LIFE HAS OPTIONS - Excellus BlueCross BlueShieldbrand.excellusbcbs.com/downloads/B_5258_Generic_Rate_Book_CN… · Plan levels are Bronze, Silver, Gold and Platinum. There is also

Your health. Your coverage.

Your choice.

National strength. Local focus. Individual care.SM

A guide to help you understand health insurance options and enrollment.

Call 1-888-669-3913 or visit ChooseExcellus.com/Help

Central New York Region

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LIFE HAS OPTIONS

B-5258 / 9621-15M

To learn more about your plan options, visit ChooseExcellus.com/Help

Getting Started with Excellus BlueCross BlueShieldThe Affordable Care Act requires you to have health insurance or pay a financial penalty. You can shop, compare and enroll in coverage through the NY State of Health Marketplace. Financial help may be available when you purchase a plan on the Marketplace. Eligibility is based on household income and size. You can also buy a plan directly through Excellus BCBS.

Here are a few questions to ask yourself before making this important choice.

1. What are the health care needs of my household?

Take an evaluation of the number of doctor visits, hospital visits and the prescriptions that you and your family have needed over the last year.

Doctor Visits ____________________

Hospital Visits ___________________

Prescriptions ____________________

2. How do I want to manage my costs?

Determine if you are comfortable with a deductible and a lower monthly cost or if you would rather pay more per month for lower and more predictable costs when getting care.

3. Can I get financial help?

You may be eligible for financial aid based on your household income and size. Find out how much at ChooseExcellus.com/Help or call 1-888-669-3913.

Estimated Tax Credit $______________

4. How do I know if my doctor accepts the plan I am choosing?

Ask your doctor if he/she accepts the health insurance company you’re considering. Excellus BCBS plans are accepted by 100% of hospitals and 99% of doctors in your area.

5. How often do I travel outside of my town?

Our BlueCard® program covers you when you travel within the U.S. You can also fill a prescription while traveling, using our National Pharmacy Network. Outside of the country, you have access to non-emergency care through the BlueCard Worldwide® Program when you travel to Canada, Mexico, Puerto Rico, the U.S. Virgin Islands, Guam, and the Mariana Islands.*

$

5 Questions to Ask Before You Buy.

*BlueCard(R) applies to metal level plans and Base only. It does not apply to Essential Plan.

Want help? We’re here for you. Call our dedicated insurance agents at: 1-888-669-3913 1

Get help paying for your plan.

It’s time to start rethinking affordable health care. You might be surprised to know that you may be able to get money towards your monthly payment through something called a tax credit. Eligibility is based on your household income and size. The chart below shows estimated eligibility.

Financial help is only available when you buy a plan on the NY State of Health Marketplace. You may also qualify for cost-sharing reductions which will reduce how much you’ll pay for out-of-pocket costs when you get care.

*Source: 2015 Federal Income Guidelines: Department of Health and Human Services. Full calculator available at http://aspe.hhs.gov/poverty/15poverty.cfm

We can answer your questions and estimate your tax credit:

1-888-669-3913 or ChooseExcellus.com/Help

Financial Assistance Eligibility by Annual Income Level*

Family Size Annual Income Eligibility for Tax Credits

$23,541 - $47,080

$31,861 - $63,720

$40,181 - $80,360

$48,501 - $97,000

$56,821 - $113,640

$65,141 - $130,280

2 To learn more about your plan options, visit ChooseExcellus.com/Help

Follow the path and get a first look at the plan that might be right for you or your family.

Think about everyone you need coverage for. Do you or they frequently

go to the doctor or hospital?

YES

YES YES NO NO

NODo you take prescription drugs? Do you take prescription drugs?

Consider Platinum or Gold.

Consider Gold or Silver.

Consider Gold.

Consider Silver or Bronze.

ESSENTIALPLAN

BASE (CATASTROPHIC)

BRONZE SILVER GOLD PLATINUM

Monthly cost

Cost when you get care

Good option if you…

need low-cost coverage. Eligibility for this plan is based on your household income and size*

need low-cost protection in the event of a catastrophic injury or illness

use health care services infrequently

need to balance your monthly premium with your out-of-pocket costs

want to save on monthly premiums while keeping your out-of-pocket costs low

may use a lot of health care services, want predictable, lower out-of-pocket costs for routine care

Let us help you find the right plan. Plan levels are Bronze, Silver, Gold and Platinum. There is also a Base plan available to people under 30. Eligibility for the Essential Plan is based on your household size and income. The benefits are essentially the same in every plan but the monthly and out-of-pocket costs differ. Preventive care is free no matter what plan you enroll in.

*other eligibility guidelines apply

Want help? We’re here for you. Call our dedicated insurance agents at: 1-888-669-3913 3

We make it easy for you to evaluate your plan options with our comparison chart. View plan options on pages 4 - 7. Select the options that may fit your needs and fill in the information in the chart below. You can use the definitions below to understand some of the key plan terms.

Words you should know. Deductible The amount of money you have to pay before the health insurance company will make any payment towards health care services. This means that you pay the cost of any services you receive, including prescription drugs, until your deductible is reached. Your deductible amount varies and is based on the plan you choose.

Example: If you have a $500 deductible, you pay 100% of your first $500 in medical bills before your insurance pays anything.

Copay This is a fixed amount you pay each time you use a medical service, like a doctor’s visit or prescription refill.

Example: If your prescription drug coverage includes a $20 copay, you pay $20 for each prescription you fill and your insurance company pays the balance.

Coinsurance Coinsurance is similar to a copay, but instead of a fixed-dollar amount, you pay a percentage of the total bill.

Example: If your coinsurance on a $100 bill is 15%, that means you pay $15 and your insurance company pays the rest.

Out-of-pocket maximum An annual limit on the amount of money that you would have to pay for health care costs, not including your monthly premiums.

Premium The amount of money you pay to a health insurance company each month for your coverage.

Health Savings Account (HSA) An HSA is a tax-free funding account owned by you that helps you pay for qualified medical expenses such as lab fees, prescription drugs, contact lenses, chiropractor visits and more. To learn more about your HSA options contact your financial advisor.

Find out what your real monthly cost could look like.

Deductible

Copay

Coinsurance

Out-of-Pocket Maximum

Monthly Premium

- Estimated Tax Credit

Estimated Premium

Fill in your plan choice.PLAN 1 PLAN 2 PLAN 3

Compare your options.

Plan Benefits & FeaturesBase

(Catastrophic - special eligibility applies)

Bronze StandardBronze Standard HSA

(HSA** qualified)Bronze Select

(HSA** qualified)Silver Standard

Tax Credit Available Not applicable Yes Yes Yes Yes

Single Deductible (the deductible amount must be reached first unless indicated otherwise)

$6,850 $3,500 $4,000 $4,500 $2,000

Family Deductible (the deductible amount must be reached first unless indicated otherwise)

$13,700 $7,000 $8,000 $9,000 $4,000

Coinsurance 0%* 50% 50%* 50%* 0%*

Single Out-of -pocket Maximum $6,850 $6,850 $6,450 $6,350 $5,500

Family Out-of -pocket Maximum $13,700 $13,700 $12,900 $12,700 $11,000

Preventive Care (Immunization, screenings)

$0 for most preventive services, not subject to

the deductible


the deductible


the deductible


the deductible


the deductible

Doctor Visit

1st three visits are covered in full and not subject to

the ded. Once you reach the deductible amount, visits

are covered in full Once you reach the deductible amount, then you pay coinsurance or a percentage of cost for

these services

Once you reach the deductible amount you will pay 50% coinsurance (a percentage of cost for services)

$30

Specialist Visit

Once you reach the deductible amount, then these services are

covered in full

$50

Hospital Services $1,500

Emergency Room $150

Lab Work $50

X-Ray $50

Prescription Drugs

Once you reach the deduct-ible amount, then you pay:

$10 for Tier 1$35 for Tier 2$70 for Tier 3




$10 for Tier 140% for Tier 250% for Tier 3

You pay: $10 for Tier 1$35 for Tier 2$70 for Tier 3

(not subject to the deductible)

Pediatric Vision Covered Covered Covered Covered Covered

Rates Through NY State of Health Base Bronze StandardBronze Standard

HSA (HSA qualified)

Bronze Select (HSA qualified)

Silver Standard

Single $209.14 $398.66 $391.97 $368.09 $537.02

Single + Spouse $418.27 $797.31 $783.95 $736.19 $1,074.05

Single + Child(ren) $355.54 $677.72 $666.36 $625.76 $912.95

Single + Spouse + Child(ren) $596.04 $1,136.17 $1,117.12 $1,049.07 $1,530.52

Child Only Not applicable $164.24 $161.50 Not applicable $221.25

All of the Standard plans are required by New York State. The benefits and out-of-pocket costs for the Standard plans will be the same for all health insurance companies. Provider networks will differ by insurance company.

Part of the Affordable Care Act is intended to improve dental coverage for children, including preventive, routine and some major dental coverage. Individuals purchasing medical coverage outside of the NY State of Health Marketplace, are required to purchase a medical plan with pediatric dental included, or a qualified stand-alone plan. By purchasing a medical plan with dental included, you can be sure your children will receive comprehensive coverage overseen by our staff of medical management experts, and both medical and pediatric dental services will count towards your out of pocket maximums.

New York State has identified the fitness facility reimbursement program as a required essential benefit that must be included for all plans, therefore the ExerciseRewards™ program cannot be removed from the plans. The rates shown do not include coverage for dependents through age 29 or pediatric dental benefits.

CERTIFIED HEALTH INSURANCE PLAN OPTIONSGet up to $600 a year towards your fitness facility membership fees and/or individual fitness class fees at participating facilities with our ExerciseRewards™ Program

Get access to more top-quality doctors, hospitals and pharmacies locally and nationwide

See more Silver plan options on the next page* Some benefits, such as pediatric vision and durable medical equipment may have different coinsurance amounts**An HSA or Health Savings Account is a tax-free funding account owned by you that helps you pay for qualified medical expenses such as lab fees, prescription drugs, contact lenses, chiropractor visits and more.~Any one person insured on a family plan will not pay more than $6,550 in compliance with the Affordable Care Act/IRS rules

Dependent through 29 rates available upon request.

4 Need more information or help enrolling? Call our dedicated insurance agents at 1-888-669-3913.

Silver Select (HSA** qualified)

Gold Standard Gold SelectCNY Preferred Gold

Available in Onondaga & Lewis Counties Only

Platinum Standard Platinum Select

Yes Yes Yes Yes Yes Yes

$2,250 $600 $750 $500 $0 $0

$4,500 $1,200 $1,500 $1,000 $0 $0

20%* 0%* 0%* 0% 0%* 0%*

$6,350 $4,000 $6,350 $5,000 $2,000 $6,350

$12,700 $8,000 $12,700 $10,000 $4,000 $12,700


the deductible


the deductible


the deductible

$0 for most preventive services, not subject to the deductible


the deductible


the deductible

Once you reach the deductible amount you

will pay 20% coinsurance (a percentage of cost for services)

$25 $25 $25 $15 $15

$40 $40 $40 $35 $25

$1,000 $750 $750 $500 $750

$150 $250 $150 $100 $150

$40 $40 $40 $35 $25

$40 $40 $40 $35 $25

Once you reach the deductible amount, then you pay:





You pay: $10 for Tier 1 $30 for Tier 2 $60 for Tier 3


Covered Covered Covered Covered Covered Covered

Plan Benefits & FeaturesBase

(Catastrophic - special eligibility applies)

Bronze StandardBronze Standard HSA

(HSA** qualified)Bronze Select

(HSA** qualified)Silver Standard

Tax Credit Available Not applicable Yes Yes Yes Yes


$6,850 $3,500 $4,000 $4,500 $2,000


$13,700 $7,000 $8,000 $9,000 $4,000

Coinsurance 0%* 50% 50%* 50%* 0%*

Single Out-of -pocket Maximum $6,850 $6,850 $6,450 $6,350 $5,500

Family Out-of -pocket Maximum $13,700 $13,700 $12,900 $12,700 $11,000



the deductible


the deductible


the deductible


the deductible


the deductible

Doctor Visit

1st three visits are covered in full and not subject to

the ded. Once you reach the deductible amount, visits

are covered in full Once you reach the deductible amount, then you pay coinsurance or a percentage of cost for

these services

Once you reach the deductible amount you will pay 50% coinsurance (a percentage of cost for services)

$30

Specialist Visit

Once you reach the deductible amount, then these services are

covered in full

$50

Hospital Services $1,500

Emergency Room $150

Lab Work $50

X-Ray $50

Prescription Drugs






$10 for Tier 140% for Tier 250% for Tier 3



Pediatric Vision Covered Covered Covered Covered Covered

Dependent through 29 rates available upon request.

4 Need more information or help enrolling? Call our dedicated insurance agents at 1-888-669-3913.

Rates Through NY State of HealthSilver Select

(HSA qualified)Gold Standard Gold Select CNY Preferred

GoldPlatinum Standard

Platinum Select

Single $469.43 $637.66 $612.13 $565.53 $740.76 $714.91

Single + Spouse $938.87 $1,275.32 $1,224.26 $1,131.05 $1,481.53 $1,429.83

Single + Child(ren) $798.04 $1,084.02 $1,040.63 $961.39 $1,259.30 $1,215.35

Single + Spouse + Child(ren) $1,337.89 $1,817.33 $1,744.58 $1,611.75 $2,111.17 $2,037.51

Child Only Not applicable $262.72 Not applicable Not applicable $305.19 Not applicable

Need help choosing the right plan for you? Call our dedicated insurance agents at 1-888-669-3913

All of the Standard plans are required by New York State. The benefits and out-of-pocket costs for the Standard plans will be the same for all health insurance companies. Provider networks will differ by insurance company.


New York State has identified the fitness facility reimbursement program as a required essential benefit that must be included for all plans, therefore the ExerciseRewards™ program cannot be removed from the plans. The rates shown do not include coverage for dependents through age 29 or pediatric dental benefits.

* Some benefits, such as pediatric vision and durable medical equipment may have different coinsurance amounts**An HSA or Health Savings Account is a tax-free funding account owned by you that helps you pay for qualified medical expenses such as lab fees, prescription drugs, contact lenses, chiropractor visits and more. ***Cost share shown applies when a St. Joesph’s Hospital provider or facility is used

Sign up for email updates and see how much you save at ChooseExcellus.com/Help 5

Central New York Region:Broome CountyCayuga CountyChemung County

Cortland County Onondaga CountySchuyler County

Steuben CountyTioga CountyTompkins County

Plan Benefits & Features Silver StandardSilver Standard

(200-250% FPL**)Silver Select

(HSA** qualified)Silver Select

(200-250% FPL**)

Plan available through Excellus BCBS or NY State of Health NY State of Health only NY State of Health only NY State of Health only

Tax Credit Available Yes Yes Yes Yes


$2,000 $1,500 $2,250 $2,250


$4,000 $3,000 $4,500 $4,500

Coinsurance 0%* 0%* 20%* 20%*

Single Out-of -pocket Maximum $5,500 $5,450 $6,350 $3,750

Family Out-of -pocket Maximum $11,000 $10,900 $12,700 $7,500






Doctor Visit $30 $30

Once you reach the deductible amount you will pay 20% coinsurance (a percentage

of cost for services)

Once you reach the deductible amount you will pay 20% coinsurance (a percentage

of cost for services)

Specialist Visit $50 $50

Hospital Services $1,500 $1,500

Emergency Room $150 $150

Lab Work $50 $50

X-Ray $50 $50

Prescription Drugs






$10 for Tier 1 $45 for Tier 2 $90 for Tier 3


$5 for Tier 1 $45 for Tier 2 $90 for Tier 3

Pediatric Vision Covered Covered Covered Covered

Rates Through NY State of Health Silver StandardSilver Standard

(200-250% FPL**)Silver Select

(HSA qualified)Silver Select

(200-250% FPL**)

Single $537.02 $537.02 $469.43 $469.43

Single + Spouse $1,074.05 $1,074.05 $938.87 $938.87

Single + Child(ren) $912.95 $912.95 $798.04 $798.04

Single + Spouse + Child(ren) $1,530.52 $1,530.52 $1,337.89 $1,337.89

Child Only $221.25 $221.25 Not applicable Not applicable


New York State has identified the fitness facility reimbursement program as a required essential benefit that must be included for all plans, therefore the ExerciseRewards program cannot be removed from the plans. The rates shown do not include coverage for dependents through age 29 or pediatric dental benefits.

Only Silver Select meets the IRS requirements for pairing with a health savings account. Subsidized health plans are not eligible for health savings accounts.

All of the Standard plans are required by New York State. The benefits and out of pocket costs for the Standard plans will be the same for all health insurance companies. Provider networks will differ by insurance company.

Below are additional Silver plan options that include cost-sharing reductions that reduce how much you pay when you get care. Eligibility is based on your Federal Poverty Level (FPL) which is determined by household income and size.

Get access to more top-quality doctors, hospitals and pharmacies locally and nationwide

Get up to $600 a year towards your fitness facility membership fees and/or individual fitness class fees at participating facilities with our ExerciseRewards™ Program

* Some benefits, such as pediatric vision and durable medical equipment may have different coinsurance amounts** Federal Poverty Level (FPL) is the minimum yearly income that a person or family needs in order to provide for their basic needs. The Department of Health and Human Services determines the FPL annually. Find out your estimated FPL using our tax credit calculator at ChooseExcellus.com/Help***An HSA or Health Savings Account is a tax-free funding account owned by you that helps you pay for qualified medical expenses such as lab fees, prescription drugs, contact lenses, chiropractor visits and more.

6 Need more information or help enrolling? Call our dedicated insurance agents at 1-888-669-3913.Dependent through 29 rates available upon request.

Rates Through NY State of HealthEssential Plan 1

(150% - 200% FPL)Essential Plan 2



(Below 100% FPL)

Single $20 $0 $0 $0

Plan Benefits & FeaturesEssential Plan 1




(Below 100% FPL)

Tax Credit Available Not Applicable Not Applicable Not Applicable Not Applicable

Preventive Care (Immunization, screenings) $0 for most preventive services $0 for most preventive services $0 for most preventive services $0 for most preventive services

Deductible $0 $0 $0 $0

Coinsurance 0% 0% 0% 0%

Out-of -pocket Maximum $2,000 $200 $200 $0

Doctor Visit $15 $0 $0 $0

Specialist Visit $25 $0 $0 $0

Hospital Services $150 $0 $0 $0

Emergency Room $75 $0 $0 $0

Lab Work $25 $0 $0 $0

X-Ray $25 $0 $0 $0

Prescription Drugs

You pay:$6 for Tier 1

$15 for Tier 2$30 for Tier 3

You pay:$1 for Tier 1$3 for Tier 2$3 for Tier 3



ExerciseRewards - Up to $400 a year for fitness facility and individual fitness class reimbursement

Included Included Included Included

Blue365 Discounts Included Included Included Included

New Coverage for 2016! Essential Plans Eligibility is based on your Federal Poverty Level (FPL) which is determined by household size and income.** To find out if you qualify for the Essential Plan call our dedicated insurance agents at 1-888-669-3913

“New York State has identified the fitness facility reimbursement program as a required essential benefit that must be included for all plans, therefore the ExerciseRewards program cannot be removed from the plans.

**Other eligibility requirements must be met to enroll.

***Must be a lawfully present immigrant (“Qualified non-citizen” immigration status without a waiting period; Humanitarian statuses or circumstances (including Temporary Protected-Status, Special Juvenile Status, asylum applicants, Convention Against Torture, victims of trafficking); Valid non-immigration visas; Legal status conferred by other laws (temporary resident status, LIFE Act, Family Unity individuals). To see a full list of eligible immigration statuses, please visit the web site at www.healthcare.gove/immigrants/immigration-status/ or call the NY State of Health at 1-855-355-5777.)

The benefits and out of pocket costs for the Essential Plans will be the same for all health insurance companies.

Sign up for email updates and see how much you save at ChooseExcellus.com/Help 7

Annual Income Eligibility for Essential Plan

Household Size Essential Plans 1 & 2 (139%-200%FPL) Essential Plans 3 & 4 (under 100%-138 FPL***)

$16,244 - $23,540 $0 - $16,243

$21,984 - $31,860 $0 - $21,983

$27,725 - $40,180 $0 - $27,724

$33,466 - $48,500 $0 - $33,465

$39,207 - $56,820 $0 - $39,206

$44,948 - $65,140 $0 - $44,947

8 To learn more about your plan options, visit ChooseExcellus.com/Help

Your Enrollment checklist. To enroll in a plan, make sure you have your:

Email address (you are required to provide an email address to enroll in the NY State of Health Marketplace)

Proof of U.S. citizenship or legal status in the form of birth certificate, “Green Card” or passport

Social Security card

Information about others you plan to enroll (spouse, children, their birth dates, Social Security numbers)

Termination letter if you recently lost coverage

Policy number(s) for any current health insurance

Most recently completed tax return. You will need to project your annual household income for the year ahead. You can refer to your tax return to help you estimate that amount.

Coverage you can count on.

More Access100% of hospitals and 99% of doctors in your area accept our plans. Plus our BlueCard® program gives you even more access to care when you travel.

More SecurityProviding quality coverage for 80+ years.

More SavingsFree preventive care — includes routine physicals, screenings and vaccinations, plus low-cost generic drugs.

More DiscountsMembers can save 45% on health and wellness products and services.

Pharmacy Home DeliverySave time and money by having your prescriptions delivered right to your home.

Want help? We’re here for you. Call our dedicated insurance agents at: 1-888-669-3913

Annual Open Enrollment Period:

November 1, 2015 – January 31, 2016

Special Enrollment Period: Certain life events like adopting a baby, aging off a parent’s plan, getting a divorce or losing coverage through an employer may qualify you for a Special Enrollment Period (SEP). Generally with an SEP, you have 60 days to get coverage.

Enrollment is available for the Essential Plan, Medicaid and Child Health Plus all year long.

Save the date.

Call 1-888-669-3913

Visit: ChooseExcellus.com/Help

15

Enrolling is quick and easy.

National strength. Local focus. Individual care.SM

Call 1-888-669-3913 or visit ChooseExcellus.com/Help

P.O. Box 22999, Rochester, NY 14692

B-5258 / 9621-15M

Documents

LIFE HAS OPTIONS - Excellus BlueCross BlueShieldbrand.excellusbcbs.com/downloads/B_5258_Generic_Rate_Book_CN… · Plan levels are Bronze, Silver, Gold and Platinum. There is also