HomeMy WebLinkAboutResolution #5418 RESOLUTION NO. 5418
A RESOLUTION APPROVING A GROUP LIFE INSURANCE PLAN 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 PLAN
WHEREAS, the City and the Insurance Committee investigated and determined what
options would be available for life 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 the life insurance policy and
coverage 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:
1. The proposed group life insurance with Blue Cross Blue Shield of Illinois for policy year
May 1,2023 —April 30,2024, as set forth in"Exhibit A,"is 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 life 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 28ffi day of March, 2023.
AYES: Alderpersons Chamberlin,Lovell, Grimm,Hale,Lingenfelter, Gossett
NAYS:None
ABSENT: Alderpersons Nelson,Fritz
APPROVED:
By: I
Kent Mc 0��owel ayor
ATTEST: Ali
Andrea 1. Smith-Walters, City Clerk
� inu�c�.n.tstnrswcla
ACeount Nam City of canton jAccount Number: 1389388 lRonowal Date: 151112023
Grandfathered Health Plan Form
The Affordable Care Act(ACA)'provides that certain group health insurance coverage in which an individual was enrolled
on March 23:2010(ACA's date of enactment)may be a-grandfathered health plan,'Gaandfalhered health plans are not
subject to certain ACA provisions.Among other requirements,in order to.maintain grandfathered health plan status;an
employers 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 Grandfalhored Health Plan Form must be signed bvthe group representative and returned to our offides by the standard
renewal paperwork deadline in'ordor to certify your.grandfathered health plan.design:If a plan is modified to a non-grandfathered
health plan design on its effective dale,it cannot later revert back to a grandfahered heai,h.plan design
For more information on grandfathered health plans and what changes or events may cause a plan to lose.grandfathered health plan.
status,go online to:bcbsfi.cont/PDF/aca_grandfatliered_plans il.pdf.If you have questions regarding this workstleat,contact your
insurance broker(tf applicabte)-or your BCBSIL account representative.The rules related to grandfathered health plans are complex.We
recommend that you seek the advice and guidance of your legal counsel re.garding:ACA'and grandfa0hered health plans:If you believe a
plan or policy has lost orwill lose grandfathered status,contact your insurance broker(if applicable)or BCBSIL representative
immediately for available benefit plan options.
Check the"Grandfathered4"box for only the benefit plan(s)in effect that quality for and that you wish to renew with a
grandfathered health plan design.
only
*,Spouse WiChIldiron) Mary
Employ" Family',!"
P89388 EPP72322 9 Yea r-Ho $993A7 $2.08G.20 S2.00a.66 $3.101.51 S56295 S11125.91
r'Yas C Ho $925.20 S1,943.01 -r $23R8.55
P95069 MPS91605 S1S70. 5 S52L29 51048.59
!-Yea t!o
C yey C tto
TO BE SIGNED BY THE GROUP REPRESENTATIVE:
1,the undersigned,a duty authorized representative of the policyholder named above(Policyholder,hereby:(i)
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 Grandfalhered Health Plan
Form,and any subsequent updates to such Form,are true,complete and accurate;(it)agree that the Policyholder will
immediately provide BCBSIL wilh'wrigen notice prior to renewal(and during the plan year.With at least 60 days advance
written notice)of any changes to the employer's or employee organization's contribution rate twiard the,cost of any tier of
coverage;and(fii)agree that BCBSIL retains the authority to determine,at its sole discretion,whetherany health'
insurance coverage constitutes a grandfathered health plan under the Affordable Care Act,applicable regulations and
interpretations thereof,
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Dearborn Life Insurance Company AppLcahon for Group Insurance
Administrative Offices:701 E.22nd Street,Lombard,Illinois 60148
0 New Application ❑ Change Group#: VF028164 Federal Tax ID#. 37-6000876
Section 1.POLICYHOLDER INFORMATION: Please Type or Print All Information.
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: Yes;Or 0 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 Z.GENERAL INFORMATION:
Product Choice(Check all that apply) Policyholder will Requested *Replacing
Contribute: Effective: Coverage
Yes/No
t_I Group Term Life El AD&D: M 100%;or ❑ Other. off, 05/01/2023 Yes
Supplemental Life ❑ AD&D: El 0%;or ❑ Other. ova 05/01/2023 Yes
Voluntary Group Vision: 0 0%;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:
1. 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.
Dxusta"d try:
4/4/2023
Authorized Signature Date(Must be signed prior to Effective Date)
Crystal L wi1kinson
Print Name and Provide Title Licensed Resident Agent(if required)
DNL9-516-0516 2 R040119 I Z6183
B1ucCross BlucShield of Illinois
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 ID(s)
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.� signed 113� Treasurer
signature Title
Crystal Wilkinson
Print Name
Insurance products Issued by Dearborn life Insurance Company,701 E.22nd St.Suite 300,Lombard,IL 60149.Blue Cross and Blue Shield of Illinois is the trade name of
Dearborn Life Insurance Company,an independent licensee of the Blue Cross and Blue Shield Assodation.BLUE CROSS®BLUE SHIELD°and the Cross and Shield
symbols are reghtered service marks of the Blue Cross and Blue Shield Assodation,an association of independent Blue Cross 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
019 °�""'°'' 1j1 �s� I t: MPS91605 BlueEdge HSA Coverage for: Individupl/Family I Plan Type: HSA
.:
0 The Summary of Benefits and Coverage(SBC)document will he p yoachoose a healthl�an.The SBC shows you how you and the Plan would share
the cost for covered health care services. NOTE: Information about the cost of this Ilan (called the rep mium)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.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.
po 1
What is the overail 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 plan 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
limit for this plan? 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.bcbsil.com or call This plan uses a provider network.You will pay less if you use a provider in the Ip an'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 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 rod vider before you get services.
Do you need a referral to No. You can see the specialist you choose without a referral.
see a s ecialis ?
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 5
E� All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. _ J
Ad
Common • • Other Importani
'ProviderServices You May Need
Medical Event (You will,pay the least)
Primary care visit to treat an No Charge 20% coinsurance Acupuncture not covered.
injury or illness Virtual visits may be available,please refer to
your policy for more details.
If you visit a health care Specialist visit No Charge 20% coinsurance none
provider's office or Preventive care/screening/ No Charge 20% coinsurance You may have to pay for services that aren't
clinic immunization preventive.Ask your provider if the services
you need are preventive. Then check what
your pJan 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% 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,
dru Thle amount ease see your
rmay pa booklet r30-day supply
prescription g Y YP pay per Y PPY
coverage is available at of a covered insulin drug, regardless of
https://www.bcbsil. quantity or type,shall not exceed $100,when
com/rx-drugs/drug-lists/ 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 300 copayment/visit
stay room) plus 20% coinsurance none
Physician/surgeon fees No Charge 20% coinsurance
Page 2 of 5
Whit You Will Pay
Common ' e . e ' e eer No.n-Participating Limitations, e e Other Important
Services e e
e e e . Provider e e .y the Infe 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
Y P 9 elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery professional No Charge 20% coinsurance
services none
Childbirth/delivery facility No Charge 300 co a ment visit
services plus 20% coinsurance
Home health care No Charge 20% 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 Durable 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) • Routine eye care(Adult
• Cosmetic surgery • 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 treatment 4 per benefit period) • Private-duty nursing
• Chiropractic care (30 visit max) • 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 an 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.ems.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Haab
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 Ilan 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 plan
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 Administfation 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.
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 (q:13Z): PPjF,%Fr-P3ZnJmlr'M , 1-800-541-2768.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-541-2768.
To see examples of how this an might cover costs or a sample meirical situation, see the next section.
Page 4 of 5
About These Coverage Examples:
This is not a cost estimator.Treatments shown are just examples of how this p—lamn might cover medical'care.Your actual costs will be diff erent
depending on the actual care you receive,the prices your providers charge,and many other#actors. Focus on the cost sharing amounts
(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you
might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having,a Baby .b
months / B 1 1 of • • 1 / 1' 1• 1 foflowup
hospital 1• well-controlled condition
■ The Ip an's overall deductible $1,500 ■ The Ip an's overall deductible $1,500 ■ The Ian's overall deductible $1,500
■ Specialist $0 ■ Specialist $0 ■ Specialist $0
® Hospital(facility) $0 ■ Hospital(facility) $0 ■ Hospital(facility) $0
® Other $0 ■ Other $0 ■ 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)
Total Example Cost 12,700 I 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 I
Deductibles eses 1,500 De ucti es 1,500 Deductibles $1,500
Copayments 0 copayments 0 Copayments 0
Coinsurance $0 Coinsurance 400 Coinsurance 20
What isn't covered What isn't covered What isn't covered
Limits or ex c usions 60 Limits or exclusions 20 Limits or exc usions 0
The total Peg would pay is 1,560 , The total Joe would pay is 1,920 The total Mia would pay is 1,520
The plan would be responsible for the other costs of these EXAMPLE covered services.
Page 5 of 5
:.: B1ueCross BlueShield of Dlinois
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 855410-6984.
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/portalAobby.jsf
Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html
bcbsil.com
09 B1ueCross B1ueShield 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 855-71 Q-6984.
Espanol Si usted o alguien a quien usted esta ayudando tiene preguntas,tiene derecho a obtener ayuda a informaci6n en su idioma sin costo alguno. Para hablar con un interprete,(lame
Spanish a]855-710-6984.
�t 855-710 6984 (cc¢J 99 i� �„>;Z►. :�tS;al c�s� cSl1t�`�+-J sJ oil�� I,s�Lu a31�1,J,�Itl y�ls al,,,l o act,,S s>S �1 CJL"01
Arabic
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Chinese
Frangais Si vous,ou quelqu'un clue 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 cout.Pour parler a 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 Ddmetscher zu
German sprechen,Men Sie bitte die Nummer 855-710-6984 an.
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Hindi f� 3i�,w Tr WF � EF fr4v 855-710-6984 qT �c l.W
Italiano Se to o qualcuno the stai aiutando avete domande,hai it diritto di ottenere aiuto a informazioni nella tua lingua gratuitamente.Per parlare con un interprete,puoi chiamare it
Italian numero 855-710-6984.
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Korean W Q o}AI 0-4 855-710-6984 `l sf 8f&1 AI 4.
Dine T'aa ni,ei doodago la'da bilca ananilwo'igii,na'idilkidgo,ts'ida bee na ah66ti'i't'aa niik'e nikd a'doolwol d66 bina'idMcidigii bee nil h odoonih
Navajo Ata'dahalne'igii bich'j'hodiilnih lctve'e 855-710-6984.
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Persian 855-710-6984 Ali .
Polski Jesli Ty lub osoba,kt6rej pomagasz, macie jakiekolwiek pytania, macie pmwo do uzyskania bezplatnej informacji i pomocy we wlasnym jgzyku.Aby porozmawiac z
Polish tlumaczem,zadzwori pod numer 855-710-6984.
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Russian LIT06bl CBA3aTbCA c nepeBOAWKOM, 1103BOHhTe 110 Tene(pOHy 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.
Urdu •w-r�Jks r 855-710-6984 e—bY a-GU°K-.Y"•Go 6C K 4-6l'J.-IC 64--JS1 (Ym j-6 ul'�J-S;�T-ic,Go cloy Jl.xrn U� k}' s` .1 j W.l Lo.S l `$4�'T_'Sl
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Vietnamese dich vien,gqi 855-710-6984.
bcbsil.com
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 PPO Coverage for: Individual/Family I Plan Type: PPO
® The Summary of Benefits and Coverage(SBC)document will help you choose a eaftti man.The SBC s owfi s you how you and the an 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 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.
� o
What is the overall Individual: Participating $500 Generally,you must pay all of the costs from rove -iders up to the deductible amount before
deductible? Non-Participating $1,000 this Ilan 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 Ilan 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. 300 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.
limit for this Ilan? Participating $1,000
Non-Participating $2,000
Family is equivalent to 3
individuals.
What is not included in the copayments,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 Ilan.uses a provider network.You will pay less if you use a provide r in the Ip an'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 plan pays(balance
billin ). Be aware,your network provider might use an out-of-network provider for some
services (such as lab work). Check with your rop vider before you get services.
Do you need a referral to No. You can see the specialist you choose without a referral.
see a soecialist?
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
0 All copavment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Services You May Whi You,Will pay
i[W,Event (You will i . i pay'- the' Informati'o"
most)
Primary care visit to treat an $20 co a ment 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
necessary.
Specialist visit 40 co a ment visit 30% oinsurance c none
provider's
rovi er's office or you visit a healthcare Preventive care/screening20 co a ment 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 copavment/ 10 copavment/ Up to 30 day retail/90 day home delivery. For
prescription prescription Out-of Network drug Provider you are
treat your illness or Preferred brand drugs 20/ 40 copayment/ 20 co a ment responsible for 25% of the eligible amount
condition prescription prescription after the copay. You may be eligible to
More information about Non-preferred brand drugs 35/ 70 copavment/ 35 co a ment synchronize your prescription refills,*please
prescription drug see benefit booklet for details. The prescription prescription y
coverage is available at Specialty drugs Covered Covered amount you may pay per 30-day supply of a
ht_pt s://www.bcbsil. covered insulin drug, regardless of quantity
com/rx-drugs/drug-lists/ or type,shall not exceed$100,when obtained
drug-lists from a Preferred Participating or Participating
Pharmacy.
If you have outpatient Facility fee (e.g., ambulatory 10% coinsurance 30% coinsurance
surgery center) none
surgery 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
WhatY 1 °ay
common ° 1 1 ° 1 1 1 ° 1 1Limitations, Exception 0 1 1
Services You. 1
Medicalrtant
(You wiltpay Provider 1 1Info- 1
Emergency room care $150 copayment/visit $150 copayment/visit c�ment 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
room) Non-Participating Providers.
stay 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;
y 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 H% 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 Skilled nursing care 10% coinsurance 30% coinsurance
recovering or have
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
What You Will Pay
Noni -Participating Limitations, Exceptions, & Other Important
Common, Participating Provider
Services You May Need
Medical Event (You p. pay the" Information
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 Ilan document for more information and a list of any other excluded services.)
• Acupuncture • Long-term care • Routine eye care (Adult
• 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.)
• Bariatric surgery . Infertility treatment 4 completed oocyte retrieval • 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
www.dol.goy/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 Wan 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 c aim. Your plan
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://ins urance.illinois.gov.
Does this plan provide Minimum Essential Coverage?Yes
Minimum Essential Coveraae 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 Coveraae.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 tolong sa Tagalog tumawag sa 1-800-541-2768.
Chineset 1-800-541-2768.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo,kwiijigo holne' 1.800-541-2768.
7o see examples of how this ►Lan might cover costs for a sample medical situation, see the next section.
Page 5of6
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 cost sharing amounts
(deductibles. copayments and coinsurance) and excluded services under the pLan. Use this information to compare the portion of costs you
might pay under different health Ijans. Please note these coverage examples are based on self-only coverage.
monthsI • 0 d a ear of routineI of I I'ncy roam visit and follow up
hospital delivery) condition
■ The Ip an's overall deductible $500 ■ The plans' overall deductible $500 ■ The Ip an's overall deductible $500
■ Specialist copavment $40 ■ Specialist copayment $40 ■ Specialist copavment $40
■ Hospital (facility) coinsurance 10% ■ Hospital (facility)coinsurance 10% ■ Hospital (facility) coinsurance 10%
■ Other coinsurance 10% ■ Other coinsurance 10% ■ 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 1 I 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 I
Deductibles 500 Deductibles 500 De uc i es 500
Copayments 70 Copayments 500 Copavments 300
Coinsurance 70 Coinsurance 10 Coinsurance 100
What isn't covered What isn't covered What isn't covered
Limits or exclusions 60 Limits or exc usions 20 Limits or exclusions $0
The total Peg would pay is $700 The total Joe would pay is $1,030 1 The total Mia would pay is 900
The pLan would be responsible for the other costs of these EXAMPLE covered services.
Page 6 of 6
h BlueCross B1ueShield
•.• \vim/ orfflinom�ois
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.htmi
bcbsil.com
v. BlueCmss B1ueShield
® oflllinois
.um,ma�n u�.d m.ed..m,w os�sni.0•.maws
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,tene derecho a obtener ayuda a informacion en su idioma sin costo alguno. Para hablar con un interprete,Ilame
Spanish a1855-710-6984.
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Arabic
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Chinese
Frangais Si vous,ou quelqu'un que vous etes entrain d'aider,avez des questions,vous avez le droit d'obtenir de('aide et('information clans votre langue a aucun coot.Pour parser a 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 Ddmetscherzu
German sprechen,Men Sie bitte die Nummer 855-710-6984 an.
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Hindi fk* ar-- �r V Wi Z EF fi C'' 855-710-6984 9z WW E01.
Italiano Se to o qualcuno the staff aiutando avete domande, hai it dlritto d1 ottenere aiuto a informazioni nella tua lingua gratuitamente.Per parlare con un interprete,puoi chiamare it
Italian numero 855-710-6984.
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Korean M Q OOFAI q� 855-710-6984 -E3-- `i Z 8I-d1 AI 4.
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Navajo Ata'dahalne'igii bich'}'hodiilnih kwe'e 855-710-6984.
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Persian 855-710-6984 -1;?4w L- 6--
Polski Je§li Ty Iub osoba,kt6rej pomagasz, macie jakiekolwiek pytania, macie prawo do uzyskania bezplatnej informacji i pomocy we wtasnym jgzyku.Aby porozmawiac z
Polish tiumaczem,zadzwoh pod numer 855-710-6984.
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Russian LIT06b1 CBA3aTbCA c nepeBOA4VIKOM, n03BOHWTe no TenecpOHy 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.
9.1J1 [ ( 1
Urdu -oars dl�4 855-710-6984�L�l L�LUY�l�L(Y��5�`.L°C9ir �LUJ-'U"Irr u1wyl..J9I a'�-}�LLL°�J�S`S cY 1 i,y�:��°�yry,J,dl.;�yu o:,.g5'�u��,�5 a.�a;,1�n.s�,LS aJ��,.ul�y„S C2'sS"i,sl
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Vietnamese Bich Mn,ggi 855-710-6984.
bcbsil.com