center)
Not covered
Not covered
$25 / retail or $50
($25 for value drugs)
/ mail service supply
$10 / retail or $20
($10 for value drugs)
/ mail service supply
Your cost if you use
In-Network
Out-of-Network
Preferred brand drugs
Generic drugs
Services You May Need
3 of 9
Coapyment waived if admitted or for
observation stay
——— none ———
Out-of-network coverage limited to out of
service area
Pre-authorization required for certain
services
Pre-authorization required for certain
services
Up to 30-day retail (90-day mail service)
supply; cost share waived for birth
control, smoking cessation and certain
orally administered anticancer drugs;
pre-authorization required for certain
drugs
Up to 30-day retail (90-day mail service)
supply; cost share waived for smoking
cessation and certain orally administered
anticancer drugs; pre-authorization
required for certain drugs
Up to 30-day retail (90-day mail service)
supply; cost share waived for certain
orally administered anticancer drugs;
pre-authorization required for certain
drugs
When obtained from a designated
specialty pharmacy; pre-authorization
required for certain drugs
Limitations & Exceptions
If you need help
recovering or have other
special health needs
If you are pregnant
If you have mental health,
behavioral health, or
substance abuse needs
If you have a hospital stay
Common
Medical Event
$250 / admission
Substance use disorder inpatient services
$20 / visit
No charge
Habilitation services
Skilled nursing care
Hospice service
No charge
20% coinsurance
$20 / visit
Rehabilitation services
Durable medical equipment
No charge
$250 / admission
Home health care
Delivery and all inpatient services
No charge
$20 / visit
Substance use disorder outpatient services
Prenatal and postnatal care
$250 / admission
$20 / visit
Mental/Behavioral health outpatient services
Mental/Behavioral health inpatient services
No charge
$250 / admission
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Your cost if you use
In-Network
Out-of-Network
Physician/surgeon fee
Facility fee (e.g., hospital room)
Services You May Need
4 of 9
Pre-authorization required
Limited to 60 visits per calendar year
(other than for autism, home health care,
and speech therapy)
Rehabilitation therapy coverage limits
apply; cost share and coverage limits
waived for early intervention services for
eligible children
Limited to 100 days per calendar year;
pre-authorization required
Cost share waived for one breast pump
per birth
Pre-authorization required for certain
services
——— none ———
——— none ———
Pre-authorization required for certain
services
Pre-authorization required
Pre-authorization required for certain
services
Pre-authorization required
Pre-authorization required
Pre-authorization required
Limitations & Exceptions
If your child needs dental
or eye care
Common
Medical Event
No charge
Not covered
No charge
Eye exam
Glasses
Dental check-up
Not covered
Not covered
Not covered
Your cost if you use
In-Network
Out-of-Network
Services You May Need
5 of 9
Limited to one exam every 24 months
——— none ———
Limited to children under age 12 (every
6 months) and under age 18 with a cleft
palate / cleft lip condition
Limitations & Exceptions
•Long-term care
•Children’s glasses
•Private-duty nursing
•Routine eye care - adult (limited to one exam every
24 months)
•Chiropractic care
•Hearing aids ($2,000 per ear every 36 months for
members age 21 or younger)
•Infertility treatment
•Bariatric surgery
•Weight loss programs (three months in qualified
program(s) per contract per calendar year)
•Routine foot care (only for patients with systemic
circulatory disease)
6 of 9
•Non-emergency care when traveling outside the U.S.
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.)
•Cosmetic surgery
•Dental care (adult)
•Acupuncture
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Excluded Services & Other Covered Services:
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
7 of 9
This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview
only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and
the policy, the terms and conditions of the policy will govern.
Disclaimer:
Language Assistance
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.
Does this Coverage Meet the Minimum Value Standard?
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 Provide Minimum Essential Coverage?
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 the Member Service number listed on your ID card or contact your plan sponsor. Note: A plan sponsor is usually the
member’s employer or organization that provides group health coverage to the member. .
Your Grievance and Appeals Rights:
If you lose coverage under the plan, then, depending upon the 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 your plan sponsor. Note: A plan sponsor is usually the member’s employer or organization that provides
group health coverage to the member. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at
1-866-444-3272 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.
Your Rights to Continue Coverage:
See the next page for important
information about these examples.
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 also will be
different.
This is
not a cost
estimator.
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.
About these
Coverage Examples:
Patient Pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$0
$270
$0
$150
$420
Patient Pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
n Amount owed to providers: $5,400
n Plan pays $5,140
n Patient Pays $260
Managing type 2 diabetes
8 of 9
$0
$180
$0
$80
$260
$2,900
$1,300
$700
$300
$100
$100
$5,400
(routine maintenance of a well-controlled
condition)
n Amount owed to providers: $7,540
n Plan pays $7,120
n Patient Pays $420
(normal delivery)
Having a baby
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.
•Costs don’t include premiums.
•Sample care costs are based on national averages
supplied to 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.
Questions: Call 1-888-543-8770 or visit us at www.bluecrossma.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.bluecrossma.com/sbcglossary or call 1-888-543-8770 to request a copy.
1130232B (9/13) PDF JI
9 of 9
pay. Generally, the lower your premium, the
more you’ll pay in out-of-pocket costs, such as
copayments, deductibles, and coinsurance.
You also should 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.
üYes. An important cost is the premium you
Are there other costs I should consider
when comparing plans?
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.
üYes. When you look at the Summary of Benefits
Can I use Coverage Examples to
compare plans?
® Registered Marks of the Blue Cross and Blue Shield Association.© 2013 Blue Cross and Blue Shield of Massachusetts, Inc., and
Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
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.
û No. Coverage Examples are not cost
Does the Coverage Example predict my
future expenses?
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.
û No. Treatments shown are just examples. The
Does the Coverage Example predict my
own care needs?
What does a Coverage Example
show?
What are some of the assumptions
behind the Coverage Examples?
Questions and answers about the Coverage Examples:
MCC Compliance
This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that
went into effect as of January 1, 2014, as part of the Massachusetts Health Care Reform Law.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross
and Blue Shield Association. © 2013 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
129108
55-0647 (7/13) 150M
Why this Matters:
See the chart starting on page 2 for your costs for services this plan covers.
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.
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.
Answers
$0
No.
Yes. $2,000 member / $4,000 family.
Questions: Call 1-888-543-8770 or visit us at www.bluecrossma.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.bluecrossma.com/sbcglossary or call 1-888-543-8770 to request a copy.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association
1 of 8
Premiums, prescription drugs, balanceWhat is not included in the
billed charges, and health care this plan Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
out-of-pocket limit?
doesn’t cover.
If you use an in-network doctor or other health care provider, this plan will pay some or all of
Yes. See www.bluecrossma.com/
the costs of covered services. Be aware, your in-network doctor or hospital may use an out-ofDoes this plan use a
findadoctor or call 1-800-821-1388 for network provider for some services. Plans use the term in-network, preferred, or participating for
network of providers?
a list of network providers.
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
This plan will pay some or all of the costs to see a specialist for covered services but only if you
Yes.
a specialist?
have the plan’s permission before you see the specialist.
Are there services this
Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document
Yes.
plan doesn’t cover?
for additional information about excluded services.
Important Questions
What is the overall
deductible?
Are there other
deductibles for specific
services?
Is there an out-of-pocket
limit on my expenses?
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.bluecrossma.com or by calling 1-888-543-8770.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2014 - 12/31/2014
Coverage for: Individual and Family | Plan Type: HMO
HMO Blue New England Enhanced Value Babson College Low Option
If you have a test
If you visit a health care
provider’s office or clinic
Common
Medical Event
$75
No charge
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
No charge
$25 / visit
$25 / visit
$25 / chiropractor visit
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Your cost if you use
In-Network
Out-of-Network
Preventive care/screening/immunization
Primary care visit to treat an injury or illness
Specialist visit
Other practitioner office visit
Services You May Need
2 of 8
——— none ———
Copayment limited to $375 per calendar
year; copayment applies per category of
test / day; pre-authorization required for
certain services
——— none ———
——— none ———
——— none ———
GYN exam limited to one exam per
calendar year
Limitations & Exceptions
•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 (or provider’s charge if it is less than the allowed
amount) for the service. For example, if the plan’s allowed amount for an overnight stay is $1,000 (and it is less than the provider’s charge), 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. (If you are eligible
to elect a Health Reimbursement Account (HRA), Flexible Spending Account (FSA) or you have elected a Health Savings Account (HSA), you may have
access to additional funds to help cover certain out-of-pocket expenses such as copayments, coinsurance, deductibles and costs related to services not
otherwise covered.)
If you have a hospital stay
If you need immediate
medical attention
If you have outpatient
surgery
More information about
prescription drug
coverage is available at
www.bluecrossma.com.
If you need drugs to treat
your illness or condition
Common
Medical Event
No charge
$25 / visit
Emergency medical transportation
Urgent care
Physician/surgeon fee
No charge
$500 / admission
$150 / visit
Emergency room services
Facility fee (e.g., hospital room)
No charge
Physician/surgeon fees
Not covered
Not covered
$25 / visit
No charge
$150 / visit
Not covered
Not covered
Not covered
Applicable cost share
(generic, preferred,
non-preferred)
Specialty drugs
$250 / admisison
Not covered
$50 / retail or $100 /
mail service supply
Non-preferred brand drugs
Facility fee (e.g., ambulatory surgery center)
Not covered
Not covered
Preferred brand drugs
$15 / retail or $30
($15 for value drugs)
/ mail service supply
Your cost if you use
In-Network
Out-of-Network
$30 / retail or $60
($30 for value drugs)
/ mail service supply
Generic drugs
Services You May Need
Pre-authorization required
Pre-authorization required
3 of 8
Copayment waived if admitted or for
observation stay
——— none ———
Out-of-network coverage limited to out of
service area
Pre-authorization required
Pre-authorization required for certain
services
Up to 30-day retail (90-day mail service)
supply; cost share waived for birth
control, smoking cessation and certain
orally administered anticancer drugs;
pre-authorization required for
certain drugs
Up to 30-day retail (90-day mail service)
supply; cost share waived for smoking
cessation smoking cessation and certain
orally administered anticancer drugs;
pre-authorization required for
certain drugs
Up to 30-day retail (90-day mail service)
supply; cost share waived for certain
orally administered anticancer drugs;
pre-authorization required for
certain drugs
When obtained from a designated
specialty pharmacy; pre-authorization
required for certain drugs
Limitations & Exceptions
If your child needs dental
or eye care
If you need help
recovering or have other
special health needs
If you are pregnant
If you have mental health,
behavioral health, or
substance abuse needs
Common
Medical Event
$500 / admission
Substance use disorder inpatient services
$25 / visit
No charge
Habilitation services
Skilled nursing care
No charge
No charge
Not covered
No charge
Hospice service
Eye exam
Glasses
Dental check-up
20% coinsurance
$25 / visit
Rehabilitation services
Durable medical equipment
No charge
$500 / admission
Home health care
Delivery and all inpatient services
No charge
$25 / visit
Substance use disorder outpatient services
Prenatal and postnatal care
$500 / admission
$25 / visit
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Your cost if you use
In-Network
Out-of-Network
Mental/Behavioral health inpatient services
Mental/Behavioral health outpatient services
Services You May Need
4 of 8
Limited to one exam every 24 months
——— none ———
Limited to children under age 12 (every
6 months) and under age 18 with a cleft
palate / cleft lip condition
Pre-authorization required
Limited to 60 visits per calendar year
(other than for autism, home health care,
and speech therapy)
Rehabilitation therapy coverage limits
apply; cost share and coverage limits
waived for early intervention services for
eligible children
Limited to 100 days per calendar year;
pre-authorization required
Cost share waived for one breast pump
per birth
Pre-authorization required for certain
services
——— none ———
——— none ———
Pre-authorization required for certain
services
Pre-authorization required.
Pre-authorization required for certain
services
Pre-authorization required
Limitations & Exceptions
•Long-term care
•Children’s glasses
•Private-duty nursing
•Routine eye care - adult (limited to one exam every
24 months)
•Chiropractic care
•Hearing aids ($2,000 per ear every 36 months for
members age 21 or younger)
•Infertility treatment
•Bariatric surgery
•Weight loss programs (three months in qualified
program(s) per contract per calendar year)
•Routine foot care (only for patients with systemic
circulatory disease)
5 of 8
•Non-emergency care when traveling outside the U.S.
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.)
•Cosmetic surgery
•Dental care (adult)
•Acupuncture
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Excluded Services & Other Covered Services:
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
6 of 8
This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview
only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and
the policy, the terms and conditions of the policy will govern.
Disclaimer:
Language Assistance
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.
Does this Coverage Meet the Minimum Value Standard?
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 Provide Minimum Essential Coverage?
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 the Member Service number listed on your ID card or contact your plan sponsor. Note: A plan sponsor is usually the
member’s employer or organization that provides group health coverage to the member. .
Your Grievance and Appeals Rights:
If you lose coverage under the plan, then, depending upon the 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 your plan sponsor. Note: A plan sponsor is usually the member’s employer or organization that provides
group health coverage to the member. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at
1-866-444-3272 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.
Your Rights to Continue Coverage:
See the next page for important
information about these examples.
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 also will be
different.
This is
not a cost
estimator.
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.
About these
Coverage Examples:
$0
$520
$0
$150
$670
7 of 8
$0
$1,990
$0
$80
$2,070
Patient Pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
Patient Pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
n Amount owed to providers: $5,400
n Plan pays $3,330
n Patient Pays $2,070
Managing type 2 diabetes
(routine maintenance of a well-controlled
condition)
n Amount owed to providers: $7,540
n Plan pays $6,870
n Patient Pays $670
(normal delivery)
Having a baby
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.
•Costs don’t include premiums.
•Sample care costs are based on national averages
supplied to 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.
Questions: Call 1-888-543-8770 or visit us at www.bluecrossma.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.bluecrossma.com/sbcglossary or call 1-888-543-8770 to request a copy.
130233BS (9/13) 4C JI
8 of 8
pay. Generally, the lower your premium, the
more you’ll pay in out-of-pocket costs, such as
copayments, deductibles, and coinsurance.
You also should 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.
üYes. An important cost is the premium you
Are there other costs I should consider
when comparing plans?
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.
üYes. When you look at the Summary of Benefits
Can I use Coverage Examples to
compare plans?
® Registered Marks of the Blue Cross and Blue Shield Association.© 2013 Blue Cross and Blue Shield of Massachusetts, Inc., and
Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
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.
û No. Coverage Examples are not cost
Does the Coverage Example predict my
future expenses?
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.
û No. Treatments shown are just examples. The
Does the Coverage Example predict my
own care needs?
What does a Coverage Example
show?
What are some of the assumptions
behind the Coverage Examples?
Questions and answers about the Coverage Examples:
MCC Compliance
This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that
went into effect as of January 1, 2014, as part of the Massachusetts Health Care Reform Law.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross
and Blue Shield Association. © 2013 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
129108
55-0647 (7/13) 150M
This Booklet provided to you by:
Thorbahn is a full service Employee Benefits consulting firm.
We partner with our clients to provide the most cost efficient,
comprehensive employee benefits programs, products, and services.
141 Longwater Drive, Suite 101
Norwell, MA 02061
(617) 847-3900