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Babson College

Benefits Guide

2014 Employee Benefits

TABLE OF CONTENTS

Overview of Benefits 3

Eligibility 4-5

Medical Coverage 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 23-24

Benefit Resources 25

Compliance Notices 26-27

Appendix:

USERRA Notice

CHIP Notice

Summary of Benefits and Coverage

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 de-tails on how the benefit plan operates. See the next page for eligibility guidelines.

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.

ELIGIBILITY

ELIGIBILITY

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

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.

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 Option- HMO 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.

MEDICAL PLAN COMPARISON

* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and state

mandates may apply.

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 hearing-impaired 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).

Additional BCBS Benefits

* The above illustration is intended as a brief overview of benefits only. Benefit maximums, plan provisions and state mandates may apply.

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

loss program each calendar year for any combination of members covered under the plan Low Protein Foods— the $5000 per member per calendar year annual limit is removed; it is now unlimited 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

New BCBS Benefits effective January 1, 2014


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 [email protected], 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 [email protected] Website: www.healthadvocate.com

MEDICAL COVERAGE

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.

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

Health & Wellness

mailto:[email protected]

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

* 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.


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


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

VSP Provider Out of Network

Vision exams $10 copay - one every 12 months Reimbursed up to $50

Lenses every 12 months

Single vision, lined bifocal and lined trifocal lenses

$10 copay combined with exam Reimbursed up to: Single vision: $50 Lined bifocal: $75

Lined trifocal: $100

Frames every 24 months

Frame selections $120 allowance for selection of frames 20% off the amount over allowance

Reimbursed up to $70

Contact Lenses in Lieu of Eyeglasses (every 12 months)

$120 allowance for contacts and the contact lens exam (fitting and evaluation)

If you choose contact lenses you will be eligible for frames 24 months from date

the contact lenses were obtained.

Note: current soft contact lens wearers may qualify for a special program that includes a contact lens exam and initial

supply of lenses.

Reimbursed up to $105

$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.

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.

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


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.

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.

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

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.

FLEXIBLE SPENDING ACCOUNTS (FSA)


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 Expenses must be incurred from January 1 through December 31

Claims Deadline Claims must be submitted by March 31 of the following year

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT

2014 Annual Contribution

Maximum

$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

FLEXIBLE SPENDING ACCOUNT/HEALTH SAVINGS ACCOUNT COMPARISON

Understanding the Differences Between Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs)

Medical FSA HSA

Eligibility To Contribute

All benefits eligible employees may participate, except those on the Blue Care

Elect Saver PPO. (Exception for PPO members enrolled in Medicare).

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).

Annual Contribution Dollar

Limits

The FSA has a maximum election limit.

$2,500.

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 include contributions to your account made

by Babson ($250 for the year for single coverage, $500 for the year for family).

Account Ownership

Your FSA account is set up and owned by Babson. The record keeper for these plans

is Crosby Benefit Systems.

The HSA account is a bank account owned by you, regardless of where you work. Wells

Fargo is the bank for Babson’s Health Savings Accounts.

Access To Your Money

You have access to your entire annual election amount (as long as you continue

participating) any time during the plan year, even if you have not had all of the money

deducted yet from your check. Most employees use the Crosby debit card for

certain payments. Not all providers accept the debit card.

You have access to what has actually been deposited into your HSA to date, like any

other bank account.

If you have an expense without sufficient funds in your HSA to pay for it, you may pay

for the cost out-of-pocket and reimburse yourself later as more funds are deposited, or

you may set up a payment plan with your provider. Most employees use the Wells

Fargo debit card to make payments. Employees may also order checks from

Wells Fargo for a small fee.

Use It or Lose It

Any money you do not spend in your FSA at the end of the year is forfeited. Be aware of the annual deadline to submit requests for reimbursement for prior year expenses –

March 31st of each year.

“Use It or Lose It” does not apply to Health Savings Accounts. Any unused funds in your HSA at the end of the plan year are yours to keep, and stay in your account indefinitely

until you spend it.

Time period for eligible expenses

The FSA is used to set aside pretax funds one “plan year” at a time. Each year, you

choose whether to participate and how much funds to set aside. Any unused funds stay

with your employer.

The HSA can be used for the current year’s medical expenses as well as to build medical savings for future plan years and retirement. If you are no longer employed at Babson and

continue your HSA, you will be charged a 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.

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.

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.

Option to Change Contributions

You can only change your election if you experience certain qualifying events such as marriage, divorce, birth of a child, etc. You

are “locked in” until the next open enrollment.

You can change your election amount anytime, as long as it does not exceed IRS

limits.

Full-time Employee Part-time Employee

Monthly Bi-Weekly Monthly Bi-Weekly

Babson's

Cost

Employee

Cost

Babson's

Cost

Employee's

Cost

Babson's

Cost

Employee

Cost

Babson's

Cost

Employee's

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

Family $1,190.15 $760.37 $549.30 $350.94 $645.31 $1,305.21 $297.83 $602.41

BCBS HMO Blue NE

Enhanced Value - Low Option

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

Family $1,190.15 $653.59 $549.30 $301.66 $645.31 $1,198.43 $297.83 $553.12

BCBS PPO Blue Care Elect

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

Family $1,190.14 $396.72 $549.30 $183.10 $825.16 $761.70 $380.84 $351.55

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

Delta Dental Care

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

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

2014 EMPLOYEE CONTRIBUTIONS

*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.

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

Long Term Disability

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 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.

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.

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

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.

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.

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

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

$58,850 ($1,137) of salary and 3% of

any amount over $58,850.

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

*The amount of $58,850 is based on 2014.

Off-Campus Education Babson may provide up to $5,250 per calendar year of tax-exempt financial support for full-time 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.

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:

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.

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.

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.

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. Part-time employees accrue vacation on a prorated basis based upon your standardhours. 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 oftime. 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.


OTHER VALUABLE BENEFITS

Babson offers several additional programs, discounts and benefits that you may want to take advantage of.

Employer Paid

Employee Assistance Program

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.

Travel Benefits

Secure Travel is a free benefits for full-time employees through Cigna, administrator of our life insurance and disability plans. Se-cure Travel provides emergency medical evacuation assistance and travel services, as well as helpful pre-trip planning assis-tance, 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 custom-er service center can even accept collect calls.

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

Access EAP Services Website: www.kgreer.com User Name: Babson Password: 9557 Phone: 800-648-9557

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.


OTHER VALUABLE BENEFITS

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 dai-ly 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 with-out 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)

Voluntary

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 [email protected]

BENEFIT RESOURCES FOR INFORMATION ABOUT… CONTACT... GO TO…

Medical Benefits Blue Cross Blue Shield

Concierge Care Center 888-543-8770,

M-F, 8:00 am-6:00 pm EST www.bcbsma.com

Health Advocate 866-695-8622, M-F, 8:00 am-9:00 pm EST

www.healthadvocate.com

Health Savings Account Wells Fargo Customer Service

Wells Fargo Health Account Manager: 866-884-7374,

M-F, 8:00 am-7:00 pm EST www.wellsfargo.com/hsa

Dental Benefits Delta Dental

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

Disability Benefits Life Insurance Benefits AD&D Insurance Benefits Cigna

617-630-4300 www.cigna.com

Retirement Benefits Fidelity TIAA-CREF

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

Tuition Benefits Human Resources 781-239-4128

hrinfo through the Babson portal

Employee Assistance Program KGA

800-648-9557, M-Th, 8:30 am-5:30 pm EST & Fri-

day, 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: 202-

331-7635 www.cigna.com

Business Travel Accident Benefit AIG/Chartis Insurance

When within U.S., call 877-244-6871; When outside the U.S., call +1 715-346-0859

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

Pet Health Insurance 800-809-9200 M-F, 8:00 am-10:30 pm (EST)

Saturday,8:30 am –8:30 pm (EST Sunday,10:00 am-6:pm (EST)

www.petplanbenefits.com

Perks@Work Babson Portal – Click “hrinfo” under Human Resources, then select Perks@Work under company info

WeCare+ Eldercare Support 855-570-CARE (2273) [email protected]

Human Resources General Benefits Information 781-239-5498

hrinfo through the Babson portal

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 Medi-caid 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 pro-vided 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 sur-gical benefits provided under this plan.

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.

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.

IDAHO – Medicaid and CHIP MONTANA – Medicaid

Medicaid Website: www.accesstohealthinsurance.idaho.gov

Medicaid Phone: 1-800-926-2588 CHIP Website: www.medicaid.idaho.gov

CHIP Phone: 1-800-926-2588

Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml Phone: 1-800-694-3084

INDIANA – Medicaid NEBRASKA – Medicaid

Website: http://www.in.gov/fssa Phone: 1-800-889-9949

Website: www.ACCESSNebraska.ne.gov

Phone: 1-800-383-4278

IOWA – Medicaid NEVADA – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562

Medicaid Website: http://dwss.nv.gov/

Medicaid Phone: 1-800-992-0900

KANSAS – Medicaid

Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

MAINE – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740 TTY 1-800-977-6741

MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120

Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831

MINNESOTA – Medicaid NORTH CAROLINA – Medicaid Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone: 1-800-657-3629

Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100

MISSOURI – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604

http://www.accesstohealthinsurance.idaho.gov/

http://www.medicaid.idaho.gov/

http://dhhs.ne.gov/medicaid/Pages/med_kidsconx.aspx

http://dwss.nv.gov

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 enroll-ment” 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 Phone: 1-855-692-5447

Medicaid Website: http://www.colorado.gov/ 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 FLORIDA – Medicaid

Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437

Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268

GEORGIA – Medicaid

Website: http://dch.georgia.gov/ Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150

http://www.askebsa.dol.gov

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 U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 OMB Control Number 1210-0137 (expires 09/30/2013)

OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

Website: http://health.utah.gov/upp Phone: 1-866-435-7414

OREGON – Medicaid and CHIP VERMONT– Medicaid

Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP

Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462

Medicaid Website: http://www.dmas.virginia.gov/rcp-HIPP.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 Phone: 401-462-5300

Website: http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm Phone: 1-800-562-3022 ext. 15473

SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid

Website: http://www.scdhhs.gov Phone: 1-888-549-0820

Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability

SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid

Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.badgercareplus.org/pubs/p-10095.htm Phone: 1-800-362-3002

TEXAS – Medicaid WYOMING – Medicaid

Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493

Website: http://health.wyo.gov/healthcarefin/equalitycare Phone: 307-777-7531

http://www.dol.gov/ebsa

http://www.cms.hhs.gov/

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ing a

cove

rage

perio

d (us

ually

one y

ear)

for

your

shar

e of th

e cos

t of c

over

ed se

rvice

s. Th

is lim

it help

s you

plan

for h

ealth

care

expe

nses

.W

hat is

not

inclu

ded

in th

e ou

t-of-p

ocke

t lim

it?Pr

emium

s, ba

lance

-bille

d cha

rges

, and

he

alth c

are t

his pl

an do

esn’t

cove

r.Ev

en th

ough

you p

ay th

ese e

xpen

ses,

they d

on’t c

ount

towar

d the

out

-of-p

ocke

t lim

it.

Does

this

plan

use

a ne

twor

k of p

rovid

ers?

Yes.

See w

ww.b

luec

ross

ma.c

om/

finda

doct

or o

r call

1-80

0-82

1-13

88 fo

r a l

ist of

prefe

rred p

rovid

ers.

If you

use a

n in-

netw

ork d

octor

or ot

her h

ealth

care

pro

vider

, this

plan w

ill pa

y som

e or a

ll of

the co

sts of

cove

red s

ervic

es. B

e awa

re, y

our in

-netw

ork d

octor

or ho

spita

l may

use a

n out-

of-ne

twor

k pro

vider

for s

ome s

ervic

es. P

lans u

se th

e ter

m in-

netw

ork,

pref

erre

d, or

partic

ipatin

g for

pr

ovid

ers i

n the

ir net

work

. See

the c

hart

startin

g on p

age 2

for h

ow th

is pla

n pay

s diffe

rent

kinds

of

prov

ider

s.Do

I nee

d a r

efer

ral to

see

a spe

cialis

t?No

.Yo

u can

see t

he sp

ecial

ist yo

u cho

ose w

ithou

t per

miss

ion fr

om th

is pla

n.

Are t

here

serv

ices t

his

plan

doe

sn’t c

over

?Ye

s.So

me of

the s

ervic

es th

is pla

n doe

sn’t c

over

are l

isted

on pa

ge 6.

See

your

polic

y or p

lan do

cume

nt for

addit

ional

infor

matio

n abo

ut ex

clude

d se

rvice

s.

www.bluecrossma.com

www.bluecrossma.com/sbcglossary

http://www.bluecrossma.com

www.bluecrossma.com/findadoctor


2 of 9

•Co

paym

ents

are fi

xed d

ollar

amou

nts (f

or ex

ample

, $15

) you

pay f

or co

vere

d hea

lth ca

re, u

suall

y whe

n you

rece

ive th

e ser

vice.

•Co

insu

ranc

e is y

our s

hare

of th

e cos

ts of

a cov

ered

servi

ce, c

alcula

ted as

a pe

rcent

of the

allo

wed

amou

nt (o

r pro

vider

’s ch

arge

if it i

s les

s tha

n the

allo

wed

amou

nt) fo

r the

servi

ce. F

or ex

ample

, if th

e plan

’s all

owed

amou

nt fo

r an o

vern

ight s

tay is

$1,00

0 (an

d it is

less

than

the p

rovid

er’s

char

ge),

your

coin

sura

nce

paym

ent o

f 20%

wou

ld be

$200

. This

may

chan

ge if

you h

aven

’t met

your

ded

uctib

le.•

The a

moun

t the p

lan pa

ys fo

r cov

ered

servi

ces i

s bas

ed on

the a

llowe

d am

ount

. If an

out-o

f-netw

ork p

rovid

er ch

arge

s mor

e tha

n the

allo

wed

amou

nt, y

ou

may h

ave t

o pay

the d

iffere

nce.

For e

xamp

le, if

an ou

t-of-n

etwor

k hos

pital

char

ges $

1,500

for a

n ove

rnigh

t stay

and t

he al

lowe

d am

ount

is $1

,000,

you m

ay

have

to pa

y the

$500

diffe

renc

e. (T

his is

calle

d bala

nce b

illing

.)•

This

plan m

ay en

cour

age y

ou to

use i

n-ne

twor

k pro

vider

s by c

harg

ing yo

u low

er d

educ

tibles

, cop

aym

ents

and c

oins

uran

ce a

moun

ts. (

If you

are e

ligibl

e to

elect

a Hea

lth R

eimbu

rseme

nt Ac

coun

t (HR

A), F

lexibl

e Spe

nding

Acc

ount

(FSA

) or y

ou ha

ve el

ected

a He

alth S

aving

s Acc

ount

(HSA

), yo

u may

have

ac

cess

to ad

dition

al fun

ds to

help

cove

r cer

tain o

ut-o

f-poc

ket e

xpen

ses s

uch a

s cop

aym

ents

, coi

nsur

ance

, ded

uctib

les an

d cos

ts re

lated

to se

rvice

s not

other

wise

cove

red.)

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

visit

a he

alth

care

pr

ovid

er’s

offic

e or c

linic

Prim

ary c

are v

isit to

trea

t an i

njury

or ill

ness

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first

Spec

ialist

visit

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first

Othe

r pra

ctitio

ner o

ffice v

isit

No ch

arge

/ ch

iropr

actor

visit

20%

coins

uran

ce /

chiro

prac

tor vi

sitDe

ducti

ble ap

plies

first

Prev

entiv

e car

e/scre

ening

/immu

nizati

onNo

char

ge20

% co

insur

ance

Dedu

ctible

appli

es fir

st for

out-o

f-ne

twor

k; lim

ited t

o age

base

d sch

edule

an

d / or

freq

uenc

y

If you

hav

e a te

st

Diag

nosti

c tes

t (x-r

ay, b

lood w

ork)

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first

Imag

ing (C

T/PE

T sca

ns, M

RIs)

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first

3 of 9

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

nee

d dr

ugs t

o tre

at

your

illne

ss o

r con

ditio

n

More

infor

matio

n abo

ut pr

escr

iptio

n dr

ug

cove

rage

is av

ailab

le at

www.

blue

cros

sma.c

om.

Gene

ric dr

ugs

$10 /

retai

l or $

20

($10

for v

alue d

rugs

) / m

ail se

rvice

supp

ly$2

0 / re

tail

Up to

30-d

ay re

tail (9

0-da

y mail

servi

ce)

supp

ly; de

ducti

ble ap

plies

first;

cost

shar

e waiv

ed fo

r birth

contr

ol, sm

oking

ce

ssati

on an

d cer

tain o

rally

admi

nister

ed

antic

ance

r dru

gs; p

re-a

uthor

izatio

n re

quire

d for

certa

in dr

ugs

Prefe

rred b

rand

drug

s$2

5 / re

tail o

r $50

($

25 fo

r valu

e dru

gs)

/ mail

servi

ce su

pply

$50 /

retai

l

Up to

30-d

ay re

tail (9

0-da

y mail

servi

ce)

supp

ly; de

ducti

ble ap

plies

first;

cost

shar

e waiv

ed fo

r smo

king c

essa

tion a

nd

certa

in or

ally a

dmini

stere

d anti

canc

er

drug

s; pr

e-au

thoriz

ation

requ

ired f

or

certa

in dr

ugs

Non-

prefe

rred b

rand

drug

s$4

5 / re

tail o

r $90

/ ma

il ser

vice s

upply

$90 /

retai

l

Up to

30-d

ay re

tail (9

0-da

y mail

se

rvice

) sup

ply; d

educ

tible

appli

es fir

st;

cost

shar

e waiv

ed fo

r cer

tain o

rally

ad

minis

tered

antic

ance

r dru

gs;

pre-

autho

rizati

on re

quire

d fo

certa

in dr

ugs

Spec

ialty

drug

sAp

plica

ble co

st sh

are

(gen

eric,

prefe

rred,

non-

prefe

rred

Not c

over

edW

hen o

btaine

d fro

m a d

esign

ated

spec

ialty

phar

macy

; pre

-auth

oriza

tion

requ

ired f

or ce

rtain

drug

sIf y

ou h

ave o

utpa

tient

su

rger

yFa

cility

fee (

e.g., a

mbula

tory s

urge

ry ce

nter)

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first

Phys

ician

/surg

eon f

ees

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first

If you

nee

d im

med

iate

med

ical a

ttent

ion

Emer

genc

y roo

m se

rvice

s$1

50 / v

isit

$150

/ visi

tDe

ducti

ble ap

plies

first;

copa

ymen

t wa

ived i

f adm

itted o

r for

obse

rvatio

n stay

Emer

genc

y med

ical tr

ansp

ortat

ionNo

char

geNo

char

geDe

ducti

ble ap

plies

first

Urge

nt ca

reNo

char

ge20

% co

insur

ance

Dedu

ctible

appli

es fir

st

http://www.bluecrossma.com

4 of 9

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

hav

e a h

ospi

tal s

tay

Facil

ity fe

e (e.g

., hos

pital

room

)No

char

ge20

% co

insur

ance

Dedu

ctible

appli

es fir

st; pr

e-au

thoriz

ation

re

quire

d

Phys

ician

/surg

eon f

eeNo

char

ge20

% co

insur

ance

Dedu

ctible

appli

es fir

st; pr

e-au

thoriz

ation

re

quire

d

If you

hav

e men

tal h

ealth

, be

havio

ral h

ealth

, or

subs

tanc

e abu

se n

eeds

Menta

l/Beh

avior

al he

alth o

utpati

ent s

ervic

esNo

char

ge20

% co

insur

ance

Dedu

ctible

appli

es fir

st

Menta

l/Beh

avior

al he

alth i

npati

ent s

ervic

esNo

char

ge20

% co

insur

ance

Dedu

ctible

appli

es fir

st; pr

e-au

thoriz

ation

re

quire

dSu

bstan

ce us

e diso

rder

outpa

tient

servi

ces

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first

Subs

tance

use d

isord

er in

patie

nt se

rvice

sNo

char

ge20

% co

insur

ance

Dedu

ctible

appli

es fir

st; pr

e-au

thoriz

ation

re

quire

d

If you

are p

regn

ant

Pren

atal a

nd po

stnata

l car

e

No ch

arge

for

pren

atal c

are;

no ch

arge

after

de

ducti

ble fo

r po

stnata

l car

e

20%

coins

uran

ceDe

ducti

ble ap

plies

first

for in

-netw

ork

postn

atal c

are a

nd ou

t-of-n

etwor

k for

pr

enata

l and

postn

atal c

are

Deliv

ery a

nd al

l inpa

tient

servi

ces

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first

5 of 9

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

nee

d he

lp

reco

verin

g or

hav

e oth

er

spec

ial h

ealth

nee

ds

Home

healt

h car

eNo

char

ge20

% co

insur

ance

Dedu

ctible

appli

es fir

st; pr

e-au

thoriz

ation

re

quire

d

Reha

bilita

tion s

ervic

esNo

char

ge20

% co

insur

ance

Dedu

ctible

appli

es fir

st; lim

ited t

o 100

vis

its pe

r cale

ndar

year

(othe

r tha

n for

au

tism,

home

healt

h car

e, an

d spe

ech

thera

py)

Habil

itatio

n ser

vices

No ch

arge

20%

coins

uran

ce

Dedu

ctible

appli

es fir

st; re

habil

itatio

n the

rapy

cove

rage

limits

apply

; cos

t sha

re

and c

over

age l

imits

waiv

ed fo

r ear

ly int

erve

ntion

servi

ces f

or el

igible

child

ren

Skille

d nur

sing c

are

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first;

limite

d to 1

00

days

per c

alend

ar ye

ar; p

re-a

uthor

izatio

n re

quire

d

Dura

ble m

edica

l equ

ipmen

t20

% co

insur

ance

20%

coins

uran

ceDe

ducti

ble ap

plies

first;

in-n

etwor

k cos

t sh

are w

aived

for o

ne br

east

pump

per

birth

Hosp

ice se

rvice

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first

If you

r chi

ld n

eeds

den

tal

or ey

e car

e

Eye e

xam

No ch

arge

20%

coins

uran

ceDe

ducti

ble ap

plies

first

for ou

t-of-

netw

ork;

limite

d to o

ne ex

am ev

ery 2

4 mo

nths

Glas

ses

Not c

over

edNo

t cov

ered

——

— no

ne —

——

Denta

l che

ck-u

p

No ch

arge

for

memb

ers w

ith a

cleft p

alate

/ clef

t lip

cond

ition

20%

coins

uran

ce

for m

embe

rs wi

th a

cleft p

alate

/ clef

t lip

cond

ition

Limite

d to m

embe

rs un

der a

ge 18

; de

ducti

ble ap

plies

first

out-o

f-netw

ork

6 of 9

Excl

uded

Ser

vice

s &

Oth

er C

over

ed S

ervi

ces:

•Ac

upun

cture

•Ch

ildre

n’s gl

asse

s

•Co

smeti

c sur

gery

•De

ntal c

are (

adult

)

•Lo

ng-te

rm ca

re

•Pr

ivate-

duty

nursi

ng

Serv

ices Y

our P

lan D

oes N

OT C

over

(Thi

s isn

’t a co

mpl

ete l

ist. C

heck

your

pol

icy o

r plan

doc

umen

t for

oth

er ex

clude

d se

rvice

s.)

•Ba

riatric

surg

ery

•Ch

iropr

actic

care

•He

aring

aids

($2,0

00 pe

r ear

ever

y 36 m

onths

for

memb

ers a

ge 21

or yo

unge

r)

•Inf

ertili

ty tre

atmen

t

•No

n-em

erge

ncy c

are w

hen t

rave

ling o

utside

the U

.S.

•Ro

utine

eye c

are -

adult

(limi

ted to

one e

xam

ever

y 24

mon

ths)

•Ro

utine

foot

care

(only

for p

atien

ts wi

th sy

stemi

c cir

culat

ory d

iseas

e)

•W

eight

loss p

rogr

ams (

three

mon

ths in

quali

fied

prog

ram(

s) pe

r con

tract

per c

alend

ar ye

ar)

Othe

r Cov

ered

Ser

vices

(Thi

s isn

’t a co

mpl

ete l

ist. C

heck

your

pol

icy o

r plan

doc

umen

t for

oth

er co

vere

d se

rvice

s and

your

cost

s for

thes

e ser

vices

.)

7 of 9

Your

Rig

hts

to C

ontin

ue C

over

age:

If you

lose

cove

rage

unde

r the

plan

, then

, dep

endin

g upo

n the

circu

mstan

ces,

Fede

ral a

nd S

tate l

aws m

ay pr

ovide

prote

ction

s tha

t allo

w yo

u to k

eep h

ealth

cove

rage

. Any

su

ch rig

hts m

ay be

limite

d in d

urati

on an

d will

requ

ire yo

u to p

ay a

prem

ium

, whic

h may

be si

gnific

antly

high

er th

an th

e pre

mium

you p

ay w

hile c

over

ed un

der t

he pl

an.

Othe

r limi

tation

s on y

our r

ights

to co

ntinu

e cov

erag

e may

also

apply

. Fo

r mor

e info

rmati

on on

your

rights

to co

ntinu

e cov

erag

e, co

ntact

your

plan

spon

sor. N

ote: A

plan

spon

sor is

usua

lly th

e mem

ber’s

emplo

yer o

r org

aniza

tion t

hat p

rovid

es

grou

p hea

lth co

vera

ge to

the m

embe

r. You

may

also

conta

ct yo

ur st

ate in

sura

nce d

epar

tmen

t, the

U.S

. Dep

artm

ent o

f Lab

or, E

mploy

ee B

enefi

ts Se

curity

Adm

inistr

ation

at

1-86

6-44

4-32

72 or

www

.dol.g

ov/eb

sa, o

r the

U.S

. Dep

artm

ent o

f Hea

lth an

d Hum

an S

ervic

es at

1-87

7-26

7-23

23 x6

1565

or w

ww.cc

iio.cm

s.gov

.

Your

Grie

vanc

e an

d A

ppea

ls R

ight

s:If y

ou ha

ve a

comp

laint

or ar

e diss

atisfi

ed w

ith a

denia

l of c

over

age f

or cl

aims u

nder

your

plan

, you

may

be ab

le to

appe

al or

file a

griev

ance

. For

ques

tions

abou

t you

r rig

hts, th

is no

tice,

or as

sistan

ce, y

ou ca

n con

tact th

e Mem

ber S

ervic

e num

ber li

sted o

n you

r ID

card

or co

ntact

your

plan

spon

sor. N

ote: A

plan

spon

sor is

usua

lly th

e me

mber

’s em

ploye

r or o

rgan

izatio

n tha

t pro

vides

grou

p hea

lth co

vera

ge to

the m

embe

r. .

Doe

s th

is C

over

age

Prov

ide

Min

imum

Ess

entia

l Cov

erag

e?Th

e Affo

rdab

le Ca

re A

ct re

quire

s mos

t peo

ple to

have

healt

h car

e cov

erag

e tha

t qua

lifies

as “m

inimu

m es

senti

al co

vera

ge.”

This

plan

or p

olicy

doe

s pro

vide m

inim

um

esse

ntial

cove

rage

.

Doe

s th

is C

over

age

Mee

t the

Min

imum

Val

ue S

tand

ard?

The A

fford

able

Care

Act

estab

lishe

s a m

inimu

m va

lue st

anda

rd of

bene

fits of

a he

alth p

lan. T

he m

inimu

m va

lue st

anda

rd is

60%

(actu

arial

value

). Th

is he

alth

cove

rage

do

es m

eet t

he m

inim

um va

lue s

tand

ard

for t

he b

enefi

ts it

prov

ides

.

Lang

uage

Ass

ista

nce

D

iscl

aim

er:

This

docu

ment

conta

ins on

ly a p

artia

l des

cripti

on of

the b

enefi

ts, lim

itatio

ns, e

xclus

ions a

nd ot

her p

rovis

ions o

f this

healt

h car

e plan

. It is

not a

polic

y. It i

s a ge

nera

l ove

rview

on

ly. It

does

not p

rovid

e all t

he de

tails

of thi

s cov

erag

e, inc

luding

bene

fits, e

xclus

ions a

nd po

licy l

imita

tions

. In th

e eve

nt the

re ar

e disc

repa

ncies

betw

een t

his do

cume

nt an

d the

polic

y, the

term

s and

cond

itions

of th

e poli

cy w

ill go

vern

.

To se

e exa

mples

of ho

w thi

s plan

migh

t cov

er co

sts fo

r a sa

mple

medic

al sit

uatio

n, se

e the

next

page

.


http://www.cciio.cms.gov

8 of 9

Abo

ut th

ese

Cov

erag

e Ex

ampl

es:

Thes

e exa

mples

show

how

this p

lan m

ight

cove

r med

ical c

are i

n give

n situ

ation

s. Us

e the

se ex

ample

s to s

ee, in

gene

ral, h

ow m

uch

finan

cial p

rotec

tion a

samp

le pa

tient

migh

t ge

t if th

ey ar

e cov

ered

unde

r diffe

rent

plans

.

This

is

not a

cos

t es

timat

or.

Don’t

use t

hese

exam

ples t

o esti

mate

your

actua

l cos

ts un

der t

his pl

an.

The a

ctual

care

you r

eceiv

e will

be

differ

ent fr

om th

ese e

xamp

les, a

nd

the co

st of

that c

are a

lso w

ill be

dif

feren

t.

See t

he ne

xt pa

ge fo

r impo

rtant

infor

matio

n abo

ut the

se ex

ample

s.

Hav

ing

a ba

by(n

orm

al d

eliv

ery)

n A

mou

nt o

wed

to p

rovid

ers:

$7,5

40n

Plan

pay

s $4

,370

n P

atien

t Pay

s $3

,170

Sam

ple c

are c

osts

:Ho

spita

l cha

rges

(moth

er)

$2,70

0Ro

utine

obste

tric ca

re$2

,100

Hosp

ital c

harg

es (b

aby)

$900

Anes

thesia

$900

Labo

rator

y tes

ts$5

00Pr

escri

ption

s$2

00Ra

diolog

y$2

00Va

ccine

s, oth

er pr

even

tive

$40

Tota

l$7

,540

Patie

nt P

ays:

Dedu

ctible

s$3

,000

Copa

ys$2

0Co

insur

ance

$0Lim

its or

exclu

sions

$150

Tota

l$3

,170

Man

agin

g ty

pe 2

dia

bete

s(ro

utin

e m

aint

enan

ce o

f a w

ell-c

ontro

lled

cond

ition

)

n A

mou

nt o

wed

to p

rovid

ers:

$5,4

00n

Plan

pay

s $1

,440

n P

atien

t Pay

s $3

,960

Sam

ple c

are c

osts

:Pr

escri

ption

s$2

,900

Medic

al Eq

uipme

nt an

d Sup

plies

$1,30

0Of

fice V

isits

and P

roce

dure

s$7

00Ed

ucati

on$3

00La

bora

tory t

ests

$100

Vacc

ines,

other

prev

entiv

e$1

00To

tal

$5,40

0

Patie

nt P

ays:

Dedu

ctible

s$3

,000

Copa

ys$8

80Co

insur

ance

$0Lim

its or

exclu

sions

$80

Tota

l$3

,960

9 of 9

Que

stio

ns a

nd a

nsw

ers

abou

t the

Cov

erag

e Ex

ampl

es:

Wha

t are

som

e of t

he as

sum

ptio

ns

behi

nd th

e Cov

erag

e Exa

mpl

es?

•Co

sts do

n’t in

clude

pre

miu

ms.

•Sa

mple

care

costs

are b

ased

on na

tiona

l ave

rage

s su

pplie

d to t

he U

.S. D

epar

tmen

t of H

ealth

and

Huma

n Ser

vices

, and

aren

’t spe

cific t

o a pa

rticula

r ge

ogra

phic

area

or he

alth p

lan.

•Th

e pati

ent’s

cond

ition w

as no

t an e

xclud

ed or

pr

eexis

ting c

ondit

ion.

•Al

l ser

vices

and t

reatm

ents

starte

d and

ende

d in

the sa

me co

vera

ge pe

riod.

•Th

ere a

re no

othe

r med

ical e

xpen

ses f

or an

y me

mber

cove

red u

nder

this

plan.

•Ou

t-of-p

ocke

t exp

ense

s are

base

d only

on tr

eatin

g the

cond

ition i

n the

exam

ple.

•Th

e pati

ent r

eceiv

ed al

l car

e fro

m in-

netw

ork

prov

ider

s. If t

he pa

tient

had r

eceiv

ed ca

re fr

om

out-o

f-netw

ork p

rovid

ers,

costs

wou

ld ha

ve be

en

highe

r.•

The p

atien

t is en

rolle

d in a

fami

ly pla

n.

Wha

t doe

s a C

over

age E

xam

ple

show

?Fo

r eac

h tre

atmen

t situ

ation

, the C

over

age E

xamp

le he

lps yo

u see

how

dedu

ctib

les, c

opay

men

ts, a

nd

coin

sura

nce c

an ad

d up.

It also

helps

you s

ee w

hat

expe

nses

migh

t be l

eft up

to yo

u to p

ay be

caus

e the

servi

ce or

trea

tmen

t isn’t

cove

red o

r pay

ment

is lim

ited.

Does

the C

over

age E

xam

ple p

redi

ct m

y ow

n ca

re n

eeds

?

û N

o. Tr

eatm

ents

show

n are

just

exam

ples.

The

care

you w

ould

rece

ive fo

r this

cond

ition c

ould

be

differ

ent b

ased

on yo

ur do

ctor’s

advic

e, yo

ur ag

e, ho

w se

rious

your

cond

ition i

s, an

d man

y othe

r fac

tors.

Does

the C

over

age E

xam

ple p

redi

ct m

y fu

ture

expe

nses

?

û N

o. Co

vera

ge E

xamp

les ar

e not

cost

estim

ators.

You c

an’t u

se th

e exa

mples

to

estim

ate co

sts fo

r an a

ctual

cond

ition.

They

ar

e for

comp

arati

ve pu

rpos

es on

ly. Yo

ur ow

n co

sts w

ill be

diffe

rent

depe

nding

on th

e car

e you

re

ceive

, the p

rices

your

pro

vider

s cha

rge,

and

the re

imbu

rseme

nt yo

ur he

alth p

lan al

lows.

Can

I use

Cov

erag

e Exa

mpl

es to

co

mpa

re p

lans?

üYe

s. W

hen y

ou lo

ok at

the S

umma

ry of

Bene

fits

and C

over

age f

or ot

her p

lans,

you’l

l find

the

same

Cov

erag

e Exa

mples

. Whe

n you

comp

are

plans

, che

ck th

e “Pa

tient

Pays

” box

in ea

ch

exam

ple. T

he sm

aller

that

numb

er, th

e mor

e co

vera

ge th

e plan

prov

ides .

Are t

here

oth

er co

sts I

shou

ld co

nsid

er

when

com

parin

g pl

ans?

üYe

s. An

impo

rtant

cost

is the

pre

miu

m yo

u pa

y. Ge

nera

lly, th

e low

er yo

ur p

rem

ium

, the

more

you’l

l pay

in ou

t-of-p

ocke

t cos

ts, su

ch as

co

paym

ents

, ded

uctib

les, a

nd co

insu

ranc

e. Yo

u also

shou

ld co

nside

r con

tributi

ons t

o ac

coun

ts su

ch as

healt

h sav

ings a

ccou

nts

(HSA

s), fle

xible

spen

ding a

rrang

emen

ts (F

SAs)

or he

alth r

eimbu

rseme

nt ac

coun

ts (H

RAs)

that

help

you p

ay ou

t-of-p

ocke

t exp

ense

s.

® Re

gister

ed M

arks

of th

e Blue

Cro

ss an

d Blue

Shie

ld As

socia

tion.©

2013

Blue

Cro

ss an

d Blue

Shie

ld of

Mass

achu

setts

, Inc.,

and

Blue

Cro

ss an

d Blue

Shie

ld of

Mass

achu

setts

HMO

Blue

, Inc.

11

3023

4BS

(9/13

) 4C

JI

Ques

tions

: Call

1-88

8-54

3-87

70 or

visit

us at

www

.blu

ecro

ssm

a.com

.If y

ou ar

en’t c

lear a

bout

any o

f the u

nder

lined

term

s use

d in t

his fo

rm, s

ee th

e Glos

sary.

You c

an vi

ew th

e Glos

sary

at w

ww.b

luec

ross

ma.c

om/sb

cglo

ssar

y or c

all 1-

888-

543-

8770

to re

ques

t a co

py.

www.bluecrossma.com


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.

MCC Compliance

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

HMO

Blu

e New

Eng

land

Valu

e Plu

s B

abso

n Co

llege

Hig

h Op

tion

Sum

mar

y of B

enefi

ts an

d Co

vera

ge: W

hat th

is Pl

an C

over

s & W

hat it

Cos

ts

C

over

age P

erio

d: 0

1/01/2

014 -

12/31

/2014

Cove

rage

for:

Indivi

dual

and F

amily

| Plan

Type

: HMO

Ques

tions

: Call

1-88

8-54

3-87

70 or

visit

us at

www

.blu

ecro

ssm

a.com

.If y

ou ar

en’t c

lear a

bout

any o

f the u

nder

lined

term

s use

d in t

his fo

rm, s

ee th

e Glos

sary.

You c

an vi

ew th

e Glos

sary

at ww

w.bl

uecr

ossm

a.com

/sbcg

loss

ary o

r call

1-88

8-54

3-87

70 to

requ

est a

copy

.1 o

f 9Bl

ue C

ross

Blue

Shie

ld of

Mass

achu

setts

is an

Inde

pend

ent L

icens

ee of

the B

lue C

ross

and B

lue S

hield

Asso

ciatio

n

This

is on

ly a s

umm

ary.

If you

wan

t mor

e deta

il abo

ut yo

ur co

vera

ge an

d cos

ts, yo

u can

get th

e com

plete

terms

in th

e poli

cy or

plan

docu

ment

at ww

w.bl

uecr

ossm

a.com

or by

callin

g 1-8

88-5

43-8

770 .

Impo

rtan

t Que

stio

nsA

nsw

ers

Why

this

Mat

ters

:W

hat is

the o

vera

ll de

duct

ible?

$0Se

e the

char

t star

ting o

n pag

e 2 fo

r you

r cos

ts for

servi

ces t

his pl

an co

vers.

Are t

here

oth

er

dedu

ctib

les fo

r spe

cific

serv

ices?

No.

You d

on’t h

ave t

o mee

t ded

uctib

les fo

r spe

cific s

ervic

es, b

ut se

e the

char

t star

ting o

n pag

e 2 fo

r oth

er co

sts fo

r ser

vices

this

plan c

over

s.

Is th

ere a

n ou

t-of-p

ocke

t lim

it on

my e

xpen

ses?

Yes.

$1,00

0 mem

ber /

$2,00

0 fam

ilyTh

e out

-of-p

ocke

t lim

it is t

he m

ost y

ou co

uld pa

y dur

ing a

cove

rage

perio

d (us

ually

one y

ear)

for

your

shar

e of th

e cos

t of c

over

ed se

rvice

s. Th

is lim

it help

s you

plan

for h

ealth

care

expe

nses

.

Wha

t is n

ot in

clude

d in

the

out-o

f-poc

ket li

mit?

Prem

iums,

pres

cripti

on dr

ugs,

balan

ce-

billed

char

ges,

and h

ealth

care

this

plan

does

n’t co

ver.

Even

thou

gh yo

u pay

thes

e exp

ense

s, the

y don

’t cou

nt tow

ard t

he o

ut-o

f-poc

ket li

mit.

Does

this

plan

use

a ne

twor

k of p

rovid

ers?

Yes.

See w

ww.b

luec

ross

ma.c

om/

finda

doct

or o

r call

1-80

0-82

1-13

88 fo

r a l

ist of

netw

ork p

rovid

ers.

If you

use a

n in-

netw

ork d

octor

or ot

her h

ealth

care

pro

vider

, this

plan w

ill pa

y som

e or a

ll of

the co

sts of

cove

red s

ervic

es. B

e awa

re, y

our in

-netw

ork d

octor

or ho

spita

l may

use a

n out-

of-ne

twor

k pro

vider

for s

ome s

ervic

es. P

lans u

se th

e ter

m in-

netw

ork,

pref

erre

d, or

partic

ipatin

g for

pr

ovid

ers i

n the

ir net

work

. See

the c

hart

startin

g on p

age 2

for h

ow th

is pla

n pay

s diffe

rent

kinds

of

prov

ider

s.Do

I nee

d a r

efer

ral to

see

a spe

cialis

t?Ye

s.Th

is pla

n will

pay s

ome o

r all o

f the c

osts

to se

e a sp

ecial

ist fo

r cov

ered

servi

ces b

ut on

ly if y

ou

have

the p

lan’s

perm

ission

befor

e you

see t

he sp

ecial

ist.

Are t

here

serv

ices t

his

plan

doe

sn’t c

over

?Ye

s.So

me of

the s

ervic

es th

is pla

n doe

sn’t c

over

are l

isted

on pa

ge 6.

See

your

polic

y or p

lan do

cume

nt for

addit

ional

infor

matio

n abo

ut ex

clude

d se

rvice

s.

www.bluecrossma.com

http://www.bluecrossma.com/sbcglossary

www.bluecrossma.com



2 of 9

•Co

paym

ents

are fi

xed d

ollar

amou

nts (f

or ex

ample

, $15

) you

pay f

or co

vere

d hea

lth ca

re, u

suall

y whe

n you

rece

ive th

e ser

vice.

•Co

insu

ranc

e is y

our s

hare

of th

e cos

ts of

a cov

ered

servi

ce, c

alcula

ted as

a pe

rcent

of the

allo

wed

amou

nt (o

r pro

vider

’s ch

arge

if it i

s les

s tha

n the

allo

wed

amou

nt) fo

r the

servi

ce. F

or ex

ample

, if th

e plan

’s all

owed

amou

nt fo

r an o

vern

ight s

tay is

$1,00

0 (an

d it is

less

than

the p

rovid

er’s

char

ge),

your

coin

sura

nce

paym

ent o

f 20%

wou

ld be

$200

. This

may

chan

ge if

you h

aven

’t met

your

ded

uctib

le.•

The a

moun

t the p

lan pa

ys fo

r cov

ered

servi

ces i

s bas

ed on

the a

llowe

d am

ount

. If an

out-o

f-netw

ork p

rovid

er ch

arge

s mor

e tha

n the

allo

wed

amou

nt, y

ou

may h

ave t

o pay

the d

iffere

nce.

For e

xamp

le, if

an ou

t-of-n

etwor

k hos

pital

char

ges $

1,500

for a

n ove

rnigh

t stay

and t

he al

lowe

d am

ount

is $1

,000,

you m

ay

have

to pa

y the

$500

diffe

renc

e. (T

his is

calle

d bala

nce b

illing

.)•

This

plan m

ay en

cour

age y

ou to

use i

n-ne

twor

k pro

vider

s by c

harg

ing yo

u low

er d

educ

tibles

, cop

aym

ents

and c

oins

uran

ce a

moun

ts. (

If you

are e

ligibl

e to

elect

a Hea

lth R

eimbu

rseme

nt Ac

coun

t (HR

A), F

lexibl

e Spe

nding

Acc

ount

(FSA

) or y

ou ha

ve el

ected

a He

alth S

aving

s Acc

ount

(HSA

), yo

u may

have

ac

cess

to ad

dition

al fun

ds to

help

cove

r cer

tain o

ut-o

f-poc

ket e

xpen

ses s

uch a

s cop

aym

ents

, coi

nsur

ance

, ded

uctib

les an

d cos

ts re

lated

to se

rvice

s not

other

wise

cove

red.)

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

visit

a he

alth

care

pr

ovid

er’s

offic

e or c

linic

Prim

ary c

are v

isit to

trea

t an i

njury

or ill

ness

$20 /

visit

Not c

over

ed—

——

none

——

—Sp

ecial

ist vi

sit$2

0 / vi

sitNo

t cov

ered

——

— no

ne —

——

Othe

r pra

ctitio

ner o

ffice v

isit

$20 /

chiro

prac

tor vi

sitNo

t cov

ered

——

— no

ne —

——

Prev

entiv

e car

e/scre

ening

/immu

nizati

onNo

char

geNo

t cov

ered

GYN

exam

limite

d to o

ne ex

am pe

r ca

lenda

r yea

r

If you

hav

e a te

st

Diag

nosti

c tes

t (x-r

ay, b

lood w

ork)

No ch

arge

Not c

over

ed—

——

none

——

—

Imag

ing (C

T/PE

T sca

ns, M

RIs)

$75

Not c

over

ed

Copa

ymen

t limi

ted to

$375

per c

alend

ar

year

; cop

ayme

nt ap

plies

per c

atego

ry of

tes

t / da

y; pr

e-au

thoriz

ation

requ

ired f

or

certa

in se

rvice

s

3 of 9

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

nee

d dr

ugs t

o tre

at

your

illne

ss o

r con

ditio

n

More

info

rmat

ion

abou

t pr

escr

iptio

n dr

ug

cove

rage

is av

ailab

le at

ww

w.bl

uecr

ossm

a.com

.

Gene

ric dr

ugs

$10 /

retai

l or $

20

($10

for v

alue d

rugs

) / m

ail se

rvice

supp

lyNo

t cov

ered

Up to

30-d

ay re

tail (9

0-da

y mail

servi

ce)

supp

ly; co

st sh

are w

aived

for b

irth

contr

ol, sm

oking

cess

ation

and c

ertai

n or

ally a

dmini

stere

d anti

canc

er dr

ugs;

pre-

autho

rizati

on re

quire

d for

certa

in dr

ugs

Prefe

rred b

rand

drug

s$2

5 / re

tail o

r $50

($

25 fo

r valu

e dru

gs)

/ mail

servi

ce su

pply

Not c

over

ed

Up to

30-d

ay re

tail (9

0-da

y mail

servi

ce)

supp

ly; co

st sh

are w

aived

for s

mokin

g ce

ssati

on an

d cer

tain o

rally

admi

nister

ed

antic

ance

r dru

gs; p

re-a

uthor

izatio

n re

quire

d for

certa

in dr

ugs

Non-

prefe

rred b

rand

drug

s$4

5 / re

tail o

r $90

/ ma

il ser

vice s

upply

Not c

over

ed

Up to

30-d

ay re

tail (9

0-da

y mail

servi

ce)

supp

ly; co

st sh

are w

aived

for c

ertai

n or

ally a

dmini

stere

d anti

canc

er dr

ugs;

pre-

autho

rizati

on re

quire

d for

certa

in dr

ugs

Spec

ialty

drug

sAp

plica

ble co

st sh

are

(gen

eric,

prefe

rred,

non-

prefe

rred)

Not c

over

edW

hen o

btaine

d fro

m a d

esign

ated

spec

ialty

phar

macy

; pre

-auth

oriza

tion

requ

ired f

or ce

rtain

drug

s

If you

hav

e out

patie

nt

surg

ery

Facil

ity fe

e (e.g

., amb

ulator

y sur

gery

cente

r)$1

50 / a

dmisi

son

Not c

over

edPr

e-au

thoriz

ation

requ

ired f

or ce

rtain

servi

ces

Phys

ician

/surg

eon f

ees

No ch

arge

Not c

over

edPr

e-au

thoriz

ation

requ

ired f

or ce

rtain

servi

ces

If you

nee

d im

med

iate

med

ical a

ttent

ion

Emer

genc

y roo

m se

rvice

s$1

50 / v

isit

$150

/ visi

tCo

apym

ent w

aived

if ad

mitte

d or f

or

obse

rvatio

n stay

Emer

genc

y med

ical tr

ansp

ortat

ionNo

char

geNo

char

ge—

——

none

——

—

Urge

nt ca

re$2

0 / vi

sit$2

0 / vi

sitOu

t-of-n

etwor

k cov

erag

e lim

ited t

o out

of se

rvice

area

www.bluecrossma.com

4 of 9

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

hav

e a h

ospi

tal s

tay

Facil

ity fe

e (e.g

., hos

pital

room

)$2

50 / a

dmiss

ionNo

t cov

ered

Pre-

autho

rizati

on re

quire

d

Phys

ician

/surg

eon f

eeNo

char

geNo

t cov

ered

Pre-

autho

rizati

on re

quire

d

If you

hav

e men

tal h

ealth

, be

havio

ral h

ealth

, or

subs

tanc

e abu

se n

eeds

Menta

l/Beh

avior

al he

alth o

utpati

ent s

ervic

es$2

0 / vi

sitNo

t cov

ered

Pre-

autho

rizati

on re

quire

d for

certa

in se

rvice

sMe

ntal/B

ehav

ioral

healt

h inp

atien

t ser

vices

$250

/ adm

ission

Not c

over

edPr

e-au

thoriz

ation

requ

ired

Subs

tance

use d

isord

er ou

tpatie

nt se

rvice

s$2

0 / vi

sitNo

t cov

ered

Pre-

autho

rizati

on re

quire

d for

certa

in se

rvice

sSu

bstan

ce us

e diso

rder

inpa

tient

servi

ces

$250

/ adm

ission

Not c

over

edPr

e-au

thoriz

ation

requ

ired

If you

are p

regn

ant

Pren

atal a

nd po

stnata

l car

eNo

char

geNo

t cov

ered

——

— no

ne —

——

Deliv

ery a

nd al

l inpa

tient

servi

ces

$250

/ adm

ission

Not c

over

ed—

——

none

——

—

If you

nee

d he

lp

reco

verin

g or

hav

e oth

er

spec

ial h

ealth

nee

ds

Home

healt

h car

eNo

char

geNo

t cov

ered

Pre-

autho

rizati

on re

quire

d

Reha

bilita

tion s

ervic

es$2

0 / vi

sitNo

t cov

ered

Limite

d to 6

0 visi

ts pe

r cale

ndar

year

(o

ther t

han f

or au

tism,

home

healt

h car

e, an

d spe

ech t

hera

py)

Habil

itatio

n ser

vices

$20 /

visit

Not c

over

ed

Reha

bilita

tion t

hera

py co

vera

ge lim

its

apply

; cos

t sha

re an

d cov

erag

e lim

its

waive

d for

early

inter

venti

on se

rvice

s for

eli

gible

child

ren

Skille

d nur

sing c

are

No ch

arge

Not c

over

edLim

ited t

o 100

days

per c

alend

ar ye

ar;

pre-

autho

rizati

on re

quire

d

Dura

ble m

edica

l equ

ipmen

t20

% co

insur

ance

Not c

over

edCo

st sh

are w

aived

for o

ne br

east

pump

pe

r birth

Hosp

ice se

rvice

No ch

arge

Not c

over

edPr

e-au

thoriz

ation

requ

ired f

or ce

rtain

servi

ces

5 of 9

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

r chi

ld n

eeds

den

tal

or ey

e car

e

Eye e

xam

No ch

arge

Not c

over

edLim

ited t

o one

exam

ever

y 24 m

onths

Glas

ses

Not c

over

edNo

t cov

ered

——

— no

ne —

——

Denta

l che

ck-u

pNo

char

geNo

t cov

ered

Limite

d to c

hildr

en un

der a

ge 12

(eve

ry 6 m

onths

) and

unde

r age

18 w

ith a

cleft

palat

e / cl

eft lip

cond

ition

6 of 9

Excl

uded

Ser

vice

s &

Oth

er C

over

ed S

ervi

ces:

•Ac

upun

cture

•Ch

ildre

n’s gl

asse

s

•Co

smeti

c sur

gery

•De

ntal c

are (

adult

)

•Lo

ng-te

rm ca

re

•No

n-em

erge

ncy c

are w

hen t

rave

ling o

utside

the U

.S.

•Pr

ivate-

duty

nursi

ng

Serv

ices Y

our P

lan D

oes N

OT C

over

(Thi

s isn

’t a co

mpl

ete l

ist. C

heck

your

pol

icy o

r plan

doc

umen

t for

oth

er ex

clude

d se

rvice

s.)

•Ba

riatric

surg

ery

•Ch

iropr

actic

care

•He

aring

aids

($2,0

00 pe

r ear

ever

y 36 m

onths

for

memb

ers a

ge 21

or yo

unge

r)

•Inf

ertili

ty tre

atmen

t

•Ro

utine

eye c

are -

adult

(limi

ted to

one e

xam

ever

y 24

mon

ths)

•Ro

utine

foot

care

(only

for p

atien

ts wi

th sy

stemi

c cir

culat

ory d

iseas

e)

•W

eight

loss p

rogr

ams (

three

mon

ths in

quali

fied

prog

ram(

s) pe

r con

tract

per c

alend

ar ye

ar)

Othe

r Cov

ered

Ser

vices

(Thi

s isn

’t a co

mpl

ete l

ist. C

heck

your

pol

icy o

r plan

doc

umen

t for

oth

er co

vere

d se

rvice

s and

your

cost

s for

thes

e ser

vices

.)

7 of 9

Your

Rig

hts

to C

ontin

ue C

over

age:

If you

lose

cove

rage

unde

r the

plan

, then

, dep

endin

g upo

n the

circu

mstan

ces,

Fede

ral a

nd S

tate l

aws m

ay pr

ovide

prote

ction

s tha

t allo

w yo

u to k

eep h

ealth

cove

rage

. Any

su

ch rig

hts m

ay be

limite

d in d

urati

on an

d will

requ

ire yo

u to p

ay a

prem

ium

, whic

h may

be si

gnific

antly

high

er th

an th

e pre

mium

you p

ay w

hile c

over

ed un

der t

he pl

an.

Othe

r limi

tation

s on y

our r

ights

to co

ntinu

e cov

erag

e may

also

apply

. Fo

r mor

e info

rmati

on on

your

rights

to co

ntinu

e cov

erag

e, co

ntact

your

plan

spon

sor. N

ote: A

plan

spon

sor is

usua

lly th

e mem

ber’s

emplo

yer o

r org

aniza

tion t

hat p

rovid

es

grou

p hea

lth co

vera

ge to

the m

embe

r. You

may

also

conta

ct yo

ur st

ate in

sura

nce d

epar

tmen

t, the

U.S

. Dep

artm

ent o

f Lab

or, E

mploy

ee B

enefi

ts Se

curity

Adm

inistr

ation

at

1-86

6-44

4-32

72 or

www

.dol.g

ov/eb

sa, o

r the

U.S

. Dep

artm

ent o

f Hea

lth an

d Hum

an S

ervic

es at

1-87

7-26

7-23

23 x6

1565

or w

ww.cc

iio.cm

s.gov

.Yo

ur G

rieva

nce

and

App

eals

Rig

hts:

If you

have

a co

mplai

nt or

are d

issati

sfied

with

a de

nial o

f cov

erag

e for

claim

s und

er yo

ur pl

an, y

ou m

ay be

able

to ap

peal

or fil

e a gr

ievan

ce. F

or qu

estio

ns ab

out y

our

rights

, this

notic

e, or

assis

tance

, you

can c

ontac

t the M

embe

r Ser

vice n

umbe

r liste

d on y

our I

D ca

rd or

conta

ct yo

ur pl

an sp

onso

r. Note

: A pl

an sp

onso

r is us

ually

the

memb

er’s

emplo

yer o

r org

aniza

tion t

hat p

rovid

es gr

oup h

ealth

cove

rage

to th

e mem

ber. .

Doe

s th

is C

over

age

Prov

ide

Min

imum

Ess

entia

l Cov

erag

e?Th

e Affo

rdab

le Ca

re A

ct re

quire

s mos

t peo

ple to

have

healt

h car

e cov

erag

e tha

t qua

lifies

as “m

inimu

m es

senti

al co

vera

ge.”

This

plan

or p

olicy

doe

s pro

vide m

inim

um

esse

ntial

cove

rage

.

Doe

s th

is C

over

age

Mee

t the

Min

imum

Val

ue S

tand

ard?

The A

fford

able

Care

Act

estab

lishe

s a m

inimu

m va

lue st

anda

rd of

bene

fits of

a he

alth p

lan. T

he m

inimu

m va

lue st

anda

rd is

60%

(actu

arial

value

). Th

is he

alth

cove

rage

do

es m

eet t

he m

inim

um va

lue s

tand

ard

for t

he b

enefi

ts it

prov

ides

.

Lang

uage

Ass

ista

nce

D

iscl

aim

er:

This

docu

ment

conta

ins on

ly a p

artia

l des

cripti

on of

the b

enefi

ts, lim

itatio

ns, e

xclus

ions a

nd ot

her p

rovis

ions o

f this

healt

h car

e plan

. It is

not a

polic

y. It i

s a ge

nera

l ove

rview

on

ly. It

does

not p

rovid

e all t

he de

tails

of thi

s cov

erag

e, inc

luding

bene

fits, e

xclus

ions a

nd po

licy l

imita

tions

. In th

e eve

nt the

re ar

e disc

repa

ncies

betw

een t

his do

cume

nt an

d the

polic

y, the

term

s and

cond

itions

of th

e poli

cy w

ill go

vern

.

To se

e exa

mples

of ho

w thi

s plan

migh

t cov

er co

sts fo

r a sa

mple

medic

al sit

uatio

n, se

e the

next

page

.

8 of 9

Abo

ut th

ese

C

over

age

Exam

ples

:

Thes

e exa

mples

show

how

this p

lan m

ight

cove

r med

ical c

are i

n give

n situ

ation

s. Us

e the

se ex

ample

s to s

ee, in

gene

ral, h

ow m

uch

finan

cial p

rotec

tion a

samp

le pa

tient

migh

t ge

t if th

ey ar

e cov

ered

unde

r diffe

rent

plans

.

This

is

not a

cos

t es

timat

or.

Don’t

use t

hese

exam

ples t

o esti

mate

your

actua

l cos

ts un

der t

his pl

an.

The a

ctual

care

you r

eceiv

e will

be

differ

ent fr

om th

ese e

xamp

les, a

nd

the co

st of

that c

are a

lso w

ill be

dif

feren

t.

See t

he ne

xt pa

ge fo

r impo

rtant

infor

matio

n abo

ut the

se ex

ample

s.

Hav

ing

a ba

by(n

orm

al d

eliv

ery)

n A

mou

nt o

wed

to p

rovid

ers:

$7,5

40n

Plan

pay

s $7

,120

n P

atien

t Pay

s $4

20

Sam

ple c

are c

osts

:Ho

spita

l cha

rges

(moth

er)

$2,70

0Ro

utine

obste

tric ca

re$2

,100

Hosp

ital c

harg

es (b

aby)

$900

Anes

thesia

$900

Labo

rator

y tes

ts$5

00Pr

escri

ption

s$2

00Ra

diolog

y$2

00Va

ccine

s, oth

er pr

even

tive

$40

Tota

l$7

,540

Patie

nt P

ays:

Dedu

ctible

s$0

Copa

ys$2

70Co

insur

ance

$0Lim

its or

exclu

sions

$150

Tota

l$4

20

Man

agin

g ty

pe 2

dia

bete

s(ro

utin

e m

aint

enan

ce o

f a w

ell-c

ontro

lled

cond

ition

)

n A

mou

nt o

wed

to p

rovid

ers:

$5,4

00n

Plan

pay

s $5

,140

n P

atien

t Pay

s $2

60

Sam

ple c

are c

osts

:Pr

escri

ption

s$2

,900

Medic

al Eq

uipme

nt an

d Sup

plies

$1,30

0Of

fice V

isits

and P

roce

dure

s$7

00Ed

ucati

on$3

00La

bora

tory t

ests

$100

Vacc

ines,

other

prev

entiv

e$1

00To

tal

$5,40

0

Patie

nt P

ays:

Dedu

ctible

s$0

Copa

ys$1

80Co

insur

ance

$0Lim

its or

exclu

sions

$80

Tota

l$2

60

9 of 9

Que

stio

ns a

nd a

nsw

ers

abou

t the

Cov

erag

e Ex

ampl

es:

Wha

t are

som

e of t

he as

sum

ptio

ns

behi

nd th

e Cov

erag

e Exa

mpl

es?

•Co

sts do

n’t in

clude

pre

miu

ms.

•Sa

mple

care

costs

are b

ased

on na

tiona

l ave

rage

s su

pplie

d to t

he U

.S. D

epar

tmen

t of H

ealth

and

Huma

n Ser

vices

, and

aren

’t spe

cific t

o a pa

rticula

r ge

ogra

phic

area

or he

alth p

lan.

•Th

e pati

ent’s

cond

ition w

as no

t an e

xclud

ed or

pr

eexis

ting c

ondit

ion.

•Al

l ser

vices

and t

reatm

ents

starte

d and

ende

d in

the sa

me co

vera

ge pe

riod.

•Th

ere a

re no

othe

r med

ical e

xpen

ses f

or an

y me

mber

cove

red u

nder

this

plan.

•Ou

t-of-p

ocke

t exp

ense

s are

base

d only

on tr

eatin

g the

cond

ition i

n the

exam

ple.

•Th

e pati

ent r

eceiv

ed al

l car

e fro

m in-

netw

ork

prov

ider

s. If t

he pa

tient

had r

eceiv

ed ca

re fr

om

out-o

f-netw

ork p

rovid

ers,

costs

wou

ld ha

ve be

en

highe

r.

Wha

t doe

s a C

over

age E

xam

ple

show

?Fo

r eac

h tre

atmen

t situ

ation

, the C

over

age E

xamp

le he

lps yo

u see

how

dedu

ctib

les, c

opay

men

ts, a

nd

coin

sura

nce c

an ad

d up.

It also

helps

you s

ee w

hat

expe

nses

migh

t be l

eft up

to yo

u to p

ay be

caus

e the

servi

ce or

trea

tmen

t isn’t

cove

red o

r pay

ment

is lim

ited.

Does

the C

over

age E

xam

ple p

redi

ct m

y ow

n ca

re n

eeds

?

û N

o. Tr

eatm

ents

show

n are

just

exam

ples.

The

care

you w

ould

rece

ive fo

r this

cond

ition c

ould

be

differ

ent b

ased

on yo

ur do

ctor’s

advic

e, yo

ur ag

e, ho

w se

rious

your

cond

ition i

s, an

d man

y othe

r fac

tors.

Does

the C

over

age E

xam

ple p

redi

ct m

y fu

ture

expe

nses

?

û N

o. Co

vera

ge E

xamp

les ar

e not

cost

estim

ators.

You c

an’t u

se th

e exa

mples

to

estim

ate co

sts fo

r an a

ctual

cond

ition.

They

ar

e for

comp

arati

ve pu

rpos

es on

ly. Yo

ur ow

n co

sts w

ill be

diffe

rent

depe

nding

on th

e car

e you

re

ceive

, the p

rices

your

pro

vider

s cha

rge,

and

the re

imbu

rseme

nt yo

ur he

alth p

lan al

lows.

Can

I use

Cov

erag

e Exa

mpl

es to

co

mpa

re p

lans?

üYe

s. W

hen y

ou lo

ok at

the S

umma

ry of

Bene

fits

and C

over

age f

or ot

her p

lans,

you’l

l find

the

same

Cov

erag

e Exa

mples

. Whe

n you

comp

are

plans

, che

ck th

e “Pa

tient

Pays

” box

in ea

ch

exam

ple. T

he sm

aller

that

numb

er, th

e mor

e co

vera

ge th

e plan

prov

ides .

Are t

here

oth

er co

sts I

shou

ld co

nsid

er

when

com

parin

g pl

ans?

üYe

s. An

impo

rtant

cost

is the

pre

miu

m yo

u pa

y. Ge

nera

lly, th

e low

er yo

ur p

rem

ium

, the

more

you’l

l pay

in ou

t-of-p

ocke

t cos

ts, su

ch as

co

paym

ents

, ded

uctib

les, a

nd co

insu

ranc

e. Yo

u also

shou

ld co

nside

r con

tributi

ons t

o ac

coun

ts su

ch as

healt

h sav

ings a

ccou

nts

(HSA

s), fle

xible

spen

ding a

rrang

emen

ts (F

SAs)

or he

alth r

eimbu

rseme

nt ac

coun

ts (H

RAs)

that

help

you p

ay ou

t-of-p

ocke

t exp

ense

s.

® Re

gister

ed M

arks

of th

e Blue

Cro

ss an

d Blue

Shie

ld As

socia

tion.©

2013

Blue

Cro

ss an

d Blue

Shie

ld of

Mass

achu

setts

, Inc.,

and

Blue

Cro

ss an

d Blue

Shie

ld of

Mass

achu

setts

HMO

Blue

, Inc.

11

3023

2B (9

/13) P

DF JI

Ques

tions

: Call

1-88

8-54

3-87

70 or

visit

us at

www

.blu

ecro

ssm

a.com

.If y

ou ar

en’t c

lear a

bout

any o

f the u

nder

lined

term

s use

d in t

his fo

rm, s

ee th

e Glos

sary.

You c

an vi

ew th

e Glos

sary

at ww

w.bl

uecr

ossm

a.com

/sbcg

loss

ary o

r call

1-88

8-54

3-87

70 to

requ

est a

copy

.

www.bluecrossma.com



MCC Compliance


HMO

Blu

e New

Eng

land

Enha

nced

Valu

e B

abso

n Co

llege

Low

Opt

ion

Sum

mar

y of B

enefi

ts an

d Co

vera

ge: W

hat th

is Pl

an C

over

s & W

hat it

Cos

ts

Cove

rage

Per

iod:

01/01

/2014

- 12/3

1/201

4Co

vera

ge fo

r: Ind

ividu

al an

d Fam

ily | P

lan Ty

pe: H

MO

Ques

tions

: Call

1-88

8-54

3-87

70 or

visit

us at

www

.blu

ecro

ssm

a.com

.If y

ou ar

en’t c

lear a

bout

any o

f the u

nder

lined

term

s use

d in t

his fo

rm, s

ee th

e Glos

sary.

You c

an vi

ew th

e Glos

sary

at w

ww.b

luec

ross

ma.c

om/sb

cglo

ssar

y or c

all 1-

888-

543-

8770

to re

ques

t a co

py.

1 of 8

Blue

Cro

ss B

lue S

hield

of Ma

ssac

huse

tts is

an In

depe

nden

t Lice

nsee

of th

e Blue

Cro

ss an

d Blue

Shie

ld As

socia

tion

This

is on

ly a s

umm

ary.

If you

wan

t mor

e deta

il abo

ut yo

ur co

vera

ge an

d cos

ts, yo

u can

get th

e com

plete

terms

in th

e poli

cy or

plan

docu

ment

at

www.

blue

cros

sma.c

om or

by ca

lling 1

-888

-543

-877

0.

Impo

rtan

t Que

stio

nsA

nsw

ers

Why

this

Mat

ters

:W

hat is

the o

vera

ll de

duct

ible?

$0Se

e the

char

t star

ting o

n pag

e 2 fo

r you

r cos

ts for

servi

ces t

his pl

an co

vers.

Are t

here

oth

er

dedu

ctib

les fo

r spe

cific

serv

ices?

No.

You d

on’t h

ave t

o mee

t ded

uctib

les fo

r spe

cific s

ervic

es, b

ut se

e the

char

t star

ting o

n pag

e 2 fo

r oth

er co

sts fo

r ser

vices

this

plan c

over

s.

Is th

ere a

n ou

t-of-p

ocke

t lim

it on

my e

xpen

ses?

Yes.

$2,00

0 mem

ber /

$4,00

0 fam

ily.Th

e out

-of-p

ocke

t lim

it is t

he m

ost y

ou co

uld pa

y dur

ing a

cove

rage

perio

d (us

ually

one y

ear)

for

your

shar

e of th

e cos

t of c

over

ed se

rvice

s. Th

is lim

it help

s you

plan

for h

ealth

care

expe

nses

.

Wha

t is n

ot in

clude

d in

the

out-o

f-poc

ket li

mit?

Prem

iums,

pres

cripti

on dr

ugs,

balan

ce-

billed

char

ges,

and h

ealth

care

this

plan

does

n’t co

ver.

Even

thou

gh yo

u pay

thes

e exp

ense

s, the

y don

’t cou

nt tow

ard t

he o

ut-o

f-poc

ket li

mit.

Does

this

plan

use

a ne

twor

k of p

rovid

ers?

Yes.

See w

ww.b

luec

ross

ma.c

om/

finda

doct

or o

r call

1-80

0-82

1-13

88 fo

r a l

ist of

netw

ork p

rovid

ers.

If you

use a

n in-

netw

ork d

octor

or ot

her h

ealth

care

pro

vider

, this

plan w

ill pa

y som

e or a

ll of

the co

sts of

cove

red s

ervic

es. B

e awa

re, y

our in

-netw

ork d

octor

or ho

spita

l may

use a

n out-

of-ne

twor

k pro

vider

for s

ome s

ervic

es. P

lans u

se th

e ter

m in-

netw

ork,

pref

erre

d, or

partic

ipatin

g for

pr

ovid

ers i

n the

ir net

work

. See

the c

hart

startin

g on p

age 2

for h

ow th

is pla

n pay

s diffe

rent

kinds

of

prov

ider

s.Do

I nee

d a r

efer

ral to

see

a spe

cialis

t?Ye

s.Th

is pla

n will

pay s

ome o

r all o

f the c

osts

to se

e a sp

ecial

ist fo

r cov

ered

servi

ces b

ut on

ly if y

ou

have

the p

lan’s

perm

ission

befor

e you

see t

he sp

ecial

ist.

Are t

here

serv

ices t

his

plan

doe

sn’t c

over

?Ye

s.So

me of

the s

ervic

es th

is pla

n doe

sn’t c

over

are l

isted

on pa

ge 5.

See

your

polic

y or p

lan do

cume

nt for

addit

ional

infor

matio

n abo

ut ex

clude

d se

rvice

s.

www.bluecrossma.com


www.bluecrossma.com



2 of 8

•Co

paym

ents

are fi

xed d

ollar

amou

nts (f

or ex

ample

, $15

) you

pay f

or co

vere

d hea

lth ca

re, u

suall

y whe

n you

rece

ive th

e ser

vice.

•Co

insu

ranc

e is y

our s

hare

of th

e cos

ts of

a cov

ered

servi

ce, c

alcula

ted as

a pe

rcent

of the

allo

wed

amou

nt (o

r pro

vider

’s ch

arge

if it i

s les

s tha

n the

allo

wed

amou

nt) fo

r the

servi

ce. F

or ex

ample

, if th

e plan

’s all

owed

amou

nt fo

r an o

vern

ight s

tay is

$1,00

0 (an

d it is

less

than

the p

rovid

er’s

char

ge),

your

coin

sura

nce

paym

ent o

f 20%

wou

ld be

$200

. This

may

chan

ge if

you h

aven

’t met

your

ded

uctib

le.•

The a

moun

t the p

lan pa

ys fo

r cov

ered

servi

ces i

s bas

ed on

the a

llowe

d am

ount

. If an

out-o

f-netw

ork p

rovid

er ch

arge

s mor

e tha

n the

allo

wed

amou

nt, y

ou

may h

ave t

o pay

the d

iffere

nce.

For e

xamp

le, if

an ou

t-of-n

etwor

k hos

pital

char

ges $

1,500

for a

n ove

rnigh

t stay

and t

he al

lowe

d am

ount

is $1

,000,

you m

ay

have

to pa

y the

$500

diffe

renc

e. (T

his is

calle

d bala

nce b

illing

.)•

This

plan m

ay en

cour

age y

ou to

use i

n-ne

twor

k pro

vider

s by c

harg

ing yo

u low

er d

educ

tibles

, cop

aym

ents

and c

oins

uran

ce a

moun

ts. (

If you

are e

ligibl

e to

elect

a Hea

lth R

eimbu

rseme

nt Ac

coun

t (HR

A), F

lexibl

e Spe

nding

Acc

ount

(FSA

) or y

ou ha

ve el

ected

a He

alth S

aving

s Acc

ount

(HSA

), yo

u may

have

ac

cess

to ad

dition

al fun

ds to

help

cove

r cer

tain o

ut-o

f-poc

ket e

xpen

ses s

uch a

s cop

aym

ents

, coi

nsur

ance

, ded

uctib

les an

d cos

ts re

lated

to se

rvice

s not

other

wise

cove

red.)

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

visit

a he

alth

care

pr

ovid

er’s

offic

e or c

linic

Prim

ary c

are v

isit to

trea

t an i

njury

or ill

ness

$25 /

visit

Not c

over

ed—

——

none

——

—Sp

ecial

ist vi

sit$2

5 / vi

sitNo

t cov

ered

——

— no

ne —

——

Othe

r pra

ctitio

ner o

ffice v

isit

$25 /

chiro

prac

tor vi

sitNo

t cov

ered

——

— no

ne —

——

Prev

entiv

e car

e/scre

ening

/immu

nizati

onNo

char

geNo

t cov

ered

GYN

exam

limite

d to o

ne ex

am pe

r ca

lenda

r yea

r

If you

hav

e a te

st

Diag

nosti

c tes

t (x-r

ay, b

lood w

ork)

No ch

arge

Not c

over

ed—

——

none

——

—

Imag

ing (C

T/PE

T sca

ns, M

RIs)

$75

Not c

over

ed

Copa

ymen

t limi

ted to

$375

per c

alend

ar

year

; cop

ayme

nt ap

plies

per c

atego

ry of

tes

t / da

y; pr

e-au

thoriz

ation

requ

ired f

or

certa

in se

rvice

s

3 of 8

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

nee

d dr

ugs t

o tre

at

your

illne

ss o

r con

ditio

n

More

info

rmat

ion

abou

t pr

escr

iptio

n dr

ug

cove

rage

is av

ailab

le at

ww

w.bl

uecr

ossm

a.com

.

Gene

ric dr

ugs

$15 /

retai

l or $

30

($15

for v

alue d

rugs

) / m

ail se

rvice

supp

lyNo

t cov

ered

Up to

30-d

ay re

tail (9

0-da

y mail

servi

ce)

supp

ly; co

st sh

are w

aived

for b

irth

contr

ol, sm

oking

cess

ation

and c

ertai

n or

ally a

dmini

stere

d anti

canc

er dr

ugs;

pre-

autho

rizati

on re

quire

d for

ce

rtain

drug

s

Prefe

rred b

rand

drug

s$3

0 / re

tail o

r $60

($

30 fo

r valu

e dru

gs)

/ mail

servi

ce su

pply

Not c

over

ed

Up to

30-d

ay re

tail (9

0-da

y mail

servi

ce)

supp

ly; co

st sh

are w

aived

for s

mokin

g ce

ssati

on sm

oking

cess

ation

and c

ertai

n or

ally a

dmini

stere

d anti

canc

er dr

ugs;

pre-

autho

rizati

on re

quire

d for

ce

rtain

drug

s

Non-

prefe

rred b

rand

drug

s$5

0 / re

tail o

r $10

0 /

mail s

ervic

e sup

plyNo

t cov

ered

Up to

30-d

ay re

tail (9

0-da

y mail

servi

ce)

supp

ly; co

st sh

are w

aived

for c

ertai

n or

ally a

dmini

stere

d anti

canc

er dr

ugs;

pr

e-au

thoriz

ation

requ

ired f

or

certa

in dr

ugs

Spec

ialty

drug

sAp

plica

ble co

st sh

are

(gen

eric,

prefe

rred,

non-

prefe

rred)

Not c

over

edW

hen o

btaine

d fro

m a d

esign

ated

spec

ialty

phar

macy

; pre

-auth

oriza

tion

requ

ired f

or ce

rtain

drug

s

If you

hav

e out

patie

nt

surg

ery

Facil

ity fe

e (e.g

., amb

ulator

y sur

gery

cente

r)$2

50 / a

dmisi

son

Not c

over

edPr

e-au

thoriz

ation

requ

ired

Phys

ician

/surg

eon f

ees

No ch

arge

Not c

over

edPr

e-au

thoriz

ation

requ

ired f

or ce

rtain

servi

ces

If you

nee

d im

med

iate

med

ical a

ttent

ion

Emer

genc

y roo

m se

rvice

s$1

50 / v

isit

$150

/ visi

tCo

paym

ent w

aived

if ad

mitte

d or f

or

obse

rvatio

n stay

Emer

genc

y med

ical tr

ansp

ortat

ionNo

char

geNo

char

ge—

——

none

——

—

Urge

nt ca

re$2

5 / vi

sit$2

5 / vi

sitOu

t-of-n

etwor

k cov

erag

e lim

ited t

o out

of se

rvice

area

If you

hav

e a h

ospi

tal s

tay

Facil

ity fe

e (e.g

., hos

pital

room

)$5

00 / a

dmiss

ionNo

t cov

ered

Pre-

autho

rizati

on re

quire

d

Phys

ician

/surg

eon f

eeNo

char

geNo

t cov

ered

Pre-

autho

rizati

on re

quire

d

www.bluecrossma.com

4 of 8

Com

mon

Med

ical

Eve

ntSe

rvic

es Y

ou M

ay N

eed

Your

cos

t if y

ou u

seLi

mita

tions

& E

xcep

tions

In-N

etw

ork

Out

-of-N

etw

ork

If you

hav

e men

tal h

ealth

, be

havio

ral h

ealth

, or

subs

tanc

e abu

se n

eeds

Menta

l/Beh

avior

al he

alth o

utpati

ent s

ervic

es$2

5 / vi

sitNo

t cov

ered

Pre-

autho

rizati

on re

quire

d for

certa

in se

rvice

sMe

ntal/B

ehav

ioral

healt

h inp

atien

t ser

vices

$500

/ adm

ission

Not c

over

edPr

e-au

thoriz

ation

requ

ired.

Subs

tance

use d

isord

er ou

tpatie

nt se

rvice

s$2

5 / vi

sitNo

t cov

ered

Pre-

autho

rizati

on re

quire

d for

certa

in se

rvice

sSu

bstan

ce us

e diso

rder

inpa

tient

servi

ces

$500

/ adm

ission

Not c

over

edPr

e-au

thoriz

ation

requ

ired

If you

are p

regn

ant

Pren

atal a

nd po

stnata

l car

eNo

char

geNo

t cov

ered

——

— no

ne —

——

Deliv

ery a

nd al

l inpa

tient

servi

ces

$500

/ adm

ission

Not c

over

ed—

——

none

——

—

If you

nee

d he

lp

reco

verin

g or

hav

e oth

er

spec

ial h

ealth

nee

ds

Home

healt

h car

eNo

char

geNo

t cov

ered

Pre-

autho

rizati

on re

quire

d

Reha

bilita

tion s

ervic

es$2

5 / vi

sitNo

t cov

ered

Limite

d to 6

0 visi

ts pe

r cale

ndar

year

(o

ther t

han f

or au

tism,

home

healt

h car

e, an

d spe

ech t

hera

py)

Habil

itatio

n ser

vices

$25 /

visit

Not c

over

ed

Reha

bilita

tion t

hera

py co

vera

ge lim

its

apply

; cos

t sha

re an

d cov

erag

e lim

its

waive

d for

early

inter

venti

on se

rvice

s for

eli

gible

child

ren

Skille

d nur

sing c

are

No ch

arge

Not c

over

edLim

ited t

o 100

days

per c

alend

ar ye

ar;

pre-

autho

rizati

on re

quire

d

Dura

ble m

edica

l equ

ipmen

t20

% co

insur

ance

Not c

over

edCo

st sh

are w

aived

for o

ne br

east

pump

pe

r birth

Hosp

ice se

rvice

No ch

arge

Not c

over

edPr

e-au

thoriz

ation

requ

ired f

or ce

rtain

servi

ces

If you

r chi

ld n

eeds

den

tal

or ey

e car

e

Eye e

xam

No ch

arge

Not c

over

edLim

ited t

o one

exam

ever

y 24 m

onths

Glas

ses

Not c

over

edNo

t cov

ered

——

— no

ne —

——

Denta

l che

ck-u

pNo

char

geNo

t cov

ered

Limite

d to c

hildr

en un

der a

ge 12

(eve

ry 6 m

onths

) and

unde

r age

18 w

ith a

cleft

palat

e / cl

eft lip

cond

ition

5 of 8

Excl

uded

Ser

vice

s &

Oth

er C

over

ed S

ervi

ces:

•Ac

upun

cture

•Ch

ildre

n’s gl

asse

s

•Co

smeti

c sur

gery

•De

ntal c

are (

adult

)

•Lo

ng-te

rm ca

re

•No

n-em

erge

ncy c

are w

hen t

rave

ling o

utside

the U

.S.

•Pr

ivate-

duty

nursi

ng

Serv

ices Y

our P

lan D

oes N

OT C

over

(Thi

s isn

’t a co

mpl

ete l

ist. C

heck

your

pol

icy o

r plan

doc

umen

t for

oth

er ex

clude

d se

rvice

s.)

•Ba

riatric

surg

ery

•Ch

iropr

actic

care

•He

aring

aids

($2,0

00 pe

r ear

ever

y 36 m

onths

for

memb

ers a

ge 21

or yo

unge

r)

•Inf

ertili

ty tre

atmen

t

•Ro

utine

eye c

are -

adult

(limi

ted to

one e

xam

ever

y 24

mon

ths)

•Ro

utine

foot

care

(only

for p

atien

ts wi

th sy

stemi

c cir

culat

ory d

iseas

e)

•W

eight

loss p

rogr

ams (

three

mon

ths in

quali

fied

prog

ram(

s) pe

r con

tract

per c

alend

ar ye

ar)

Othe

r Cov

ered

Ser

vices

(Thi

s isn

’t a co

mpl

ete l

ist. C

heck

your

pol

icy o

r plan

doc

umen

t for

oth

er co

vere

d se

rvice

s and

your

cost

s for

thes

e ser

vices

.)

6 of 8

Your

Rig

hts

to C

ontin

ue C

over

age:

If you

lose

cove

rage

unde

r the

plan

, then

, dep

endin

g upo

n the

circu

mstan

ces,

Fede

ral a

nd S

tate l

aws m

ay pr

ovide

prote

ction

s tha

t allo

w yo

u to k

eep h

ealth

cove

rage

. Any

su

ch rig

hts m

ay be

limite

d in d

urati

on an

d will

requ

ire yo

u to p

ay a

prem

ium

, whic

h may

be si

gnific

antly

high

er th

an th

e pre

mium

you p

ay w

hile c

over

ed un

der t

he pl

an.

Othe

r limi

tation

s on y

our r

ights

to co

ntinu

e cov

erag

e may

also

apply

. Fo

r mor

e info

rmati

on on

your

rights

to co

ntinu

e cov

erag

e, co

ntact

your

plan

spon

sor. N

ote: A

plan

spon

sor is

usua

lly th

e mem

ber’s

emplo

yer o

r org

aniza

tion t

hat p

rovid

es

grou

p hea

lth co

vera

ge to

the m

embe

r. You

may

also

conta

ct yo

ur st

ate in

sura

nce d

epar

tmen

t, the

U.S

. Dep

artm

ent o

f Lab

or, E

mploy

ee B

enefi

ts Se

curity

Adm

inistr

ation

at

1-86

6-44

4-32

72 or

www

.dol.g

ov/eb

sa, o

r the

U.S

. Dep

artm

ent o

f Hea

lth an

d Hum

an S

ervic

es at

1-87

7-26

7-23

23 x6

1565

or w

ww.cc

iio.cm

s.gov

.Yo

ur G

rieva

nce

and

App

eals

Rig

hts:

If you

have

a co

mplai

nt or

are d

issati

sfied

with

a de

nial o

f cov

erag

e for

claim

s und

er yo

ur pl

an, y

ou m

ay be

able

to ap

peal

or fil

e a gr

ievan

ce. F

or qu

estio

ns ab

out y

our

rights

, this

notic

e, or

assis

tance

, you

can c

ontac

t the M

embe

r Ser

vice n

umbe

r liste

d on y

our I

D ca

rd or

conta

ct yo

ur pl

an sp

onso

r. Note

: A pl

an sp

onso

r is us

ually

the

memb

er’s

emplo

yer o

r org

aniza

tion t

hat p

rovid

es gr

oup h

ealth

cove

rage

to th

e mem

ber. .

Doe

s th

is C

over

age

Prov

ide

Min

imum

Ess

entia

l Cov

erag

e?Th

e Affo

rdab

le Ca

re A

ct re

quire

s mos

t peo

ple to

have

healt

h car

e cov

erag

e tha

t qua

lifies

as “m

inimu

m es

senti

al co

vera

ge.”

This

plan

or p

olicy

doe

s pro

vide m

inim

um

esse

ntial

cove

rage

.

Doe

s th

is C

over

age

Mee

t the

Min

imum

Val

ue S

tand

ard?

The A

fford

able

Care

Act

estab

lishe

s a m

inimu

m va

lue st

anda

rd of

bene

fits of

a he

alth p

lan. T

he m

inimu

m va

lue st

anda

rd is

60%

(actu

arial

value

). Th

is he

alth

cove

rage

do

es m

eet t

he m

inim

um va

lue s

tand

ard

for t

he b

enefi

ts it

prov

ides

.

Lang

uage

Ass

ista

nce

D

iscl

aim

er:

This

docu

ment

conta

ins on

ly a p

artia

l des

cripti

on of

the b

enefi

ts, lim

itatio

ns, e

xclus

ions a

nd ot

her p

rovis

ions o

f this

healt

h car

e plan

. It is

not a

polic

y. It i

s a ge

nera

l ove

rview

on

ly. It

does

not p

rovid

e all t

he de

tails

of thi

s cov

erag

e, inc

luding

bene

fits, e

xclus

ions a

nd po

licy l

imita

tions

. In th

e eve

nt the

re ar

e disc

repa

ncies

betw

een t

his do

cume

nt an

d the

polic

y, the

term

s and

cond

itions

of th

e poli

cy w

ill go

vern

.

To se

e exa

mples

of ho

w thi

s plan

migh

t cov

er co

sts fo

r a sa

mple

medic

al sit

uatio

n, se

e the

next

page

.


http://www.cciio.cms.gov

7 of 8

Abo

ut th

ese

C

over

age

Exam

ples

:

Thes

e exa

mples

show

how

this p

lan m

ight

cove

r med

ical c

are i

n give

n situ

ation

s. Us

e the

se ex

ample

s to s

ee, in

gene

ral, h

ow m

uch

finan

cial p

rotec

tion a

samp

le pa

tient

migh

t ge

t if th

ey ar

e cov

ered

unde

r diffe

rent

plans

.

This

is

not a

cos

t es

timat

or.

Don’t

use t

hese

exam

ples t

o esti

mate

your

actua

l cos

ts un

der t

his pl

an.

The a

ctual

care

you r

eceiv

e will

be

differ

ent fr

om th

ese e

xamp

les, a

nd

the co

st of

that c

are a

lso w

ill be

dif

feren

t.

See t

he ne

xt pa

ge fo

r impo

rtant

infor

matio

n abo

ut the

se ex

ample

s.

Hav

ing

a ba

by(n

orm

al d

eliv

ery)

n A

mou

nt o

wed

to p

rovid

ers:

$7,5

40n

Plan

pay

s $6

,870

n P

atien

t Pay

s $6

70

Sam

ple c

are c

osts

:Ho

spita

l cha

rges

(moth

er)

$2,70

0Ro

utine

obste

tric ca

re$2

,100

Hosp

ital c

harg

es (b

aby)

$900

Anes

thesia

$900

Labo

rator

y tes

ts$5

00Pr

escri

ption

s$2

00Ra

diolog

y$2

00Va

ccine

s, oth

er pr

even

tive

$40

Tota

l$7

,540

Patie

nt P

ays:

Dedu

ctible

s$0

Copa

ys$5

20Co

insur

ance

$0Lim

its or

exclu

sions

$150

Tota

l$6

70

Man

agin

g ty

pe 2

dia

bete

s(ro

utin

e m

aint

enan

ce o

f a w

ell-c

ontro

lled

cond

ition

)

n A

mou

nt o

wed

to p

rovid

ers:

$5,4

00n

Plan

pay

s $3

,330

n P

atien

t Pay

s $2

,070

Sam

ple c

are c

osts

:Pr

escri

ption

s$2

,900

Medic

al Eq

uipme

nt an

d Sup

plies

$1,30

0Of

fice V

isits

and P

roce

dure

s$7

00Ed

ucati

on$3

00La

bora

tory t

ests

$100

Vacc

ines,

other

prev

entiv

e$1

00To

tal

$5,40

0

Patie

nt P

ays:

Dedu

ctible

s$0

Copa

ys$1

,990

Coins

uran

ce$0

Limits

or ex

clusio

ns$8

0To

tal

$2,07

0

8 of 8

Que

stio

ns a

nd a

nsw

ers

abou

t the

Cov

erag

e Ex

ampl

es:

Wha

t are

som

e of t

he as

sum

ptio

ns

behi

nd th

e Cov

erag

e Exa

mpl

es?

•Co

sts do

n’t in

clude

pre

miu

ms.

•Sa

mple

care

costs

are b

ased

on na

tiona

l ave

rage

s su

pplie

d to t

he U

.S. D

epar

tmen

t of H

ealth

and

Huma

n Ser

vices

, and

aren

’t spe

cific t

o a pa

rticula

r ge

ogra

phic

area

or he

alth p

lan.

•Th

e pati

ent’s

cond

ition w

as no

t an e

xclud

ed or

pr

eexis

ting c

ondit

ion.

•Al

l ser

vices

and t

reatm

ents

starte

d and

ende

d in

the sa

me co

vera

ge pe

riod.

•Th

ere a

re no

othe

r med

ical e

xpen

ses f

or an

y me

mber

cove

red u

nder

this

plan.

•Ou

t-of-p

ocke

t exp

ense

s are

base

d only

on tr

eatin

g the

cond

ition i

n the

exam

ple.

•Th

e pati

ent r

eceiv

ed al

l car

e fro

m in-

netw

ork

prov

ider

s. If t

he pa

tient

had r

eceiv

ed ca

re fr

om

out-o

f-netw

ork p

rovid

ers,

costs

wou

ld ha

ve be

en

highe

r.

Wha

t doe

s a C

over

age E

xam

ple

show

?Fo

r eac

h tre

atmen

t situ

ation

, the C

over

age E

xamp

le he

lps yo

u see

how

dedu

ctib

les, c

opay

men

ts, a

nd

coin

sura

nce c

an ad

d up.

It also

helps

you s

ee w

hat

expe

nses

migh

t be l

eft up

to yo

u to p

ay be

caus

e the

servi

ce or

trea

tmen

t isn’t

cove

red o

r pay

ment

is lim

ited.

Does

the C

over

age E

xam

ple p

redi

ct m

y ow

n ca

re n

eeds

?

û N

o. Tr

eatm

ents

show

n are

just

exam

ples.

The

care

you w

ould

rece

ive fo

r this

cond

ition c

ould

be

differ

ent b

ased

on yo

ur do

ctor’s

advic

e, yo

ur ag

e, ho

w se

rious

your

cond

ition i

s, an

d man

y othe

r fac

tors.

Does

the C

over

age E

xam

ple p

redi

ct m

y fu

ture

expe

nses

?

û N

o. Co

vera

ge E

xamp

les ar

e not

cost

estim

ators.

You c

an’t u

se th

e exa

mples

to

estim

ate co

sts fo

r an a

ctual

cond

ition.

They

ar

e for

comp

arati

ve pu

rpos

es on

ly. Yo

ur ow

n co

sts w

ill be

diffe

rent

depe

nding

on th

e car

e you

re

ceive

, the p

rices

your

pro

vider

s cha

rge,

and

the re

imbu

rseme

nt yo

ur he

alth p

lan al

lows.

Can

I use

Cov

erag

e Exa

mpl

es to

co

mpa

re p

lans?

üYe

s. W

hen y

ou lo

ok at

the S

umma

ry of

Bene

fits

and C

over

age f

or ot

her p

lans,

you’l

l find

the

same

Cov

erag

e Exa

mples

. Whe

n you

comp

are

plans

, che

ck th

e “Pa

tient

Pays

” box

in ea

ch

exam

ple. T

he sm

aller

that

numb

er, th

e mor

e co

vera

ge th

e plan

prov

ides .

Are t

here

oth

er co

sts I

shou

ld co

nsid

er

when

com

parin

g pl

ans?

üYe

s. An

impo

rtant

cost

is the

pre

miu

m yo

u pa

y. Ge

nera

lly, th

e low

er yo

ur p

rem

ium

, the

more

you’l

l pay

in ou

t-of-p

ocke

t cos

ts, su

ch as

co

paym

ents

, ded

uctib

les, a

nd co

insu

ranc

e. Yo

u also

shou

ld co

nside

r con

tributi

ons t

o ac

coun

ts su

ch as

healt

h sav

ings a

ccou

nts

(HSA

s), fle

xible

spen

ding a

rrang

emen

ts (F

SAs)

or he

alth r

eimbu

rseme

nt ac

coun

ts (H

RAs)

that

help

you p

ay ou

t-of-p

ocke

t exp

ense

s.

® Re

gister

ed M

arks

of th

e Blue

Cro

ss an

d Blue

Shie

ld As

socia

tion.©

2013

Blue

Cro

ss an

d Blue

Shie

ld of

Mass

achu

setts

, Inc.,

and

Blue

Cro

ss an

d Blue

Shie

ld of

Mass

achu

setts

HMO

Blue

, Inc.

13

0233

BS (9

/13) 4

C JI

Ques

tions

: Call

1-88

8-54

3-87

70 or

visit

us at

www

.blu

ecro

ssm

a.com

.If y

ou ar

en’t c

lear a

bout

any o

f the u

nder

lined

term

s use

d in t

his fo

rm, s

ee th

e Glos

sary.

You c

an vi

ew th

e Glos

sary

at ww

w.bl

uecr

ossm

a.com

/sbcg

loss

ary o

r call

1-88

8-54

3-87

70 to

requ

est a

copy

.

www.bluecrossma.com



MCC Compliance


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