certified health insurance plan options rochester … · the benefits and out-of-pocket costs for...

A nonprofit independent licensee of the Blue Cross Blue Shield AssociationB-5295Y20 / 13338-19M RA

CERTIFIED HEALTH INSURANCE PLAN OPTIONSGet up to $400 or $600 a year toward qualified fitness facility dues and/or fitness classes with our ExerciseRewards™ Program

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

Need help choosing the right plan for you? Call our dedicated Insurance Agents at 1-866-613-8506.

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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. Any one person insured on a family plan will not pay more than $8,150 in compliance with the Affordable Care Act. The rates shown do not include coverage for dependents through age 29 or respective 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. Subsidized health plans are not eligible for health savings accounts. Unless noted above, the deductible must be met first before paying the cost share listed for all benefits. Note to diabetic drug and supply users: In accordance with the contract language/benefit mandates provided by New York State, if your plan includes a deductible, diabetic drugs and supplies are subject to the deductible amount.

STANDARD

Plan Benefits & Features

Base (Catastrophic) Must be under age 30

or qualify for a hardship exemption

Bronze Standard HSA (HSA** qualified)

Bronze Standard Silver Standard Plus 3 Silver Standard Gold Standard Plus 3 Gold Standard Platinum Standard

Tax Credit Available (On-Exchange Only) Not Applicable Yes Yes Yes Yes Yes Yes Yes

Deductible Single/Family $8,150 / $16,300 $5,500 / $11,000 $4,425 / $8,850 $1,875 / $3,750 $1,300 / $2,600 $650 / $1,300 $600 / $1,200 $0 / $0

Out-of-Pocket Maximum (OOPM) Single/Family $8,150 / $16,300 $6,550 / $13,100 $8,150 / $16,300 $8,150 / $16,300 $7,900 / $15,800 $5,000 / $10,000 $4,000 / $8,000 $2,000 / $4,000

Aggregation Type (How the deductible and/or OOPM is met) Individual Individual Individual Individual Individual Individual Individual Individual

Coinsurance You pay 0% You pay 50% You pay 50% You pay 30%* You pay 0%* You pay 20%* You pay 0%* You pay 0%*

Preventive Care (Immunizations, screenings)$0 for most preventive

services, not subject to the deductible

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

services, not subject to the deductible

Doctor Visit (PCP)

First 3 visits covered in full and not subject to the deductible.

4th visit & afterward deductible applies; after deductible is met,

visits are covered in full

First 3 visits covered in full and not subject to the deductible.

4th visit & afterward deductible applies; after deductible is met,

visits are covered in full Once you reach the deductible amount you will

pay 50% coinsurance (a percentage of cost for

services)

First 3 PCP visits at $35, not subject to deductible; 4th and

after, deductible/$35 copay$30

First 3 PCP visits at $25, not subject to deductible; 4th and

after, deductible/$25 copay $25 $15

Specialist Visit (SPC)

Once you meet the deductible amount, then these services

are covered in full

Once you reach the deductible amount you will

pay 50% coinsurance (a percentage of cost for

services)

$55 $50 $40 $40 $35

Hospital Services $1,500 $1,500 $1,000 $1,000 $500

Emergency Room $250 $250 $150 $150 $100

Lab Work Primary/Specialist $35 PCP / $55 SPC $30 PCP / $50 SPC $25 PCP / $40 SPC $25 PCP / $40 SPC $15 PCP / $35 SPC

Basic X-Ray/ Advanced Imaging (MRI, etc.) Primary/Specialist $35 PCP / $55 SPC $30 PCP / $50 SPC $25 PCP / $40 SPC $25 PCP / $40 SPC $15 PCP / $35 SPC

Prescription Drugs

Once you meet the deductible amount, then you pay:$10 for Tier 1$35 for Tier 2 $70 for Tier 3

You pay:$10 for Tier 1$40 for Tier 2$80 for Tier 3

(not subject to the deductible)







Telemedicine - MDLive Program Included Included Included Included Included Included Included Included

Pediatric Vision* Covered Covered Covered Covered Covered Covered Covered Covered

Rates Through NY State of Health

Single $218.28 $407.89 $415.67 $578.72 $606.44 $661.04 $662.26 $783.94

Single + Spouse $436.56 $815.78 $831.34 $1,157.44 $1,212.89 $1,322.08 $1,324.51 $1,567.87

Single + Child(ren) $371.08 $693.42 $706.63 $983.82 $1,030.95 $1,123.77 $1,125.84 $1,332.69

Single + Spouse + Child(ren) $622.09 $1,162.48 $1,184.65 $1,649.34 $1,728.37 $1,883.97 $1,887.43 $2,234.21

Child Only N/A $168.05 $171.26 N/A $249.86 N/A $272.84 $322.98

ROCHESTER REGION:

Individual Aggregation:Deductible: Each covered family member only needs to satisfy his or her own individual deductible (not the entire family amount). Once this amount is met, the member will pay a copay or coinsurance for covered services.

Out of Pocket Maximum (OOPM): Each covered family member only needs to satisfy his or her own OOPM. Once this amount is met, covered services are paid by the health plan.

Family Aggregation:Deductible: For plans covering more than one person, the entire family deductible must be met by one or any combination of covered members. Once this amount is met, members will pay a copay or coinsurance for covered services.

Out of Pocket Maximum (OOPM): For plans covering more than one person, the entire family OOPM must be met by one or any combination of covered members. Once this amount is met, covered services are paid by the health plan for the entire family.

Monroe

Livingston

Ontario

Wayne

YatesSeneca

Below are additional 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. (Plans with other FPLs are available.)

STANDARD NON-STANDARD

Plan Benefits & FeaturesSilver Standard Plus 3

(200-250% FPL)Silver Standard

(200-250% FPL**)Silver Select

(HSA** qualified, 200-250% FPL)

Tax Credit Available (On-Exchange Only) Yes Yes Yes

Deductible Single/Family $1,725 / $3,450 $1,100 / $2,200 $2,250 / $4,500

Out-of-Pocket Maximum (OOPM) Single/Family $6,500 / $13,000 $6,500 / $13,000 $5,500 / $11,000

Aggregation Type (How the deductible and/or OOPM is met) Individual Individual Family

Coinsurance You pay 25%* You pay 0%* You pay 20%*

Preventive Care (Immunizations, screenings) $0 for most preventive services, not subject to the deductible

Doctor Visit (PCP) First 3 PCP visits at $35, not subject to deductible; 4th and after, deductible/copay $30

Once you meet the deductible amount, then you pay 20% coinsurance or a percentage of cost for these services

Specialist Visit (SPC) $55 $50

Acupuncture Visit (up to 10) Not Covered Not Covered

Hospital Services $1,500 $1,500

Once you meet the deductible amount, then you pay 20% coinsurance or a percentage of cost for these services

Emergency Room $250 $250

Lab Work Primary/Specialist $35 PCP / $55 SPC $30 PCP / $50 SPC

Basic X-Ray/ Advanced Imaging (MRI, etc.) Primary/Specialist $35 PCP / $55 SPC $30 PCP / $50 SPC

Prescription Drugs





Once you meet the deductible amount, then you pay:$5 for Tier 1

$45 for Tier 2$90 for Tier 3

Telemedicine - MDLive Program Included Included Included

Pediatric Vision* Covered Covered Covered


Single $578.72 $606.44 $521.56

Single + Spouse $1,157.44 $1,212.89 $1,043.11

Single + Child(ren) $983.82 $1,030.95 $886.65

Single + Spouse + Child(ren) $1,649.34 $1,728.37 $1,486.44

Child Only N/A $249.86 N/A

fpullano

Highlight

Need help choosing the right plan for you? Call our dedicated Insurance Agents at 1-866-613-8506.

9:15 AM 75%

1 2 3

4 5 6

7 8 9

* 0 #

Get up to $400 or $600 a year toward qualified fitness facility dues and/or fitness classes with our ExerciseRewards™ Program

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

Essential Plan - Rates as low as $0 a month for eligible individuals Eligibility is based on your household size, income and other eligibility requirements. Essential Plan 1 and 2 feature packages with and without vision and dental benefits. If you choose to enroll in a plan that includes this coverage, there is an added monthly cost. Vision and dental benefits are always included with Essential Plan 3 and 4. To find out if you qualify for the Essential Plan, call our dedicated insurance agents.

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. ***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.gov/immigrants/immigration-status// or call the NY State of Health at 1-855-355-5777.) ††Rates for this plan will depend on what county you live in.

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

Annual Income Eligibility for Essential Plan

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

$17,237 - $24,980 $0 - $17,236

$23,337 - $33,820 $0 - $23,336

$29,436 - $42,660 $0 - $29,435

$35,536 - $51,500 $0 - $35,535

$41,636 - $60,340 $0 - $41,635

$47,735 - $69,180 $0 - $47,734

Plan Benefits & Features

Essential Plan 1(151% - 200% FPL)

Essential Plan 1 Plus Vision and Dental

(151% - 200% FPL)


Essential Plan 2 Plus Vision and Dental

(139% - 150% FPL)


Essential Plan 4(Below 100% FPL)

Deductible $0 $0 $0 $0 $0 $0

Coinsurance 0% 0% 0% 0% 0% 0%

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

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

Doctor Visit $15 $15 $0 $0 $0 $0

Specialist Visit $25 $25 $0 $0 $0 $0

Hospital Services $150 $150 $0 $0 $0 $0

Emergency Room $75 $75 $0 $0 $0 $0

Lab Work $25 $25 $0 $0 $0 $0

Basic X-Ray/ Advanced Imaging (MRI, etc.) $25 $25 $0 $0 $0 $0

Adult Vision Exam

Not Available

$15

Not Available

$0 $0 $0

Glasses and Contact Lenses 10% $0 $0 $0

Adult Dental Coverage Included Yes Yes Yes Yes

Telemedicine - MDLive Program $10 $10 $0 $0 $0 $0

Prescription Drugs


You pay:$1 for Tier 1$3 for Tier 2$3 for Tier3

You pay:$0 for Tiers 1-3


Single $20 $39.99 - $40.21†† $0 $30.67 - $31.21†† $0 $0

NON-STANDARD

Plan Benefits & FeaturesBronze Select

(HSA** qualified)Silver Select

(HSA** qualified)Gold Select Platinum Select

Tax Credit Available (On-Exchange Only) Yes Yes Yes Yes

Deductible Single/Family $5,000 / $10,000 $2,400 / $4,800 $750 / $1,500 $0 / $0

Out-of-Pocket Maximum (OOPM) Single/Family $6,550 / $13,100 $6,900 / $13,800 $7,850 / $15,700 $6,350 / $12,700

Aggregation Type (How the deductible and/or OOPM is met) Family Family Individual Individual

Coinsurance You pay 50% You pay 20%* You pay 0%* You pay 0%*

Preventive Care (Immunizations, screenings)

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




Doctor Visit (PCP)

Once you meet the deductible amount, then you will pay 50%

coinsurance (a percentage of cost for services)

Once you meet the deductible amount, then you pay 20%

coinsurance or a percentage of cost for these services

$25 $15

Specialist Visit (SPC) $40 $25

Acupuncture Visit (up to 10) $40 $25

Hospital Services $750 $750

Emergency Room $250 $150

Lab Work $40 $25

Basic X-Ray/ Advanced Imaging (MRI, etc.) Primary/Specialist $40 PCP / $100 SPC $15 PCP / $100 SPC

Prescription Drugs

Once you meet the deductible amount, then you pay:

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

Once you meet the deductible amount, then you pay:

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


not subject to deductible

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

Telemedicine - MDLive Program Included Included Included Included

Pediatric Vision* Covered Covered Covered Covered


Single $406.29 $521.56 $665.82 $785.88

Single + Spouse $812.57 $1,043.11 $1,331.65 $1,571.75

Single + Child(ren) $690.69 $886.65 $1,131.90 $1,335.99

Single + Spouse + Child(ren) $1,157.92 $1,486.44 $1,897.60 $2,239.75

Child Only N/A N/A N/A N/A

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. Any one person insured on a family plan will not pay more than $8,150 in compliance with the Affordable Care Act. The rates shown do not include coverage for dependents through age 29 or respective 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. Subsidized health plans are not eligible for health savings accounts. Unless noted above, the deductible must be met first before paying the cost share listed for all benefits. Note to diabetic drug and supply users: In accordance with the contract language / benefit mandates provided by New York State, if your plan includes a deductible, diabetic drugs and supplies are subject to the deductible amount.

ROCHESTER REGION:

NEW FOR 2020:Acupuncture: All non-standard plans cover up to ten acupuncture visits per year.

Bronze Standard 3 PCP Visits Covered in Full: On the Bronze Standard plans, your first three Primary Care Physician visits are covered in full, even if your deductible hasn’t been met.

Monroe

Livingston

Ontario

Wayne

YatesSeneca

certified health insurance plan options rochester … · the benefits and out-of-pocket costs for...

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