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Home My WebLink AboutResolution #5417 RESOLUTION NO. 5417 A RESOLUTION APPROVING GROUP DENTAL AND VISION PLANS FOR THE CITY OF CANTON EMPLOYEES AND RETIREES,EFFECTIVE MAY 1,2023,AND AUTHORIZING THE MAYOR AND/OR THE CITY CLERK TO EXECUTE ALL NECESSARY AND RELATED AGREEMENTS AND DOCUMENTS IN RELATION TO SAID INSURANCE PLANS WHEREAS, the City of Canton, Illinois (the"City")provides dental and vision insurance to not only its various Union employees, but also to certain non-Union employees and elected officials; WHEREAS, the City and the Insurance Committee investigated and determined what options would be available for dental and vision insurance purposes to continue said coverage for City employees; WHEREAS, the City, upon discussion and recommendation of the Insurance Committee, has determined that it is necessary and in the best interest to obtain group dental and vision insurance through Blue Cross Blue Shield of Illinois for the policy term period May 1, 2023 through April 30, 2024. NOW, THEREFORE, BE IT RESOLVED BY THE MAYOR AND THE CITY COUNCIL OF THE CITY OF CANTON,FULTON COUNTY, ILLINOIS AS FOLLOWS: l. The proposed dental and health insurance plans with Blue Cross Blue Shield of Illinois for policy year May 1, 2023 — April 30, 2024, as set forth in "Exhibit A," are hereby APPROVED. 2. The Mayor and the City Clerk are hereby authorized and directed to execute and deliver any and all agreements and/or other related documents to obtain group dental and vision insurance with Blue Cross Blue Shield of Illinois on behalf of the City for May 1, 2023 — April 30, 2024. 3. This Resolution shall be in full force and effective immediately upon its passage by the City Council of the City of Canton and approval by the Mayor thereof. PASSED AND APPROVED THIS 28th day of March, 2023. AYES: Alderpersons Chamberlin, Lovell, Grimm,Hale, Lingenfelter, Gossett NAYS:None ABSENT: Alderpersons Nelson, Fritz APPROVED: By: ww) al Kent McDowell, Mayor ATTEST: �Iljotii6 - Andrea Y Smith-Walters, City Clerk UIncCrts+:Muk'shrcla Q,�� of IlGnals Account Nam Clty of Canton jAccount Number: 1389388 ji1onowal pate: _FSi-imo2s Grandfathered Health Plan Form The Affordable Care Act(ACA)provides that certain group health insurance coverage in which an individual was enrolled on rvlaich 23,2010(ACA's date of enactment)maybe a'grandlalhered health plan:Grandfathered health plans are not subject to certain ACA provisions.Among other requirements,in order to maintain grandfatheretl health plan status,an Employer's or employee organization's contribution rate toward the cost of any tier of coverage cannot decrease by more Than five(5)percentage points since March 23,2010. This Grandfathered Health Plan Form must be sinned by the group representative and returned to our offices by the standard renewal paperwork deadline in order to certify your grandfatheretl health plan design.If a plan is modified to a non-grand lathered health plan design on Its effective dale.it cannot later revert back to a grandfathered health plan design For more information on grandfatheretl health plans and what changes or events may cause a plan to lose grandfathered health plan status,go online to:bcbsil.com(PDFtaca_grand(athered_plans_ii.pdf.If you have questions regarding this worksheet,contact your insurance broker(if applicable)or your BCBSIL account representative.The rules related to gmndfathered health plans are complex.We recommend that you seek the advice and guidance of your legal counsel regarding ACA and grandfalhered health plans.If you believe a plan or policy has fast or will lose grandfatheretl status,contact your insurance broker(if applicable)or BCBSIL representative immediately for available benefit plan options. Check the"Grandfathered?"box for only the benefit plan(s)in effect that qualify for and that you wish to renew with a grandfathered health plan design. only Faintly Employee P893$9 aPP72322 lr vet r-Ha FS6a3<7 S2.(>36.25 S2 ` }asT rr 003.66 53.701.51 5592 91, 51.12591 9u._9P95069 hPS91605 5925.2U 51943.01 S1S70.-552388.5 S5_ $1045 I-Yes l`NO T Yes To BE SIGNED BY THE GROUP REPRESENTATIVE: 1,the undersigned,a duly authorized representative of the policyholder named above('Policyhoiderl,hereby:(1) represent that I am knowledgeable as to standards associated with a"grandfathered health plan"as set forth in the Affordable Care Act and applicable regulations.and that the information contained in this Grandfathered Health Plan Form,and any subsequent updates to such Form,are true,complete and accurate;(fi)agree that the Foficyholder will immediately provide BCBSIL with written notice prior to renewal(and during the plan year,with at least 60 days advance writfen notice)of any changes to the employers or employee organization's contribution rate toward Ilia cost of any tier of coverage;and(u)agree that BCBSIL:elalns the authority to determine,at its sole discretion•whether any health insurance coverage constitutes a grandfathered health plan under the Affordable Care Act,applicable regulations and interpretations thereof, Print ame nnI We LAI 3(3 b/aoa-3 wgna re a e Cross are Sue Sraetd d Ilyn,^.!s,a O,Jtscn ty H:ath Cara Sehi:a Cerim-ea n. c R'^•"Legal Rese"Canpmre/.an indapea;,m Umwes or tn?Shm Cross a aJ Saw Sr e%d Ass==on Dearborn Life Insurance Company Application for Group Insurance Administrative Offices:701 E.22nd Street,Lombard,Illinois 60148 0 New Application ❑ Change Group#: VF028164 Federal Tax 1D# 37-6000876 Section 1.POLICYHOLDER INFORMATION: Please Type or Print All lnformation. Policyholder(full legal name): City of Canton Address(not PO box): 2 N Main Street City Canton State: IL Zip: 61520 Subsidiaries or Affiliates to be covered: FYes;or [] No (If more than one,indicate on separate sheet and attach to this application) If Yes:Company Name: Address(not PO box): City: , State: Zip: Premium is payable on the first of the insurance month unless mutually agreed upon by the Policyholder and the insurance company. Section 2.GENERAL INFORMATION: Product Choice(Check all that apply) Policyholder will Requested *Replacing Contribute: Effective: Coverage Yes/No Group Term Life 0 AD&D: El 100%;or ❑ Other: % 05/01/2023 Yes I] Supplemental Life ❑ AD&D: 0%;or ❑ Other. % 05/01/2023 Yes 0 Voluntary Group Vision: I] o%;or ❑ Other. % 05/01/2023 Yes *Enclose a copy of each in force policy to be replaced. DNL9-516-0516 I R040119 I Z6183 Dearborn Life Insurance Company Application for Group Insurance Administrative Offices:701 E.22nd Street,Lombard,Illinois 60148 Section 3.POLICYHOLDER STATEMENT: The Policyholder or authorized representative(Policyholder)applies for a group insurance policy's)through Dearborn Life Insurance Company. The Policyholder represents and certifies that: I. This application must be approved in writing by Dearborn 5. If the Policyholder does not collect or pay premiums by the Life Insurance Company.Issuing the insurance policy is premium due date,the policy will terminate at the end of the evidence of approval.Coverage for insureds under the group policy's grace period;and policy is effective when the insured applies and is approved for coverage by Dearborn Life Insurance Company.The 6. Even with the purchase of a disability policy, the Policyholder will not collect premium from an insured who Policyholder may be required to buy disability coverage requires medical underwriting until Dearborn Life Insurance under a state disability benefit act or law;and Company approves the insured's application for coverage; and 7. The Policyholder will: a) send Dearborn Life Insurance Company applications of individual insureds prior to the 2. Dearborn Life Insurance Company will issue a policy only if eligibility date;b)give certificates to all insureds;c)report Dearborn Life Insurance Company decides that the group is changes in the insured group to Dearborn Life Insurance an acceptable risk based on Dearborn Life Insurance Company Company;and d)keep records of insured eligibility. underwriting practices and procedures; otherwise Dearborn Life Insurance Company has no liability except to refund 8. The information given and statements made on this premium.The Policyholder must return to individual insureds application are complete and correct. Misstatements or any part of the premium paid by those insureds;and omissions of information may affect the validity of any insurance policy issued and cause the denial of an otherwise 3. The premium rates are contingent, based on the accuracy valid claim. of insured eligibility data given to Dearborn Life Insurance Company by the Policyholder.Misstatements on an insured's 9. Statements made by the Policyholder are representations application or failure by the Policyholder or insured to report and not warranties.No statement made by any insured will new medical information before an insured's effective date of be used in any contest unless a copy of the instrument coverage may cause a change to the coverage or premium rate containing the statement is or has been given to the insured as of the policy effective date;and or, in case of death or incapacity of the insured, to his beneficiary or personal representative. 4. The Policyholder and insureds are subject to all the policy terms and provisions and trust agreements,if applicable.They may be amended from time to time,and This application and the payment of premium are consideration for any master policy and certificates issued.This application is part of any insurance policy issued.The authorized signature on this application is acceptance of the policy terms. DxuStpucd by: 4/4/2023 " Authorized Signature Date(Must be signed prior to Effective Date) Crystal L wilkinson Print Name and Provide Title Licensed Resident Agent(if required) DNL9-516-0516 2 R040119 I Z6183 P:o BlucCross BlueShield of H iuois ANCILLARY GROUP BENEFITS PROPOSAL ACCEPTANCE LETTER CITY OF CANTON VF028164 Policyholder Policyholder has reviewed the ancillary proposal from Blue Cross and Blue Shield of Illinois (BCBSIL)to provide ancillary insurance benefits for its employees. By signing below, Policyholder acknowledges that it accepts the BCBSIL proposal to insure its employees according to the agreed terms and conditions stated in the proposal with date and Quote ID/s indicated below. 05/01/2023 179803 (LIFE) 52621(VISION) Date Quote IDIs) Please note that the proposal provides only basic information on the features of our policy. In the event of conflict between the proposal and our policy,the terms of our policy will govern. Crystal Wilkinson 0 W 113 p Treasurer signature Title Crystal Wilkinson Print Name Insurance products issued by Dearborn Life Insurance Company,701 E 22nd St Suite 300,Lombard,IL 60148.Blue Goss and Blue Shield of Illinois is the trade name of Dearborn life Insurance Company,an independent licensee of the Blue Cross and Blue Shle/d Association.BLUE CROSS°BLUE SHIELD®and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association,an association of independent Blue Goss and Blue Shield Plans. City of Canton Employee Benefits-Effective date 5-1-2023 Carrier Coverage E ES EC ESC BCBS PPO medical $993.41 $2,086.26 $2,008.66 $3,101.51 BPP72322 BCBS HSA Medical $925.20 $1,943.01 $1,870.75 $2,888.55 M PS91605 BCBS PPO Dental $21.45 $42.90 $55.49 $84.41 Medical and Dental are on one billing statement City of Canton Acct.#389388 Also a bill: Parlin Ingersoll Library Also a bill : Canton Park District Ancillary Benefits Basic Life,Deps. Life,Vision&Supplement Life BCBS Vision $7.60 $14.44 $15.20 $22.35 BCBS Basic Life-ees: $40k $9.20 per ees. Life-dependents $3.88 per unit Supplement Life Age Rated for ees.,sp., and ch Summary of Benefits and Coverage: What this Plan Covers &What You Pay for Covered Services Coverage Period: 05/01/2023-04/30/2024 IpacC�nslllue$t,lclQ. MPS91605 BlueEdge HSA Coverage for: Individual/Family I Plan Type: HSA •#' orillinols The Summary of Benefits and Coverage(SBC)document wild help you choose a health Plan The SBC shows you flow you and the-plan would share the cost for covered health care services. NOTE: Information about the cost of this pLan.(called the premium)will be provided separately. This is only a summary. For more information about your coverage,or to get a copy of the complete terms of coverage,visit www.bcbsil.com/member/policy- forms/2023 or by calling 1-800-541-2768. For general definitions of common terms, such as allowed amount, balance billin%coinsurance, copayment, deductible provi er or other underlined terms see the Glossary.You can view the Glossary at https://www.healthcare.gov/sbe-glossary/or call 1-855-756-4448 to request a copy. --- - -- --- -- -- - -- ---------- ._......_........... ------ ME What is the overall Individual: Generally,you must pay all of the costs from providers up to the deductible amount before deductible? Participating/ this plan begins to pay. If you have other family members on the policy,the overall family Non-Participating $1,500 deductible must be met before the plan begins to pay. Family: Participating/ Non-Participating $3,000 Are there services covered Yes. Doesn't apply to certain This.plan covers some items and services even if you haven't yet met the deductible amount. before you meet your preventive care. But a copayment or coinsurance may apply. For example,this plater covers certain preventive deductible? services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/. Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of-pocket Yes. Individual: The out-of-pocket limit is the most you could pay in a year for covered services. If you have Umft for thisplan? Participating/ other family members in this plan.the overall family out-of-pocket limit must be met. Non-Participating $3,000 Family: Participating/ Non-Participating $6,000 What is not included in the Premiums,balance billed charges, Even though you pay these expenses,they don't count toward the out-of-pocket limit. out-of-pocket limit? and health care this Plan doesn't cover. Will you pay less if you use Yes. See www.bebsiil.com or call This plan uses a provider network.You will pay less if you use a provider in the plan network. a network provider? 1-800-541-2768 for a list of You will pay the most if you use an out-of-network provider, and you might receive a bill from Participating Providers. a provider for the difference between the provider's charge and what your plan pays(balance billing). Be aware,your network provider might use an out-of-network provider for some services (such as lab work). Check with your rovider before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL Non-HMO LG-2023 Page a of 5 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. D a o ° ® a e ° o . a ea ® A A 0 8 a , ° o ea e a aAl Primary care visit to treat an No Charge 20% coinsurance Acupuncture not covered. injury or illness Virtual visits may be available,please refer to If you visit a health care your policy for more details. provider's office or Specialist visit No Charge 20% coinsurance none clinic Preventive care/screening/ No Charge 20% coinsurance You may have to pay for services that aren't immunization preventive.Ask your provider if the services you need are preventive. Then check what your Ian will pay for. Diagnostic test (x-ray, blood No Charge 20% coinsurance If you have a test work) none Imaging CT/PET scans,MRIs) No Charge 20% coinsurance `^ Preferred generic drugs 20% coinsurance 20% coinsurance Certain women's preventative services will be If you need drugs to Non-preferred generic drugs 20% coinsurance 20% coinsurance covered with no cost to the member. For a treat your illness or Preferred brand drugs 20% coinsurance 20°i° coinsurance full list of these prescriptions and/or services, condition Non-preferred brand drugs 20% coinsurance 20% coinsurance please contact customer service.You may be More information about Specialty drugs 20% coinsurance 20% coinsurance eligible to sychronize your prescription refills, *please see your benefit booklet for details. prescription drug The amount you may pay per 30-day supply coveraae is available at of a covered insulin drug, regardless of https://wWw bcbsil,_ quantity or type,shall not exceed $100,when corn/rdrugj i -clruca. a -lis s obtained from a Preferred Participating or drug-lists Participating Pharmacy. If you have outpatient Facility fee (e.g., ambulatory No Charge 20% coinsurance surgery center) none surgery Physician/surgeon fees No Charge 20% coinsurance Emergency room care 10% coinsurance 10% coinsurance If you need immediate Emergency medical No Charge No Charge none medical attention transportation Urgent care No Charge 20% coinsurance If you have a hospital Facility fee (e.g., hospital No Charge 30p copayment/visit stay room) plus 20%coinsurance none Physician/surgeon fees No Charge 20% coinsurance Page 2 of 5 AW1 11Pay A 1 ° 1 1 ° 1 1 e ° ffi e 1 e 1 A ®tifee l 1 e . 1 / 1 tb ° e 1 A A 0 A e Outpatient services No Charge 20% coinsurance Preauthorization is required for Psychological testing; Neuropsychological testing; Electroconvulsive therapy; Repetitive If .you need mental Transcranial magnetic Stimulation;and health, behavioral Intensive Outpatient Treatment. health,or substance Virtual visits may be available for Outpatient abuse services services, please refer to your policy for more details. Inpatient services No Charge 300 copayment/visit plus 20% coinsurance none Office visits No Charge 20% coinsurance Cost sharing does not apply to certain preventive services. Depending on the type of services, copayment,coinsurance or deductible may apply. Maternity care may If you are pregnant include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional No Charge 20% coinsurance services Childbirth/delivery facility No Charge 300 copayment/visit none services plus 20% coinsurance Home health care No Charge 20°i° coinsurance Rehabilitation services No Charge 20% coinsurance Habilitation services No Charge 20% coinsurance none If you.need help Skilled nursing care No Charge 300 copayment/visit recovering or have plus 20% coinsurance other special health gurable medical equipment No Charge 20% coinsurance Benefits are limited to items used to serve a needs medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). Hospice services No Charge 20% coinsurance none Children's eye exam Not Covered Not Covered If your child needs Children's glasses Not Covered Not Covered none dental or eye care Children's dental check-up Not Covered Not Covered Page 3 of 5 Excluded Services& Other Covered Services: Services Your Plan Generally Does NOT Cover(Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture ® Dental care (Adult o Routine eye care Adult Cosmetic surgery o Long-term care - Weight loss programs � Other Covered Services(Limitations may apply to these services.This isn't a complete list. Please see your Plan document.) Bariatric surgery ® Infertility— teatment 4 per ene it perio ® Private-duty nursing ® Chiropractic care (30 visit max) o Non-emergency care when traveling outside the - Routine foot care(Only in connection with ® Hearing aids (for children 1 per ear every 24 U.S. diabetes) months,for adults up to $2500 per ear every 24 months) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:the pLan at 1-800-541-2768, U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA(3272) or www.dol.gov/ebsa/healthreform,or Department of Health and Human Services,Center for Consumer Information and Insurance Oversight,at 1-877-267-2323 x61565 or www.cciio.cros.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace-,visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights:There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your >i lan documents also provide complete information on how to submit a c aim appeal or a grievance for any reason to your Ilan. For more information about your rights,this notice, or assistance, contact: Blue Cross and Blue Shield of Illinois at 1-800-541-2768 or visit.www.bcbsil.com or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA(3272)or visit www.dol.00v/ebsa/healthreform.Additionally,a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) 527-9431 or visit http://insurance.illinois.gov. Does this plan provide Minimum Essential Coverage?Yes Minimum Essential Coverage generally includes IP ans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP,TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage,you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards?Yes If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay fora Ilan through the Marketplace. Language Access Services: Spanish (Espanol): Para obtener asistencia en Espanol, Ilame al 1-800-541-2768. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-541-2768. Chinese (rp3Z): -ip1j#jTf 1-800-541-2768. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-541-2768. To see examples of how this pLan might cover costs for a sample medical situation, see the next section. Page 4 of 5 About These Coverage Examples: ' depending. Y p Y providers - ..- ...._ u to -.-. . - .. This is not a cost estimator.Treatments shown are just examples of how this Ian might cover medical care.Your actual costs will be different on the actual care you receive,the aces our charge,and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the p>la_n. Use this information to compare the portion of costs you j might pay under different health plans.please note these coverage examples are based on self-only coverage. Peg s a ® e s 9 o e ° s o o 0 0 ® ® o e o� er o e o 0 o ® . s' imy) w4controlIed o e e • The Ip an's overall deductible $1,500 ® The plaWs overall deductible $1,500 m The plaWs overall deductible $1,500 ® Specialist $0 ® Specialist $0 ® Specialist $0 ® Hospital (facility) $0 ® Hospital (facility) $0 ® Hospital (facility) $0 • Other $0 ® Other $0 N Other $0 This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care(including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test(x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) i Total Example Cost 12,700 ! ; Total Example Cost 5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example,Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing , De uctib el s ---u—� $1,500 _ Ded ucti6 sle — $1,500 �Deducti6 el s $11500 Coaayments 0 Copayments 0 Copayments V Coinsurance 0 Coinsurance $400 Coinsurance $20 What isn't covered_ What isn't covered. _ What isn't covered Limits or exclusions _$60 Limits or exclusions $20 Limits or exclusions $0 The total Peg would pay is $1,560 i The total Joe would pay is j $1,9zu i ; The total Mia would pay is I- 1,520 The Ilan would be responsible for the other costs of these EXAMPLE covered services. Page 5 of 5 BlueCross B1ueSlueld of Illinois 0 0 Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex,gender identity, age, sexual orientation, health status or disability. To receive language or communication assistance free of charge, please call us at 855.710-6984. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: hfps://ocrportal.hhs.gov/ocr/portalAobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.htmi bcbsil.com B1ueCross BlueShield of Illinois If you,or someone you are helping, have questions,you have the right to get help and information in your language at no cost. To talk to an interpreter, call 855-710-6984. Espanol Si usted o alguien a quien usted esta ayudando tiene preguntas,Vene derecho a obtener ayuda a informacion en su idioma sin costo alguno. Para hablar con un interprete,Ilame Spanish a]855-710-6984. I 855-710 6984 cam+ 4 Js9 J e Arabic I I� c � tA�,.v.:till. aa1S.3 a,l c�s��'�`�'.JSJ.ail u��13 s.�ct.au31�L,c),9�-�I cs9 cal clt�'al:uWi o.�t�.,,� g,I Ji A.�BLS�I Chinese 'X �iiW —RJ6SK IE7ttAflb J 91aVA��, � .9 fIj� PARR �I as l 1 J f1�o AA—MRATA, � �a� VM 855-710-69840 Frangais Si vous,ou quelqu'un que vous 6tes en train d'aider,avez des questions,vous avez le droit d'obtenir de]'aide et('information dans votre langue a aucun coot.Pour parler a un French interprete,appelez 855-710-6984. Deutsch Falls Ste oderjemand, dem Sie helfen,Fragen haben, haben Sie das Recht,kostenlose Hilfe and Informationen in Ihrer Sprache zu erhalten. Um mit einem Ddmetscher zu German sprechen,Men Sie bitte die Nummer 855-710-6984 an. DIOdRL& -sl ctu-k ZL$-tctt dal �-tEE sit z(ztt slzl dal Bits cft c tsa-1 ;7zt.(4t.CL34. 8Mu 34 CttCtcl ��tl slzt, dl ctu!A taatt ct)-Ot c-Lttttui. 3-LEE 14-1 Gujarati 3ALRt c{l 4Utctcltatt sbsa 0. F�tittIAztt ;it2L ollci 82 ct1 �-tt� Ott *t t2 855-710-6984 'd2 BIC-t S Z. f4z� 3frq-O�, ur 3Tm fir uFzF r z5T T' t tTr47, v� f, cfr 3uq--'P� 3mwt err ar f�r:Fw err 3FR zilm-hTt wcj wc�:r Bh7 yftT t7l Hindi Wl' 3�� TT art W�T W r4CT 855-710-6984 qZ- WW q4l. Italiano Se to o qualcuno the staff aiutando avete domande, hai i] diritto di ottenere aiuto a informazioni nella tua lingua gratuitamente.Per padare con un interprete,puoi chiamare it Italian numero 855-710-6984. LE-�ii01 2-10-11 :-IoF g� A801- e A[ROI -N`OI 5tCfc�q 41of` T—a-i�-! Di'_1LF 25-f oi5YEl -181—1 0+01-i32- Cz T %L �1P-17f 5.tet-ICf. o0 1A01- Korean M Q 8[A I 0 855-710-6984 -i a--- `111 of AN AI 4. Dine T'aa ni,ei doodago la'da b16 ananilwo'igii,na'idilkidgo,ts'ida bee na ahooti'i't'aa niik'e nika a'doolwol doo bina'idilkidigii bee nil h odoonih Navajo Ata'dahalne'igii bich'i'hodiilnih kive'e 855-710-6984. JU oJUw L3ESL"L5.4 t? s i L: - alai L:AL i ulc—�kLI y,- d CjL'ul� �sb a�c�yy�jL,ja,aS �I�IJ�yl Lj� Persian 855-710-6984 -1�vt3 L�-L-L-3. Polski Je§li Ty lub osoba,ktorej pomagasz, macie jakiekolWek pytania, macie prawo do uzyskania bezplatnej informacji i pomocy we wlasnym jgzyku.Aby porozmaWac z Polish tlumaczem,zadzwon pod numer 855-710-6984. PycCKM6 Ecm4 y sac 14FIM 4enOBeKa, KOTOpOMy Bbl noMoraeTe,B03HMKFIM BOnpOCbl,y Bac eCTb npaBo Ha 6ecnllaTHYIO nOMOL4b 11 11HCl)OpMa4W1O, npeAOCTaBneHHyD Ha BaweM A3blKe. Russian LITo6b1 CHg3aTbC3q c nepeBoAtmKOM, n0390HVITe no TenedpOHy 855-710-6984. Tagalog Kung ikaw,o ang isang taong iyong tinutulungan ay may mga tanong,may karapatan kang makakuha ng tulong at impormasyon sa iyong wika nang walang bayad. Upang Tagalog makipag-usap sa isang tagasalin-wika,tumawag sa 855-710-6984. 3.�Jt Urdu urs JIB A 855-710-6984,e d G'S GO�dy e—V e �'" G"6r- K AIL Jsl ct-&j cs;l 4,o e 0 cr,Ujl Jl xr c's��crN c'OrS Tieng Viet Ne"u quy v], hoac ngLrd ma quy vi gi6p W,cb cau hai,thi quy vi co quy6n durgc gulp MY va nh�n thong tin bang ngon ngCr cua minh mien phi.De not chuyOn vbi mot thong Vietnamese dich vien,gqi 855-710-6984. bcbsil.colm Summary of Benefits and Coverage: What this Plan Covers &What You Pay for Covered Services Coverage Period: 05/01/2023-04/30/2024 BPP72322 BluePrint PP® Coverage for: Individual/Family I Plan Type: PPO f erage document wi I help you choose a ea e shows you ow you an the plan would T e Summary o Benefits and Coverage(SgCy-d oku m-------- I -____ ' h S9C_ Iio__ h_ d--h-__ shiri the cost for covered health care services. NOTE: Information about the cost of this p an (called the premium)will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage,visit www.bcbsil.com/member/policy- forms/2023 or by calling 1-800-541-2768. For general definitions of common terms, such as allowed amount, balance billing . coinsurance copayment deductible provider or other underlined terms see the Glossary.You can view the Glossary at https://www.healthcare.gov/sbc-glossary/or call 1-855-756-4448 to request a copy. What is the overall lndi;7i—d6al: Participating -5 0 Generally,you must pay all of the costs from providers up to the deductible amount before deductible Non-Participating $1,000 this Ulan begins to pay. If you have other family members on the plan each family member Family is equivalent to 3 must meet their own individual deductible until the total amount of deductible expenses paid individuals. by all family members meets the overall family deductible. Are there services covered Yes. Doesn't apply to certain This plan covers some items and services even if you haven't yet met the-deductible amount. before you meet your preventive care. Copays and per But a copayment or coinsurance may apply. deductible occurrence Deductibles don't count toward the Deductible. Are there other Yes. 000 Deductible for You must pay all of the costs for these services up to the specific deductible amount before deductibles for specific Non-Participating hospital this plan begins to pay for these services. services? admission.There are no other specific Deductibles. What is the out-of-pocket Yes. Individual: The out-of-pocket limit is the most you could pay in a year for covered services. lhnft for this plan? Participating $1,000 Non-Participating $2,000 Family is equivalent to 3 individuals. What is not included in the copay men ts, Deductible Even though you pay these expenses,they don't count toward the out-of-pocket limit. out-of-pocket limit? Premiums balance billed charges and health care this Plan doesn't cover. Will you pay less if you use Yes. See www.bcbsil.com or call This plan uses a provider network.You will pay less if you use a provider in the plan's network. a network provider? 1-800-541-2768 for a list of You will pay the most if you use an out-of-network provider and you might receive a bill from Participating Providerss. a provider for the difference between the provider's charge and what your pLafl pays(balance billing). Be aware,your network provider might use an out-of-network provider for some services (such as lab work). Check with your gm ider before you et services. Do you need a referral to No. You can see the specialist you choose without a referral. see a Alzgdi kWis ? I Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL Non-HMO LG-2023 Page 1 of 6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. j Willa 1 c ® ° ® . a ° e o o e e e a e 3 a e . ° e a a e . o e 0 Primary care visit to treat an $20 copayment/visit 30% coinsurance No benefits will be provided for services injury or illness which are not, in the reasonable judgment of Blue Cross and Blue Shield, medically nec If you visit a health care S ecialis visit 40 copayment/visit 30% coinsurance none provider's office or Preventive care/screenin 20 copayment/visit 30% coinsurance Individuals age 16 and over are limited to one clinic, immunization physical exam plus one gynecological exam per calendar year. You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will Pay for. Diagnostic test (x-ray, blood 10% coinsurance 30% coinsurance If you have a test work) none Imaging CT/PET scans,MRIs 10% coinsurance 30% coinsurance If you need drugs to Generic drugs 10/ 20 copayment/ 10 copayment/ Up to 30 day retail/90 day home delivery. For treat your illness or prescription prescription Out-of Network drug Provider you are condition Preferred brand drugs 20/ 40 copayment/ 20 copayment/ responsible for 25% of the eligible amount prescription prescription after the copay. You may be eligible to More information about Non-preferred brand drugs 35/ 70 copayment/ 35 copayment/ synchronize your prescription refills,*please prescription drug prescription prescription see your benefit booklet for details. The coverage is available at Specialty drugs Covered Covered amount you may pay per 30-day supply of a h1tps://www.bcbsi1. covered insulin drug, regardless of quantity comirx-d rug s/dmcjz fists or type,shall not exceed$100,when obtained dru -li is from a Preferred Participating or Participating _ Pharmacy. If you have outpatient Facility fee (e.g., ambulatory 10% coinsurance 30% coinsurance surgery surgery center) none Physician/surgeon fees 10%coinsurance 30% coinsurance *For more information about limitations and exceptions, see the plan or policy document at www.bcbsil.com/member/policy-forms/2023. Page 2 of 6 ® ° common o . e e e e e . e e a e A e e B 1 . e 0 Will 0 ° e B 9 WI IB "farm e eAV Emergency room care $150 copayyment/visit $150 copayment/visit I copayment waived if admitted. If you need immediate Emergency medical 20% coinsurance 20% coinsurance medical attention transportation none _ Urgent care 10% coinsurance 30% coinsurance If you have a hospital Facility fee (e.g., hospital 10% coinsurance 30% coinsurance 300 Deductible per admission for stay room) Non-Participating Providers. _ Physician/surgeon fees 10% coinsurance 30% coinsurance none Outpatient services 10%coinsurance 30% coinsurance Preauthorization is required for Psychological If you need mental testing; Neuropsychological testing; Electroconvulsive therapy; Repetitive health,behavioral Transcranial magnetic Stimulation;and health,or substance Intensive Outpatient Treatment. abuse services Inpatient services 10% coinsurance 30% coinsurance 300 Deductible per admission for Non-Participating Providers. Office visits 20 copayment 30% coinsurance Copayment applies to first prenatal visit per pregnancy.Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance or deductible may apply. Maternity care may include tests If you are pregnant and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional 10% coinsurance 30% coinsurance services $300 Deductible per admission for Childbirth/delivery facility 10% coinsurance 30% coinsurance Non-Participating Providers. _ services Home health care 10% coinsurance 30% coinsurance Rehabilitation services 10% coinsurance 30% coinsurance Habilitation services 10% coinsurance 30% coinsurance none If you need help recovering or have oinsurance Skilled nursing care 10% coinsurance 30% c other special health Durable medical equipment 10% coinsurance 30% coinsurance Benefits are limited to items used to serve a needs medical purpose. DME benefits are provided for both purchase and rental equipment(up to the purchase price). Hospice services 10% coinsurance 30% coinsurance none Page 3 of 6 WhatBill Pak Common ° 0 1 ° 0 1 B ° 1 1 @ fxopp ',on A p sMay ervleWVou, A ' B A A B44so povi1 1 1 / 0 1 Children's eye exam Not Covered Not Covered If your child needs Children's glasses Not Covered Not Covered none dental or eye care Children's dental check-up Not Covered Not Covered Excluded Services&Other Covered Services: Services Your Plan Generally Does NOT Cover(Check your policy or plan document for more information and a list of any other excluded services.) ® Acupuncture ® Long-term care ® Routine eye care A u t ® Cosmetic surgery ® Most coverage provided outside the United States. ® Weight loss programs ® Dental care (Adult) See www.bcbsil.com Other Covered Services(Limitations may apply to these services. This isn't a complete list. Please see your plan document.) A, Bariatric surgery ® Infertility treatment 4 completed oocyte retrieval o Private-duty nursing Chiropractic care maximum,with special approval up to 6 per ® Routine foot care (Only in connection with ® Hearing aids (for children 1 per ear every 24 benefit period) diabetes) months,for adults up to $2,500 per ear every 24 ® Non-emergency care when traveling outside the months) U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:the pLan at 1-800-541-2768, U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or wwwdol.gov/ebsa/healthreform, or Department of Health and Human Services,Center for Consumer Information and Insurance Oversight,at 1-877-267-2323 x61565 or www.cciio.cros.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim.This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your an documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights,this notice, or assistance, contact: Blue Cross and Blue Shield of Illinois at 1-800-541-2768 or visit www.bcbsil.com or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA(3272)or visit www.dol.gov/ebsa/healthreform.Additionally,a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) 527-9431 or visit http://insurance.illinois.gov. Does this plan provide Minimum Essential Coverage?Yes Minimum Essential Coverage generally includes plans , health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage,you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards?Yes If your plan doesn't meet the Minimum Value Standards,you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Page 4 of 6 Language Access Services: Spanish (Espanol): Para obtener asistencia en Espanol, Ilame al 1-800-541-2768. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-541-2768. Chinese (►$p3Z): , 1-800-541-2768. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-541-2768. To see examples of ow this plaij might cover costs or a sample medical situation, see th e next section. Page 5 of 6 About These Coverage Examples: This is not a cost estimator.Treatments shown are just examples of how this plan might cover medical care.Your actual costs will be different ' depending on the actual care you receive,the prices your providers charge,and many other factors. Focus on the costsharing amounts (deductibles,copayments and coinsurance) and excluded services under the VLan. Use this information to compare the portion of costs you might pay under different health ns. Please note these coverage examples are based on self-only coverage. 77 e a o D o u ° o o e o o ® e o e o e eo 0 0 0 0 s ® +" ® e eo o a e IN The plans overall deductible $500 a The Ip an's overall deductible $500 ® The Ip an►s overall deductible $500 M Specialist copayment $40 ® Specialist copayment $40 ® Specialist copayment $40 ® Hospital (facility)coinsurance 10% ® Hospital(facility)coinsurance 10% ® Hospital (facility) coinsurance 10% ® Other coinsurance 10% ® Other coinsurance 10% a Other coinsurance 10% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care(including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test(x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment(crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit(anesthesia) Durable medical equipment (glucose meter) Total Example Cost 12,700 ; Total Example Cost 5,600 ; i Total Example Cost 2 800 —_�_. In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: .Cost Sharing` -- _Cost Sharing _ _ Cost Sharing. DeeductibTes 500 Defiuctib-1es -- 500 De uctb el s — $500 Copayments $70 Copayments 500 Copayments $300 Coinsurance $70 Coinsurance $10 Coinsurance $100 What isn't covered _ What isn't covered What isn't covered_ Limits or exc usions $60 Limits or exclusions $20 Limits or exclusions —$0 The total Peg would pay is ; The total Joe would pay is 1,030 ! ; The total Mia would pay is i 900 The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 6 . B1ueCross B1ueShield offlKnois -ro.o-a.mu�,,.ac.m.um,.roe4e snae,�aum Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age, sexual orientation, health status or disability. To receive language or communication assistance free of charge, please call us at 855-710-6984. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html bcbsil.com BlueCross B1ueSWeld ®,v oflllinois NMMime(NeJNGve ServkeCnpwnPm,aMW W14ga1Pese.re Cnmpvry, anlndepmtlme NanxedNe dueGma eMeF,eSniddnuma W n If you,or someone you are helping,have questions,you have the right to get help and information in your language at no cost. To talk to an interpreter, call 855-710-6984. Espanol Si usted o alguien a quien usted esta ayudando tiene preguntas,gene derecho a obtener ayuda a informaci6n en su idioma sin costo alguno. Para hablar con un int6rprete,(lame Spanish al 855-710-6984. auy,3i Arabic 1855-710-6984?,Jl �,J,�l 64-)jA y. °L!a--D. asLSJ a,l'DJa v° A9 T X 7FH71</L a Ny�L J1_ I+dJN,+ +r�L13�� /L�� "IIrI� ��IL�lia _� �6 y�i 1 O Chinese `Jp411�f1A1,�.P ,Ai;�j—Tl ate, UA � � 855-710 6984 Frangais Si vous,ou quelqu'un que vous etes en train d'aider,avez des questions,vous avez le droit d'obtenir de I'aide et('information dans votre langue a aucun coot.Pour parler&un French interprete,appelez 855-710-6984. Deutsch Falls Sie oderjemand,dem Sie helfen,Fragen haben, haben Sie das Recht,kostenlose Hilfe and Informationen in Ihrer Sprache zu erhalten. Um mit einem Dclmetscher zu German sprechen,Men Sie bitte die Nummer 855-710-6984 an. OJO�Qktt Odl ctl-tc� :btuctt c-A I-tEE aft zatt 51u �Actt 819 o[tv czt[aack ;7ziAt.;Au. siu��-t 646-Lcl '�Rl512, c-tl c04-1 [d-tt I►ttl?, ct}•Ot Qit-t�tiui 466 bt-1 Gujarati 34RMt 4ulct-LL-i FQitR2tt COL citct Butt 14 zlt *4R 855-710-6984 'iR BIC-1 39q*, err arrq• 'fir UPTF EFT ;; tU47, q�� :fr aXT21`7 3M--;ft -rwr ai f�r:aT(;:W RFzrcTr 3ftz onawtr WuF w�w zb r 3ftWrz t l Hindi fWr 3mzml • U Z117 ZF i EF f�I`CT 855-710-6984 qT WW f° I. Italiano Se to o qualcuno the staff aiutando avete domande, hai it dritto d ottenere aiuto a informazioni nella tua lingua grahlitamente.Per parlare con un interprete,puoi chiamare it Italian numero 855-710-6984. EF01 0f0 1 �1lof 5E` �loE7E l�Fo01 ��01G°� �lol $�� ziLr �a�t oi�z �lof�l �01� Cz T �!` ai_I7E �tet�ICF. o�Af7F Korean E 210 AI c 855-710-6984 El k[8 f d'hl 4. Dine T'ad ni,ei 400dago la'da bilca ananilwo'igii,na'idilkidgo,ts'idd bee na ah66ti'i'f6A niik'e nika a'doolwol d66 bina'idilkidigli bee nil h odoonih. Navajo Ata'dahahie'igii bich'i'hodiilnih kNve'e 855-710-6984. ".Ju e,)L-,t t L sl&w�Ji°cS Ls Persian 411 y.n a sii5 G dS yl a� 855-71 D-6984 Polski Jesli Ty lub osoba,kt6rej pomagasz, macie jakiekolwliek pylania, macie prawo do uzyskania bezplatnej informacji i pomocy we wlasnym jgzyku.Aby porozmawiac z Polish tiumaczem,zadzwrorl pod numer 855-710-6984. PYCCK14A Ecilm y sac NnW 4enoBeKa, KOTOpOMy Bbl noMoraeTe,B03Hl4Kn14 BOnpOCbl,y BaC eCTb IlpaBo Ha 6ecnnaTHylo nOMOLl b H IMPOPM 41410, npeAocTaBneHHyio Ha BaweM A3blKe. Russian 4To6b1 CB513aTbCq c nepeeoA4HKoM, nO3BOHMTe no TenegboHy 855-710-6984. Tagalog Kung ikaw,o ang isang taong iyong tinutulungan ay may mga tanong,may kampatan kang makakuha ng tulong at impormasyon sa iyong w ika hang walang bayad. Upang Tagalog makipag-usap sa isang tagasalin-wika,tumawag sa 855-710-6984. Urdu �JiL 855-710-6984�G¢d G�Lill;6-Gd°�CSw•�°car_ l e-U�plc 6-il!-.J3I•'•�'=4-Lq-A( I,L.5;,1 i,�c°u`�,l J1a)-,AiA 1Uk d�}��y1 ors L)-C,s-)j�—.I s-�l Sys yi_4 Ti4ng Vint N6u quy vi, ho c ngv&i ma quy vi giup dam,c6 cau h6i,thi quj vi co quy�n dLrgc giup MY W nh�n thong tin bAng ngon ngCr c6a minh mien phi.De n6i chuycn vai mot thong Vietnamese dich vien,gqi 855-710-6984. bcbsilxom