Important Questions Answers Why this Matters:
This is only a summary.
at www.HealthReformPlanSBC.com or by calling 1-855-586-6960.
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document
Network: Individual $6,300 / Family $12,600.
Out–of–Network: Individual $12,600 / Family
$25,200. Does not apply to in-network
preventive care.
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.
What is the overall
deductible?
No.
You must pay all of the costs for these services up to the specific deductible
amount before this plan begins to pay for these services.
Are there other deductibles
For specific services?
Yes. Network: Individual $6,300 / Family
$12,600; Out–of–Network: Individual
Unlimited / Family Unlimited .
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.
Is there an
out-of-pocket limit
on my expenses?
Premiums, balance-billed charges, penalties
for failure to obtain pre-authorization for
services and health care this plan doesn't
cover.
Even though you pay these expenses, they don't count toward the out-of
pocket limit.
What is not included in
the out-of-pocket limit?
No.
This plan will pay for covered services only up to this limit during each
coverage period, even if your own need is greater. You're responsible for all
expenses above this limit. The chart starting on page 2 describes specific
coverage limits, such as limits on the number of office visits.
Is there an overall
annual limit on what
the plan pays?
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-of-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 of providers.
Does this plan use a
network of providers?
Yes. See www.aetna.com or call
1-855-586-6960 for a list of network
providers.
No.
You can see the specialist you choose without permission from this plan.
Do I need a referral to
see a specialist?
Yes.
Some of the services this plan doesn't cover are listed on page 5. See your
policy or plan document for additional information about excluded services.
Are there services this
plan doesn't cover?
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual + Family | Plan Type: POS
Coverage Period: To Be Determined
Questions: Call 1-855-586-6960 or visit us at www.HealthReformPlanSBC.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.HealthReformPlanSBC.com or call 1-855-586-6960 to request a copy.
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TX Aetna Memorial Hermann Bronze HSA Eligible
:
Limitations & Exceptions
Your Cost If
You Use an
Out–of–Network
Provider
Services You May Need
Your Cost If
You Use a
Network Provider
Common
Medical Event
50% coinsurance0% coinsurance
Primary care visit to treat an injury or
illness
–––––––––––none–––––––––––
50% coinsurance0% coinsuranceSpecialist visit
–––––––––––none–––––––––––
50% coinsurance for
Chiropractic care
0% coinsurance for
Chiropractic (Chiro)
care
Other practitioner office visit
Coverage is limited to 35 visits for Physical
Therapy(PT)/Occupational Therapy
(OT)/Speech Therapy (ST)/Chiro
combined. Benefit limits are shared between
rehab and non-autism hab services.
50% coinsuranceNo charge
Preventive care /screening
/immunization
If you visit a health
care provider's office
or clinic
Age and frequency schedules may apply.
50% coinsurance0% coinsuranceDiagnostic test (x-ray, blood work)
–––––––––––none–––––––––––
50% coinsurance0% coinsuranceImaging (CT/PET scans, MRIs)
If you have a test
Precertification required for out-of-network
care. Benefits will be reduced by 50% up to
$400 per service or supply if precertification
is not obtained.
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
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.)
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the
plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you
haven't met your deductible.
This plan may encourage you to use network providers by charging you lower deductibles, copayments, and coinsurance amounts.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual + Family | Plan Type: POS
Coverage Period: To Be Determined
Questions: Call 1-855-586-6960 or visit us at www.HealthReformPlanSBC.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.HealthReformPlanSBC.com or call 1-855-586-6960 to request a copy.
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TX Aetna Memorial Hermann Bronze HSA Eligible
:
Limitations & Exceptions
Your Cost If
You Use an
Out–of–Network
Provider
Services You May Need
Your Cost If
You Use a
Network Provider
Common
Medical Event
50% coinsurance
(retail)
0% coinsurance (retail
and mail order)
Preferred generic drugs
50% coinsurance
(retail)
0% coinsurance (retail
and mail order)
Preferred brand drugs
50% coinsurance
(retail)
0% coinsurance (retail
and mail order)
Non-preferred generic/brand drugs
Covers up to a 30-day supply (retail
prescription); 31-90 day supply (mail order
prescription). Applicable cost share plus
difference (brand minus generic cost)
applies for brand when generic available.
No charge for preferred generic
FDA-approved women's contraceptives
in-network. Precertification and Step
therapy required.
50% coinsurance for
up to a 90 day supply
0% coinsurance for up
to a 90 day supply
Specialty drugs
If you need drugs to
treat your illness or
condition.
More information
about prescription
drug coverage is
available at
www.aetna.com/phar
macy-insurance/individ
uals-families
–––––––––––none–––––––––––
50% coinsurance0% coinsurance
Facility fee (e.g., ambulatory surgery
center)
–––––––––––none–––––––––––
50% coinsurance0% coinsurancePhysician/surgeon fees
If you have
outpatient surgery
–––––––––––none–––––––––––
0% coinsurance0% coinsuranceEmergency room services
Out-of-network emergency room services
cost share same as in-network. No coverage
for non-emergency care.
0% coinsurance0% coinsuranceEmergency medical transportation
OON cost-share same as network.
50% coinsurance0% coinsuranceUrgent care
If you need
immediate medical
attention
No coverage for non-urgent care.
50% coinsurance0% coinsuranceFacility fee (e.g., hospital room)
Precertification required for out-of-network
care. Benefits will be reduced by 50% up to
$400 per service or supply if precertification
is not obtained.
50% coinsurance0% coinsurancePhysician/surgeon fee
If you have a hospital
stay
–––––––––––none–––––––––––
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: To Be Determined
Questions: Call 1-855-586-6960 or visit us at www.HealthReformPlanSBC.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.HealthReformPlanSBC.com or call 1-855-586-6960 to request a copy.
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TX Aetna Memorial Hermann Bronze HSA Eligible
:
Limitations & Exceptions
Your Cost If
You Use an
Out–of–Network
Provider
Services You May Need
Your Cost If
You Use a
Network Provider
Common
Medical Event
50% coinsurance0% coinsurance
Mental/Behavioral health outpatient
services
–––––––––––none–––––––––––
50% coinsurance0% coinsurance
Mental/Behavioral health inpatient
services
Precertification required for out-of-network
care. Benefits will be reduced by 50% up to
$400 per service or supply if precertification
is not obtained.
50% coinsurance0% coinsurance
Substance use disorder outpatient
services
–––––––––––none–––––––––––
50% coinsurance0% coinsurance
Substance use disorder inpatient
services
If you have mental
health, behavioral
health, or substance
abuse needs
Precertification required for out-of-network
care. Benefits will be reduced by 50% up to
$400 per service or supply if precertification
is not obtained.
50% coinsurance
Prenatal: No charge;
Postnatal: 0%
coinsurance
Prenatal and postnatal care
–––––––––––none–––––––––––
50% coinsurance0% coinsuranceDelivery and all inpatient services
If you are pregnant
Precertification required for out-of-network
care. Benefits will be reduced by 50% up to
$400 per service or supply if precertification
is not obtained.
50% coinsurance0% coinsuranceHome health care
Coverage is limited to 60 visits.
50% coinsurance0% coinsuranceRehabilitation services
Coverage is limited to 35 visits for
PT/OT/ST/Chiro combined. Benefit limits
are shared between rehabilitation and
non-autism habilitation services.
50% coinsurance0% coinsuranceHabilitation services
If you need help
recovering or have
other special health
needs
Coverage is limited to 35 visits for
PT/OT/ST/Chiro combined. Benefit limits
are shared between rehabilitation and
non-autism habilitation services.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: To Be Determined
Questions: Call 1-855-586-6960 or visit us at www.HealthReformPlanSBC.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.HealthReformPlanSBC.com or call 1-855-586-6960 to request a copy.
071000-020020-051521
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TX Aetna Memorial Hermann Bronze HSA Eligible
:
Limitations & Exceptions
Your Cost If
You Use an
Out–of–Network
Provider
Services You May Need
Your Cost If
You Use a
Network Provider
Common
Medical Event
50% coinsurance0% coinsuranceSkilled nursing care
Coverage is limited to 25 days.
Precertification required for out-of-network
care. Benefits will be reduced by 50% up to
$400 per service or supply if precertification
is not obtained.
50% coinsurance0% coinsuranceDurable medical equipment
–––––––––––none–––––––––––
50% coinsurance0% coinsuranceHospice service
Precertification required for out-of-network
care. Benefits will be reduced by 50% up to
$400 per service or supply if precertification
is not obtained.
50% coinsuranceNo chargeEye exam
Coverage is limited to 1 exam per calendar
year.
50% coinsurance0% coinsuranceGlasses
Coverage is limited to 1 set of frames and 1
set of contact lenses or eyeglass lenses per
calendar year.
Not coveredNot coveredDental check-up
If your child needs
dental or eye care
Not covered.
(This isn't a complete list. Check your policy or plan document for other excluded services.)
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover
Acupuncture - except as form of anesthesia.
Bariatric surgery
Cosmetic surgery - except when medically
necessary.
Dental care (Adult & Child) - except accidental
injury.
Infertility treatment - except the diagnosis and
surgical treatment of underlying conditions.
Long-term care
Non-emergency care when traveling outside the
U.S.
Private-duty nursing
Routine foot care
Weight loss programs
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: To Be Determined
Questions: Call 1-855-586-6960 or visit us at www.HealthReformPlanSBC.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.HealthReformPlanSBC.com or call 1-855-586-6960 to request a copy.
071000-020020-051521
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TX Aetna Memorial Hermann Bronze HSA Eligible
:
(This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)
Other Covered Services
Chiropractic care - limited to 35 visits
PT/OT/ST/Chiro combined.
Hearing aids - limited to 1 hearing aid per ear, per
36 months.
Routine eye care (Adult) - limited to 1 exam per
calendar year.
Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep health insurance coverage as long as you pay your premium. There are exceptions,
however, such as if:
You commit fraud
The insurer stops offering services in the State
You move outside the coverage area
For more information on your rights to continue coverage, contact the insurer at 1-855-586-6960. You may also contact your state insurance department at (512)
463-6169, www.tdi.texas.gov.
Your Grievance and Appeals Rights:
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 us by calling the toll free number on your Medical ID Card. You may also contact the Texas
Department of Insurance, (512) 463-6169, www.tdi.texas.gov.
Language Access Services:
Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-586-6960.
Para obtener asistencia en Español, llame al 1-855-586-6960.
1-855-586-6960.
-------------------To see examples of how this plan might cover costs for a sample medical situation, see the next page.-------------------
Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-586-6960.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS
Coverage Period: To Be Determined
Questions: Call 1-855-586-6960 or visit us at www.HealthReformPlanSBC.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.HealthReformPlanSBC.com or call 1-855-586-6960 to request a copy.
071000-020020-051521
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TX Aetna Memorial Hermann Bronze HSA Eligible
:
About these Coverage
Examples:
Amount owed to providers: $7,540
Plan pays: $2,190
Patient pays: $5,350
Sample care costs:
Amount owed to providers: $5,400
Plan pays: $50
Patient pays: $5,350
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$200
$500
$2,100
$2,700
$900
$900
$40
$7,540
Patient pays:
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
$5,200
$0
$0
$5,350
$150
$5,350
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Deductibles
Copays
Coinsurance
Limits or exclusions
$5,270
$0
$0
$80
$700
$300
$1,300
$2,900
$5,400
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.
Education
Laboratory tests
Vaccines, other preventive
$200
$100
$100
Having a baby
(normal delivery)
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
Total
Total
Total
This is not
a cost
estimator.
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.
See the next page for
important information about
these examples.
Coverage Examples Coverage for: Individual + Family | Plan Type: POS
Coverage Period: To Be Determined
Questions: Call 1-855-586-6960 or visit us at www.HealthReformPlanSBC.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.HealthReformPlanSBC.com or call 1-855-586-6960 to request a copy.
071000-020020-051521
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TX Aetna Memorial Hermann Bronze HSA Eligible
:
Questions and answers about the Coverage Examples:
What are some of the assumptions
behind the Coverage Examples?
What does a Coverage
Example show?
Can I use Coverage Examples to
compare plans?
Does the Coverage Example
predict my own care needs?
Are there other costs I should
consider when comparing plans?
Does the Coverage Example
predict my future expenses?
Costs don't include premiums.
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.
The 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.
Treatments shown are just examples.
Coverage Examples are not cost
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.
you pay. Generally, the lower your
premium, the more you'll pay in
out-of-pocket costs, such as copayments,
deductibles, and coinsurance. You should
also 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.
Benefits 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.
When you look at the Summary of
An important cost is the premium
No.
No.
Yes.
Yes.
Sample care costs are based on national
averages supplied by 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.
Coverage Examples Coverage for: Individual + Family | Plan Type: POS
Coverage Period: To Be Determined
Questions: Call 1-855-586-6960 or visit us at www.HealthReformPlanSBC.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.HealthReformPlanSBC.com or call 1-855-586-6960 to request a copy.
071000-020020-051521
8 of 8
TX Aetna Memorial Hermann Bronze HSA Eligible
:
