Professional Documents
Culture Documents
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at
www.xjt.com or by calling 1-866-664-8737.
Important Questions
What is the overall
deductible?
Are there other deductibles
for specific services?
Is there an outofpocket
limit on my expenses?
What is not included in the
outofpocket limit?
Is there an overall annual
limit on what the plan pays?
Does this plan use a
network of providers?
Do I need a referral to see a
specialist?
Are there services this plan
doesnt cover?
Answers
Network: $2,500 Individual* / $5,000 Family
Non-Network: $2,500 Individual* / $5,000 Family / Per
calendar year.
Does not apply to services listed below as No Charge.
*Doesnt apply if policy covers 2+ people
No, there are no other deductibles.
Medical/Pharmacy- Network: $5,000 Individual* / $10,000
Family
Non-Network: $5,000 Individual* / $10,000 Family
*Doesnt apply if policy covers 2+ people
Premium, balanced-billed charges, health care this plan
doesnt cover, penalties for failure to obtain pre-notification
for services.
This policy has no overall annual limit on the amount it will
pay each year.
Questions: Call 1-866-664-8737 or visit us at www.xjt.com . If you arent clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call the number above to request a copy.
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Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plans allowed amount for
an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you havent met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to
pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500
difference. (This is called balance billing.)
This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common Medical
Event
Specialist visit
If you visit a health care
providers office or
clinic
Other practitioner office visit
Preventive
care/screening/immunization
Diagnostic test (x-ray, blood
work)
Imaging (CT/PET scans,
MRIs)
No Charge
Not Covered
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Emergency medical
transportation
Urgent care
Retail: N/A
Mail Order: N/A
Retail: N/A
Mail Order: N/A
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Habilitation services
Not Covered
Not Covered
Eye exam
Not Covered
Not Covered
Glasses
Not Covered
Not Covered
Dental check-up
Not Covered
Not Covered
Mental/Behavioral health
outpatient services
Mental/Behavioral health
inpatient services
Substance use disorder
outpatient services
Substance use disorder
inpatient services
Delivery and all inpatient
services
Home health care
Rehabilitation services
If you need help
recovering or have
other special health
needs
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact us at 1-866-664-8737 or visit www.myuhc.com.
Additionally, a consumer assistance program can help you file your appeal. A list of states with Consumer Assistance Programs is available at
www.dol.gov/ebsa/healthreform and http://cciio.cms.gov/programs/consumer/capgrants/index.html.
The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does
provide minimum essential coverage.
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This is
not a cost
estimator.
Dont use these examples to
estimate your actual costs under
this plan. The actual care you
receive will be different from these
examples, and the cost of that care
also will be different.
If other than individual coverage,
the Patient Pays amount may be
more.
Having a baby
(normal delivery)
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$2,500
$0
$960
$150
$3,610
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,500
$0
$550
$80
$3,130
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Questions: Call 1-866-664-8737 or visit us at www.xjt.com . If you arent clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf Or call the number above to request a copy.
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