Steward Community Care Choice 2000 (HSA)

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Steward Community Care Choice 2000 (HSA) Benefit Summary Benefits effective April 1, 2013 and beyond The FCHP difference FCHP Steward Community Care is a limited network HMO plan designed in partnership by Fallon Community Health Plan and Steward Health Care. Providing world-class health care where you live, FCHP Steward Community Care includes the benefits and coverage you deserve at an affordable price. It also includes the extras that FCHP members have long enjoyed, including our rich It Fits! fitness benefit, $0 wellness visits and eye exams, and other valuable member discounts. Introducing The Healthy Health Plan!* A program that rewards subscribers for being and becoming healthy. Simply click on the My Healthy Health Plan link on fchp.org, fill out your health assessment, and you will be eligible to receive up to $200 in financial incentives! See the Value-added features section for more details. How to receive care: With FCHP Steward Community Care Choice 2000, you can choose to get your care from doctors, specialists, hospitals and health care facilities in the FCHP Steward Community Care network. For a complete list of FCHP Steward Community Care providers, visit our Web site at fchp.org/steward. Obtaining specialty care When you want to visit a specialist, talk with your PCP first. He or she will help arrange specialty care for you. The following services do not require a referral when you see a provider in the FCHP Steward Community Care network: routine obstetrics/gynecology care, screening eye exams and behavioral health services. For medically necessary services that are not available at an FCHP Steward Community Care facility, you may receive care at either Brigham and Women s Hospital or Massachusetts General Hospital. For more information on referral procedures for specialty services, consult your FCHP Steward Community Care Member Handbook/Evidence of Coverage. Emergency medical care Emergency services do not require referral or authorization. When you have an emergency medical condition, you should go to the nearest emergency department or call your local emergency communications system (police, fire department or 911). For more information on emergency benefits and plan procedures for emergency services, consult your FCHP Steward Community Care Member Handbook/Evidence of Coverage. Choosing a primary care provider (PCP) Your relationship with your PCP is very important because he or she will work with FCHP to provide or arrange most of your care. As a member of FCHP Steward Community Care Choice 2000, you must select a PCP. To do this, just complete the section on your FCHP membership enrollment form. If you need help choosing a PCP, you can speak with a member of our Customer Service Department. FCHP Steward Community Care provides access to a network that is smaller than FCHP Select Care. In this plan, members have access to network benefits only from the providers in FCHP Steward Community Care. Please consult the FCHP Steward Community Care provider directory a paper copy can be requested by calling our Customer Service Department at 1-800-868-5200 or visit the provider search tool at fchp.org to determine which providers are included in FCHP Steward Community Care. Page 1

Plan specifics Benefit period The benefit period, sometimes referred to as a benefit year, is the 12-month span of plan coverage, and the time during which the deductible, out-of-pocket maximum and specific benefit maximums accumulate. Deductible A deductible is the amount of allowed charges you pay per benefit period before payment is made by the plan for certain covered services. The amount that is put toward your deductible is calculated based on the allowed charge or the provider s actual charge whichever is less. Embedded deductible Please note that once any one member in a family accumulates $2,500 of services that are subject to the family deductible, that individual member s deductible is considered met, and that family member will receive benefits for covered services less any applicable copayments. Varies by employer $2,000 individual/ $4,000 family $2,500 Out-of-pocket maximum The out-of-pocket maximum is the total amount of deductible, coinsurance and copayments you are responsible for in a benefit period. The out-of-pocket maximum does not include your premium charge or any amounts you pay for services that are not covered by the plan. Benefits Office Routine physical exams (according to MHQP preventive guidelines) $0 Office visits (primary care provider) Office visits (specialist) Office visits (limited service clinics, e.g., Minute Clinic) Routine eye exams (one every 12 months) $0 Short-term rehabilitative services (60 visits per benefit period) Prenatal care Preventive services Tests, immunizations and services geared to help screen for diseases and improve early detection when symptoms or diagnosis are not present Diagnostic services Tests, immunizations and services that are intended to diagnose, check the status of, or treat a disease or condition Imaging (CAT, PET, MRI, Nuclear Cardiology) Chiropractic care (12 visits per benefit period) $5,000 individual/ $10,000 family $40 per visit $25 first visit only Page 2

Benefits Prescriptions Please note: Specialty medication that falls under the medical benefit will apply towards your deductible. For more information, please contact FCHP s Customer Service Department at 1-800-868-5200. Prescription drugs, insulin and insulin syringes Generic contraceptives and contraceptive devices Brand contraceptives with no generic equivalent (prior authorization required) Brand contraceptives with a generic equivalent (prior authorization required) Prescription medication refills obtained through the mail order program Prilosec OTC, Prevacid 24HR, omeprazole OTC (prescription required) Inpatient hospital services Room and board in a semiprivate room (private when medically necessary) Physicians and surgeons services Physical and respiratory therapy Intensive care services Maternity care Same-day surgery Same-day surgery in a hospital outpatient or ambulatory care setting Emergencies Emergency room visit Skilled nursing Skilled care in a semiprivate room Tier 1/Tier 2/Tier 3/ Tier 4 $5/$15/$30/$50 $0 With prior authorization: $0 Tier 3: $30 Tier 4: $50 $10/$30/$60/$150 (90-day supply) $5 $100 copayment (waived if admitted) Page 3

Benefits Substance abuse Office visits Detoxification in an inpatient setting Rehabilitation in an inpatient setting Mental health Office visits Services in a general or psychiatric hospital Other health services Skilled home health care services Durable medical equipment Medically necessary ambulance services Value-added features It Fits!, an annual benefit period fitness reimbursement (including school and town sports programs, gym memberships, home fitness equipment, Weight Watchers, aerobics, Pilates and yoga classes) The Healthy Health Plan!*, a program that rewards subscribers for being and becoming healthy If you re already in great health, terrific! If you could use a little help to get healthier, you can choose to enroll in a customized action health plan that may include regular health coaching, wellness workshops, interactive tools and more! Oh Baby!, a program that provides prenatal vitamins, a convertible car seat, breast pump and other little extras for expectant parents all at no additional cost. Free 24/7 nurse call line Free chronic care management Free stop-smoking program Member discount program Free online access to health and wellness encyclopedia CVS Caremark ExtraCare Health Card provides 20% discount on CVS/pharmacybrand health related items. FCHP Family Fun provides discounts at Massachusetts and New Hampshire attractions 30% coinsurance $200 individual $400 family Page 4

Exclusions Hearing aids and the evaluation for a hearing aid (for age 22 and above) Long-term rehabilitative services Nonprescription drugs and vitamins Cosmetic surgery Experimental procedures or services that are not generally accepted medical practice Dental services not described in the FCHP Steward Community Care Member Handbook/Evidence of Coverage Routine foot care Custodial confinement Some services may require prior authorization. A complete list of benefits and exclusions is in the FCHP Steward Community Care Member Handbook/Evidence of Coverage, available by request. This is only a summary of benefits and exclusions. Questions? If you have any questions, please contact Fallon Community Health Plan Customer Service at 1-800-868-5200 (TTY users, please call TRS Relay 711), or visit our Web site at fchp.org. *Pending DOI Approval This health plan meets minimum creditable coverage standards and will satisfy the individual mandate that you have health insurance. As of January 1, 2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen (18) years and older, must have health coverage that meets the minimum creditable coverage standards set by the Commonwealth Health Insurance Connector. Benefits may vary by employer group. Weight Watchers is a registered trademark of Weight Watchers International, Inc. Page 5

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