Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
This is only a summary. For more information about this plan, or to get a copy of the plan documents, contact Direct Health
Insurance Company at 1-800-555-1234 or www.directhealth.com once you have enrolled in health coverage.
Important Questions
What is the overall
deductible?
Answers
$1,000/$2,500 designated
network
$2,500/$7,500 network
Why This Matters:
Generally, you must pay all the costs from doctors, hospitals, labs up to the
deductible amount before this plan begins to pay. If you have other family
members on the policy, they have to meet their own deductible until the family
deductible amount has been met.
$5,000/$15,000 nonnetwork
Are there services
covered before you
meet your
deductible?
Yes
This plan covers some items and services even if you haven’t yet met the
annual deductible amount. But a copayment or coinsurance may apply. See
Common Medical Events chart.
Are there other
deductibles for
specific services?
Yes
Congenital heart disease surgery services; hospital inpatient services; lab, xray and major diagnostic (CT, PET, MRI, MRA, etc.); and outpatient services
have specific and separate deductibles in addition to the annual deductible.
Please check with your health plan for full details.
What is the out-ofpocket limit for this
plan?
$4,000/$10,000
designated network
$6,000/$20,000 network
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.
$15,000/$45,000 nonnetwork
If you have other family members on the policy, they have to meet their own
out-of-pocket limit until the family out-of-pocket limit has been met.
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Important Questions
Answers
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
Why This Matters:
What is not included
in the out-of-pocket
limit?
Premiums, balance-billed
charges, copayments,
coinsurance, deductibles
on certain services and
health care this plan
doesn’t cover, and any
charges from non-network
services.
Even though you pay these expenses, they don’t count toward the out-ofpocket limit.
Does this plan use a
network of providers
or tiers of provider
network?
Yes. This plan uses tiers
of network providers. See
www.directhealth.com or
call 1-800-555-1234 for a
list of participating
providers. Dental and
vision benefits may use
different provider
networks.
If you use “designated network” or “network” provider, this plan covers some
or all of the covered costs. You will pay more if you use a non-network
provider or providers not in the “designated network”. Be aware, your
“designated network” or “network” provider may use a non-network provider
for some services (such as lab work). Check with your provider before you get
services.
Do I need a referral
to see a specialist?
No.
You can see the specialist you choose without getting a referral.
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
All copayment and coinsurance costs shown in this chart are after your overall deductible has been met, if an overall deductible
applies. You should review the Services Your Plan Does NOT Cover for information about what services will not be covered
by this plan.
Common
Medical Event
Services You May Need
Primary care visit to treat
an injury or illness
Specialist visit
If you visit a health
care provider’s
office or clinic
If you have a test
Preventive care/screening/
immunization
Diagnostic test (x-ray,
blood work)
Advanced Imaging
(CT/PET scans, MRIs)
Your Cost If
You Use a
Level 1
Designated
Network
Provider
$25
copay/visit
$50
copay/visit
Your Cost If
You Use a
Level 2
Network
Provider
Your Cost If
You Use a
Level 3
Non-Network
Provider
$45
copay/visit
$65
copay/visit
40%
coinsurance
40%
coinsurance
No charge
40%
coinsurance
$50
copay/test
$100
$50 copay/test
copay/test
40%
coinsurance
40%
coinsurance
No charge
$30 copay/test
Limitations, Exceptions and
Other Important Information
The copayment/coinsurance and
deductible apply for the following
services received in doctor’s
office: lab, x-ray, diagnostic
services, outpatient drugs,
outpatient surgery and outpatient
therapy.
You may have to pay for services
that are not preventive. Ask your
provider if the service is needed
to treat a condition or is a
recommended preventive service.
Then call and check with your
plan what they will pay for.
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Tier 1 drugs (generic and
certain preferred brands)
Tier 2 drugs (generic and
certain preferred brands)
If you need
prescription drugs
to treat your illness
or condition
More information
about prescription
drug coverage
www.directhealth/dr
ug.com.
Your Cost If
You Use a
Level 1
Designated
Network
Provider
$10
copay/drug
$15
copay/drug
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
Your Cost If
You Use a
Level 2
Network
Provider
Your Cost If
You Use a
Level 3
Non-Network
Provider
$20
copay/drug
40%
coinsurance
after $50
copay/drug
$25
copay/drug
40%
coinsurance
after $75
copay/drug
Tier 3 drugs (non-preferred
brands)
$50
copay/drug
$75
copay/drug
40%
coinsurance
after $100
copay/drug
Specialty drugs
20%
coinsurance
40%
coinsurance
Not covered
Limitations, Exceptions and
Other Important Information
Copayment/coinsurance will not
apply to drugs that are considered
preventive services.
Prior authorization is required.
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you have
outpatient surgery
If you need
immediate medical
attention
Services You May Need
Your Cost If
You Use a
Level 1
Designated
Network
Provider
Your Cost If
You Use a
Level 2
Network
Provider
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
Your Cost If
You Use a
Level 3
Non-Network
Provider
Limitations, Exceptions and
Other Important Information
Services provided by a nonnetwork physician in a
“designated network” or
“network” facility will be based
on “designated network” or
“network” benefit levels.
However, you will be
responsible to the non-network
physician for any amount billed
over the eligible amount.
Facility fee (e.g.,
ambulatory surgery center)
20%
coinsurance
30%
coinsurance
40%
coinsurance
Physician/surgeon fees
$50
copay/visit
$65
copay/visit
40%
coinsurance
Emergency room services
$500
copay/visit
40%
coinsurance
40%
coinsurance
If you are admitted to a
“designated network’ or a
“network” hospital directly from
the emergency room you will not
have to pay these amounts. If
you choose to stay in a nonnetwork hospital after the date
we decide a transfer is medically
appropriate, benefits will not
exceed the non-network benefit
level.
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Emergency medical
transportation
Urgent care
If you have a
hospital stay
If you need mental
health, behavioral
health or substance
abuse services
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
Your Cost If
You Use a
Level 1
Designated
Network
Provider
$100 copay/
Your Cost If
You Use a
Level 2
Network
Provider
Your Cost If
You Use a
Level 3
Non-Network
Provider
$250 copay/
$250 copay/
transport
transport
transport
$75
copay/visit
$100
copay/visit
40%
coinsurance
Facility fee (e.g., hospital
room)
$100
deductible;
then 20%
coinsurance
$250
deductible;
then 20%
coinsurance
$1,000
deductible;
then 40%
coinsurance
Physician/surgeon fees
$50
copay/visit
$65
copay/visit
40%
coinsurance
Outpatient services
$35 copay/
visit; 20%
coinsurance/
other
outpatient
services
$50 copay/
visit; 30%
coinsurance/
other
outpatient
services
40%
coinsurance
Limitations, Exceptions and
Other Important Information
Copayment applies to the first 5
days of inpatient care. You
must obtain prior authorization
for services received in a nonnetwork hospital. If you fail to
obtain prior authorization,
benefits will be reduced to 50%
of eligible expenses.
50 visit limit. Prior authorization
required for intensive treatment
programs, electro-convulsive
treatment, psychological testing,
extended visits beyond 50.
Failure to obtain prior
authorization will result in benefits
being reduced to 50% of eligible
charge.
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Inpatient services
Office visits
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
Your Cost If
You Use a
Level 1
Designated
Network
Provider
Your Cost If
You Use a
Level 2
Network
Provider
Your Cost If
You Use a
Level 3
Non-Network
Provider
20%
coinsurance
after you
pay $100
per day
copay
20%
coinsurance
after you
pay $200
per day
copay.
40%
coinsurance
after you
pay $500
per day
copay.
$25
copay/visit
$45
copay/visit
40%
coinsurance
If you are pregnant
Limitations, Exceptions and
Other Important Information
Prior authorization required
unless a non-scheduled
admission. Must notify the plan
as soon as reasonably possible
for non-scheduled admission.
Failure to obtain prior
authorization will result in
benefits being reduced to 50%
of eligible charge.
Copayment does not apply to
first visit with “designated
network” or “network” physician.
No cost-share for preventive
services.
Childbirth/delivery
professional services
$50
copay/visit
$65
copay/visit
40%
coinsurance
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Childbirth/delivery
facility services
Home health care
Your Cost If
You Use a
Level 1
Designated
Network
Provider
$100
deductible;
then 20%
coinsurance
$50
copay/visit
Your Cost If
You Use a
Level 2
Network
Provider
$250
deductible;
then 20%
coinsurance
$65
copay/visit
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
Your Cost If
You Use a
Level 3
Non-Network
Provider
Limitations, Exceptions and
Other Important Information
$1,000
deductible;
then 40%
coinsurance
Copayment applies to the first 5
days of inpatient care. You
must obtain prior authorization
for services received in a nonnetwork hospital. If you fail to
obtain prior authorization,
benefits will be reduced to 50%
of eligible expenses.
40%
coinsurance
Limited to 100 visits per year.
Prior authorization required.
Failure to obtain prior
authorization will result in
benefits being reduced to 50%
of eligible expenses.
If you need help
recovering or have
other special health
needs
Rehabilitation services
$5
copay/visit
$10
copay/visit
$25
copay/visit
• Physical Therapy: 40 visits per
year
• Occupational Therapy: 40 visits
per year
• Speech Therapy: 40 visits per
year
40 visit per year maximum for
pulmonary, cardiac or cognitive
therapy. The 40 per year visit
maximum does not apply to
Autism Spectrum Disorder
treatment.
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Your Cost If
You Use a
Level 1
Designated
Network
Provider
Your Cost If
You Use a
Level 2
Network
Provider
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
Your Cost If
You Use a
Level 3
Non-Network
Provider
Habilitation services
$5
copay/visit
$10
copay/visit
$25
copay/visit
Skilled nursing care
20%
coinsurance
after you
pay $100
per day
copay
20%
coinsurance
after you
pay $200
per day
copay.
40%
coinsurance
after you
pay $500
per day
copay.
Limitations, Exceptions and
Other Important Information
• Physical Therapy: 40 visits per
year
• Occupational Therapy: 40 visits
per year
• Speech Therapy: 40 visits per
year
40 visit per year maximum for
pulmonary, cardiac or cognitive
therapy. The 40 per year visit
maximum does not apply to
Autism Spectrum Disorder
treatment.
Prior authorization is required.
Failure to obtain prior
authorization will result in 50%
reduction in eligible expenses
for non-emergency care.
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Durable medical
equipment
If your child
needs dental or
eye care
Your Cost If
You Use a
Level 1
Designated
Network
Provider
20%
coinsurance
Your Cost If
You Use a
Level 2
Network
Provider
30%
coinsurance
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
Your Cost If
You Use a
Level 3
Non-Network
Provider
Limitations, Exceptions and
Other Important Information
40%
coinsurance
Prior authorization required.
Mobility devices and speech aid
devices and tracheoesophageal voice devices are
limited to one per lifetime. To
receive network benefits, you
must purchase or rent the DME
from the vender we identify or
purchase it directly from the
prescribing “designated
network” or “network” physician.
Hospice services
$20 copay
$30 copay
$50 copay
Prior authorization is required.
Failure to obtain prior
authorization will result in 50%
reduction in eligible expenses.
Eye exam
$25
copay/visit
$35
copay/visit
Not covered
Limit of 1 exam per year. For
dependents up to age 19.
Glasses
$25
copay/visit
$35
copay/visit
Not covered
Limit of 1 pair of eyeglasses per
year. No coverage for contact
lenses.
Dental check-up
$25
copay/visit
$35
copay/visit
Not covered
Limit of 2 visits per year.
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
•
Acupuncture
•
Cosmetic surgery
•
Dental care (adult)
•
Non-emergency care when traveling
outside the U.S.
•
Routine eye care (adult)
•
Routine foot care
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for
these services.)
•
Chiropractic care (30 visits per year)
•
Hearing aids (1 per lifetime)
•
Diabetes
•
Prosthetic and Orthotic Devices
•
Infertility Treatment
•
Obesity Surgery
Additional consumer protections may be available under your plan. For instance, several agencies and organizations are available
to assist if you have a complaint (also called grievance or appeal) against your plan, for a denial of a claim, or if you want to continue
your coverage after coverage would otherwise end. For more information about your rights if a claim is denied, review the
explanation of benefits for that medical claim. Your plan documents also provide complete information to submit a claim appeal or a
grievance for any reason to your plan.
State DOI, 1-800-888-8888 or http://statedoi.state.gov/consumer/complaints for complaints, grievances, appeals and external
reviews.
Healthcare.gov www.HealthCare.gov or call 1-800-318-2596 for more coverage options.
As required by the Affordable Care Act:
Does this plan provide Minimum Essential Coverage?
Yes
If you don’t have Minimum Essential Coverage, you’ll have to pay a penalty unless you get an exemption from the requirement that
you have health coverage.
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
Direct Health Insurance Company: Star PPO Plus
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Does this coverage meet the Minimum Value Standard?
Coverage Period: 01/01/2016 – 12/31/2016
Coverage for: Individual + Family | Plan Type: PPO
Yes
If your coverage doesn’t meet the Minimum Value Standard, you can get exchange coverage and may be eligible for a premium tax
credit to help you buy coverage through the marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-555-1234
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-555-1234.
Chinese (୰ᩥ): ዴᯝ㟂せ୰ᩥⓗᖎຓ㸪庆㕷㓢扨₹⚆䪐1-800-555-1234.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-555-1234.
----------------To see examples of how this plan might cover costs for a sample medical situation, see the next section.-----------------
For definitions of common terms, see the Glossary at www.hhs.cms.gov or call 1-800-555-1234 to request a copy.
How cost
share works
For the examples below, this
cost-sharing information is used:
These three examples show the patient how health insurance covers the costs of medical
care and how deductibles, copayments and coinsurance impact what the patient’s will pay.
Do not use these examples below to estimate what you will pay.
What you pay will be different, depending on the care you need, if you get
in-network care, what your doctor and other providers charge, and other factors.
Annual deductible for in-network services received $1,000
Copayment for doctor visit
$50
In-network doctor visit
(managing diabetes)
Emergency room
in-network visit
$0
Deductible left to meet
$500
Copayment
$50
Copayment
$500
Example allowed amount
$200
(amount on which plan
will base payment)
Coinsurance Not applicable
Example allowed amount
$2,500
(amount on which plan
will base payment)
Calculating example out-of-pocket costs
$500
80%
20%
Having a baby
in-network
Deductible left to meet
Coinsurance Not applicable
Copayment for emergency room visit
Coinsurance
(plan pays)
(patient pays)
Deductible left to meet
$1,000
Copayment Not applicable
Coinsurance (plan pays)
80%
Example allowed amount
$20,000
(amount on which plan
will base payment)
Calculating example out-of-pocket costs
Calculating example out-of-pocket costs
Example allowed amount
$200
Example allowed amount
$2,500
Example allowed amount
$20,000
Deductible left to meet
– $0
Deductible left to meet
– $500
Deductible left to meet
– $1,000
Copayment
– $50
Copayment
– $500
Copayment
– $0
Coinsurance
– $0
Coinsurance
– $0
Coinsurance
– $3,800
In this example, patient pays
$50
In this example, patient pays
$1,000
In this example, patient pays
$4,800
In this example, plan pays
$150
In this example, plan pays
$1,500
In this example, plan pays
$15,200
)RUGH¿QLWLRQVRIFRPPRQWHUPV, see the Glossary at www.[insert].com or Call 1-800-[insert] to request a copy.
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