New York Q 2016 Rate Sheet
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1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions New York Q 2016 Rate Sheet New York Rating Area 8 Plan options1 NY Platinum NYC Community Plan SM $20 NYC Community Plan SM $30 NY Platinum OAEPO $25 NY Gold OAEPO % Primary care physician/specialist office visit Inpatient hospital/outpatient surgery NY08 (9/15) $20/$35; 30% $500/$150; 30% $30/$50; 30% $1,000/$150; 30% $25/$40 $30/$50; $500 copay per admission/ Covered in Full 10% Emergency room $100 $150 $150 $150; Network deductible2 $0/$0; $5,000/$10,000 Network plan coinsurance 0%; 30% after deductible $1,000/ $2,000; $5,250/$10,500 $0/$0; $5,000/$10,000 0%; 30% after deductible $1,000/ $2,000; $5,250/$10,500 $0/$0 $1,000/$2,000 0% 10% $4,000/$8,000 $4,000/$8,000 Out-of-network deductible2 Prescription Drugs S (26 dep age): N/A N/A $ $ E/S (26 dep age): N/A N/A $1, $1, P/C (26 dep age): N/A N/A $1, $1, F (26 dep age): N/A N/A $2, $2, S (30 dep age): N/A N/A $ $ E/S (30 dep age): N/A N/A $1, $1, P/C (30 dep age): N/A N/A $1, $1, F (30 dep age): N/A N/A $2, $2,217.07
2 Plan options NY Gold Savings Plus OAEPO % OAEPO % OAEPO % OAEPO % HSA PY Emb Primary care physician/specialist office visit Tier 1: $30/$50; Tier 2: $50/$70 Inpatient hospital/outpatient surgery $40/$70; $30/$50; 10% Tier 1: 10% 20% 40% 10% Tier 2: 30% Emergency room $150; $200; $200; 10% Network deductible2 Tier 1: $1,000/$2,000 Tier 2: $3,000/$6,000 Network plan coinsurance $2,000/$4,000 $2,000/$4,000 $2,600/$5,200 Tier 1: 10% 20% 40% 10% Tier 2: 30% Tier 1: $3,000/$6,000 Tier 2: $6,600/$13,200 $6,600/$13,200 $5,500/$11,000 $6,000/$12,000 Out-of-network deductible2 Prescription Drugs S (26 dep age): $ $ $ $ E/S (26 dep age): $1, $1, $1, $1, P/C (26 dep age): $1, $1, $1, $1, F (26 dep age): $1, $1, $1, $1, S (30 dep age): $ $ $ $ E/S (30 dep age): $1, $1, $1, $1, P/C (30 dep age): $1, $1, $1, $1, F (30 dep age): $1, $1, $1, $1, Health benefits and health insurance plans are offered, underwritten and/or administered by Aetna Health Inc., Aetna Health Insurance Company of New York and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products. 2
3 Plan options OAEPO % Savings Plus OAEPO % Savings Plus OAEPO % Savings Plus OAEPO % HSA PY Emb Primary care physician/specialist office visit $40 / $75 Tier 1: $40/$60; Tier 2: $50/$75 Tier 1: $50/$75; Tier 2: 40% Tier 1: 10% Tier 2: 30% Inpatient hospital/outpatient surgery 30% Tier 1: 20% Tier 1: 20% Tier 1: 10% Tier 2: 40% Tier 2: 40% Tier 2: 30% Emergency room $200; $200; 20% Tier1/Tier 2: 10% Network deductible2 $3,000/$6,000 Tier 1: $2,000/$4,000 Tier 2: $4,000/$8,000 Tier 1: $2,500/$5,000 Tier 2: $4,500/$9,000 Tier 1: $2,600/$5,200 Tier 2: $4,000/$8,000 Network plan coinsurance 30% Tier 1: 20% Tier 1: 20% Tier 1: 10% Tier 2: 40% Tier 2: 40% Tier 2: 30% $6,600/$13,200 Tier 1: $5,800/$11,600 Tier 2: $6,600/$13,200 Tier 1: $6,000/$12,000 Tier 2: $6,600/$13,200 Out-of-network deductible2 Prescription Drugs S (26 dep age): $ $ $ $ E/S (26 dep age): $1, $1, $1, $1, P/C (26 dep age): $1, $ $ $ F (26 dep age): $1, $1, $1, $1, S (30 dep age): $ $ $ $ E/S (30 dep age): $1, $1, $1, $1, P/C (30 dep age): $1, $1, $ $1, F (30 dep age): $1, $1, $1, $1, Tier 1: $5,500/$11,000 Tier 2: $6,450/$12,900 3
4 Plan options3 OAEPO % OAEPO % OAEPO % OAEPO % HSA Emb Primary care physician/specialist office visit 50% $25 / 30% 40% 40% Inpatient hospital/outpatient surgery 50% 30% 40% 40% Emergency room 50% 30% 40% 40% Network deductible2 $3,500/$7,000 $4,500/$9,000 $5,000/$10,000 $4,500/$9,000 Network plan coinsurance 50% 30% 40% 40% $6,850/$13,700 $6,850/$13,700 $6,450/$12,900 $6,450/$12,900 Out-of-network deductible2 Prescription Drugs S (26 dep age): $ $ $ $ E/S (26 dep age): $1, $1, $1, $1, P/C (26 dep age): $ $ $ $ F (26 dep age): $1, $1, $1, $1, S (30 dep age): $ $ $ $ E/S (30 dep age): $1, $1, $1, $1, P/C (30 dep age): $ $ $ $ F (30 dep age): $1, $1, $1, $1,
5 Plan options3 OAEPO % HSA Emb PY OAEPO % HSA Emb OAEPO % HSA Emb PY Savings Plus OAEPO % Primary care physician/specialist office visit 40% 20% 20% Tier 1: 30% Tier 2: 50% Inpatient hospital/outpatient surgery 40% 20% 20% Tier 1: 30% Tier 2: 50% Emergency room 40% 20% 20% 30% Network deductible2 $4,500/$9,000 $5,000/$10,000 $5,000/$10,000 Tier 1: $4,500/$9,000 Tier 2: 6,000/$12,000 Network plan coinsurance 40% 20% 20% Tier 1: 30% Tier 2: 50% $6,450/$12,900 $6,450/$12,900 $6,450/$12,900 Tier 1: $6,500/$13,000 Tier 2: $6,850/$13,700 Out-of-network deductible2 Prescription Drugs S (26 dep age): $ $ $ $ E/S (26 dep age): $1, $1, $1, $ P/C (26 dep age): $ $ $ $ F (26 dep age): $1, $1, $1, $1, S (30 dep age): $ $ $ $ E/S (30 dep age): $1, $1, $1, $1, P/C (30 dep age): $ $ $ $ F (30 dep age): $1, $1, $1, $1,
6 Plan options OAMC /70 HSA Emb OAMC /70 HSA Emb OAMC /80 HSA Emb FH Primary care physician/specialist office visit Inpatient hospital/outpatient surgery Tier 1: 10% Tier 1: Covered in full Tier 1: Covered in full Tier 2: 30% Tier 2: 30% Tier 2: 20% Tier 1: 10% Tier 1: Covered in full Tier 1: Covered in full Tier 2: 30% Tier 2: 30% Tier 2: 20% Emergency room 10% Covered in full Covered in full Network deductible2 $2,600/$5,200 $3,000/$6,000 $3,000/$6,000 Network plan coinsurance 10% 0% 0% $5,000/$10,000 $5,500/$11,000 $5,500/$11,000 Out-of-network deductible2 3,500/$7,000 $4,000/$8,000 $4,000/$8,000 Out-of-network plan coinsurance 30% 30% 20% Prescription Drugs $7,000/$14,000 $8,000/$16,000 $8,000/$16,000 S (26 dep age): $ $ $ E/S (26 dep age): $1, $1, $1, P/C (26 dep age): $1, $1, $1, F (26 dep age): $1, $1, $2, S (30 dep age): $ $ $ E/S (30 dep age): $1, $1, $1, P/C (30 dep age): $1, $1, $1, F (30 dep age): $2, $2, $2,
7 Footnotes 1 The NYC Community Plan is only available to employers who are located in one of the five boroughs of New York City Manhattan, Bronx, Queens, Staten Island and Brooklyn. 2Amounts over the allowable charge and failure to precertify penalty does not apply toward out-of-pocket limit; network/ out-of-network deductibles and out of pocket accumulate separately. In-network preferred/in-network out of pocket amounts accumulate combined. Tier 1 and Tier 2 deductibles and out of pocket amounts accumulate combined. Certain services may not apply toward the deductible. 3 These HSA compatible plans are administered on a plan year and calendar year basis. 7
8 This material is for information only. An application must be completed to obtain coverage. Rates and benefits vary by location. Health benefits and health insurance plans contain exclusions and limitations. These quoted rates are for a 12-month period from the effective date of coverage and are valid only for the benefits level and conditions stated and such other terms and conditions as set forth in the Aetna Group Policy or official renewal letters. Any changes in benefits level, conditions stated or other terms of the policy may require change in rates. These rates apply only to the Aetna service areas stated above. These rates are subject to final approval by Aetna. Rates have been filed with the NY State Department of Insurance. Aetna reserves the right to modify the final rates based on actual enrollment. Investment services are independently offered through HealthEquity, Inc. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Aetna Inc NY08 (9/15)
New York Q 2016 Rate Sheet
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions New York 1 100 1Q 2016 Rate Sheet New York Rating Area 5 Plan options1 NY Platinum NYC Community Plan SM $20
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Our service area includes these counties in: North Carolina: Durham, Wake.
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