Enrollment Packet HEALTH 2020

New Health Insurance Marketplace Coverage Form Approved
Options and Your Health Coverage OMB No. 1210-0149
(expires 5-31-2020)

PART A: General Information

When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health
Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic
information about the new Marketplace.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The
Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible
for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance
coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or
offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on
your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible
for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be
eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does
not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.5% of your household
income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the
Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your
employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer
contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for
Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-
tax basis.

How Can I Get More Information?

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health
insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered
by the plan is no less than 60 percent of such costs.

PART B: Information About Health Coverage Offered by Your Employer

This section contains information about any health coverage offered by your employer. If you decide to complete an
application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered
to correspond to the Marketplace application.

3. Employer name 4. Employer Identification Number (EIN)

Health Rehab Solutions 45-5281410

5. Employer address 6. Employer phone number

690 N. Meridian Rd, Ste 201 406-756-1128

7. City 8. State 9. ZIP code

Kalispell MT 59901

10. Who can we contact at this job?

Teresa Challans

11. Phone number (if different from above) 12. Email address

406-756-1128 ext. 312 [email protected]

You are not eligible for health insurance coverage through this employer. You and your family may be able to obtain
health coverage through the Marketplace, with a new kind of tax credit that lowers your monthly premiums and with
assistance for out-of-pocket costs.

HIPAA CONFIDENTIALITY & NON-DISCLOSURE

Every provider of medical services and equipment has a legal and ethical responsibility to
safeguard the privacy of all patients and to protect the confidentiality of their heath
information. The provider must also assure that its employees, independent contractors, and
business associates keep protected health information confidential. I understand that in the
course of my employment or other affiliation with Health & Rehab Solutions, I may come into
possession of confidential information. I also understand that my personal access codes used
to access computer systems are also an integral aspect of this confidential information. I also
understand that certain personal health information is needed by the company for medical
insurance purposes but is transmitted only through secure methods. My employer will keep all
information covered under HIPAA secure and this information will only be used as necessary.

By signing this document, I understand and agree to the following:
1. I agree to hold confidential or proprietary information or trade secrets (“confidential
information”) in trust and confidence and agree that it shall be used only for the
contemplated purposes, shall not be used for any other purpose, or disclosed to any
third party without written consent and authorization.
2. Confidential information shall not be disclosed to any employee, consultant or third party
unless they agree to execute and be bound by the terms of the agreement and have
been authorized to do so.
3. I agree not to disclose or discuss any patient, member, human resources, and/or
management information with others, including friends and family, who do not have a
need-to-know.
4. I agree not to discuss patient, human resources, or administrative information where
others can overhear the conversation, e.g. in hallways, elevators, public transportation,
at restaurants or social events. It is not acceptable to discuss clinical information in
public areas even if a member’s name is not used. This can raise doubts with patients
and other providers about our respect for patient’s privacy.
5. I agree to keep papers with protected health information in a secure place, to promptly
remove them from un-secured locations such as copy machines and conference rooms,
and to place them in the appropriate locked bin for shredding when they are no longer
needed.
6. If I am the last employee to leave the facility, I understand that it is my responsibility to
ensure that all access doors are locked.
7. I agree to allow the company necessary access to my information covered under HIPAA
for purposes related to my medical insurance benefits.

I have received the HIPAA STANDARDS document and agree with the above statements.

© 2018 HRS. All Rights Reserved.

Special Enrollment Rights Notice

If you are declining enrollment for yourself or your dependents (including your spouse)
because of other health insurance coverage, you may in the future be able to enroll
yourself or your dependents in this plan, provided that you request enrollment within 30
days after your coverage ends. In addition, if you have a new dependent as a result of
marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself
and your dependents, provided that you request enrollment within 30 days after the
marriage, birth, adoption, or placement for adoption.

The Newborns’ and Mothers’ Health Protection Act (the Newborns’
Act or NMHPA) – Content of Required Notice

The DOL regulations contain the following statement, which will be deemed to satisfy the
employer's obligation to describe the federal requirements relating to hospital length of stay
under NMHPA:

Group health plans and health insurance issuers generally may not, under Federal law,
restrict benefits for any hospital length of stay in connection with childbirth for the mother
or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours
following a cesarean section. However, Federal law generally does not prohibit the
mother's or newborn's attending provider, after consulting with the mother, from
discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).
In any case, plans and issuers may not, under Federal law, require that a provider obtain
authorization from the plan or the issuer for prescribing a length of stay not in excess of 48
hours (or 96 hours).

Women’s Health and Cancer Rights Act Enrollment Notice

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under
the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving
mastectomy-related benefits, coverage will be provided in a manner determined in consultation
with the attending physician and the patient, for:

* all stages of reconstruction of the breast on which the mastectomy was performed;

* surgery and reconstruction of the other breast to produce a symmetrical appearance;

* prostheses; and

* treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to
other medical and surgical benefits provided under this plan.

Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your
employer, your state may have a premium assistance program that can help pay for coverage, using funds from
their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be
eligible for these premium assistance programs but you may be able to buy individual insurance coverage
through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact
your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a
program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under
your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled.
This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being
determined eligible for premium assistance. If you have questions about enrolling in your employer plan,
contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health
plan premiums. The following list of states is current as of July 31, 2016. Contact your State for more
information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid

Website: http://myalhipp.com/ Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-855-692-5447 Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid

The AK Health Insurance Premium Payment Program Website: http://dch.georgia.gov/medicaid
Website: http://myakhipp.com/ - Click on Health Insurance Premium Payment (HIPP)
Phone: 1-866-251-4861 Phone: 404-656-4507
Email: [email protected]
Medicaid Eligibility: INDIANA – Medicaid
http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
Healthy Indiana Plan for low-income adults 19-64
ARKANSAS – Medicaid Website: http://www.hip.in.gov
Phone: 1-877-438-4479
Website: http://myarhipp.com/ All other Medicaid
Phone: 1-855-MyARHIPP (855-692-7447) Website: http://www.indianamedicaid.com
Phone 1-800-403-0864
COLORADO – Medicaid
IOWA – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943 Website: http://www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/ Website:
Phone: 1-785-296-3512 http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
KENTUCKY – Medicaid
NEW JERSEY – Medicaid and CHIP
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570 Medicaid Website:
http://www.state.nj.us/humanservices/
LOUISIANA – Medicaid dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
Website: CHIP Website: http://www.njfamilycare.org/index.html
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 CHIP Phone: 1-800-701-0710
Phone: 1-888-695-2447
NEW YORK – Medicaid

Website:
http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public- Website: http://www.ncdhhs.gov/dma
assistance/index.html Phone: 919-855-4100
Phone: 1-800-442-6003
TTY: Maine relay 711 NORTH DAKOTA – Medicaid

MASSACHUSETTS – Medicaid and CHIP Website:
http://www.nd.gov/dhs/services/medicalserv/medicaid/
Website: http://www.mass.gov/MassHealth Phone: 1-844-854-4825
Phone: 1-800-462-1120
OKLAHOMA – Medicaid and CHIP
MINNESOTA – Medicaid
Website: http://www.insureoklahoma.org
Website: http://mn.gov/dhs/ma/ Phone: 1-888-365-3742
Phone: 1-800-657-3739

MISSOURI – Medicaid OREGON – Medicaid

Website: Website: http://healthcare.oregon.gov/Pages/index.aspx
http://www.dss.mo.gov/mhd/participants/pages/hipp.ht http://www.oregonhealthcare.gov/index-
m
Phone: 573-751-2005 es.html
Phone: 1-800-699-9075
MONTANA – Medicaid
PENNSYLVANIA – Medicaid
Website:
http://dphhs.mt.gov/MontanaHealthcarePrograms/HIP Website: http://www.dhs.pa.gov/hipp
P Phone: 1-800-692-7462
Phone: 1-800-694-3084
RHODE ISLAND – Medicaid
NEBRASKA – Medicaid
Website: http://www.eohhs.ri.gov/
Website: Phone: 401-462-5300
http://dhhs.ne.gov/Children_Family_Services/AccessNe
braska/Pages/accessnebraska_index.aspx SOUTH CAROLINA – Medicaid
Phone: 1-855-632-7633
Website: http://www.scdhhs.gov
NEVADA – Medicaid Phone: 1-888-549-0820

Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900

2

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid

Website: http://dss.sd.gov Website: http://www.hca.wa.gov/free-or-low-cost-
Phone: 1-888-828-0059 health-care/program-administration/premium-
payment-program
TEXAS – Medicaid Phone: 1-800-562-3022 ext. 15473

Website: http://gethipptexas.com/ WEST VIRGINIA – Medicaid
Phone: 1-800-440-0493
Website:
UTAH – Medicaid and CHIP http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/
Pages/default.aspx
Website: Phone: 1-877-598-5820, HMS Third Party Liability
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip WISCONSIN – Medicaid and CHIP
Phone: 1-877-543-7669
Website:
VERMONT– Medicaid https://www.dhs.wisconsin.gov/publications/p1/p10095.
pdf
Website: http://www.greenmountaincare.org/ Phone: 1-800-362-3002
Phone: 1-800-250-8427
WYOMING – Medicaid

Website: https://wyequalitycare.acs-inc.com/
Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP

Medicaid Website:
http://www.coverva.org/programs_premium_assistance.
cfm
Medicaid Phone: 1-800-432-5924
CHIP Website:
http://www.coverva.org/programs_premium_assistance.
cfm
CHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since July 31, 2016, or for more information
on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a
collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number.
The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by
OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a
collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also,
notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of
information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per
respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee
Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue,
N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

3

Deductible Excluded Services
An amount you could owe
Health care services that your plan doesn’t pay for or
during a coverage period cover.
(usually one year) for
covered health care Formulary

services before your plan A list of drugs your plan covers. A formulary may
begins to pay. An overall include how much your share of the cost is for each drug.
deductible applies to all or Jane pays Her plan pays Your plan may put drugs in different cost sharing levels
almost all covered items or tiers. For example, a formulary may include generic
100% 0% drug and brand name drug tiers and different cost sharing
amounts will apply to each tier.
and services. A plan with (See page 6 for a detailed
example.) Grievance
an overall deductible may
also have separate deductibles that apply to specific A complaint that you communicate to your health insurer
or plan.
services or groups of services. A plan may also have only
Habilitation Services
separate deductibles. (For example, if your deductible is
$1000, your plan won’t pay anything until you’ve met Health care services that help a person keep, learn or
improve skills and functioning for daily living. Examples
your $1000 deductible for covered health care services include therapy for a child who isn’t walking or talking at
subject to the deductible.) the expected age. These services may include physical
and occupational therapy, speech-language pathology,
Diagnostic Test and other services for people with disabilities in a variety
of inpatient andor outpatient settings.
Tests to figure out what your health problem is. For
example, an x-ray can be a diagnostic test to see if you Health Insurance
have a broken bone.
A contract that requires a health insurer to pay some or
Durable Medical Equipment (DME) all of your health care costs in exchange for a premium.
A health insurance contract may also be called a “policy”
Equipment and supplies ordered by a health care provider or “plan”.
for everyday or extended use. DME may include: oxygen
equipment, wheelchairs, and crutches. Home Health Care

Emergency Medical Condition Health care services and supplies you get in your home
under your doctor’s orders. Services may be provided by
An illness, injury, symptom (including severe pain), or nurses, therapists, social workers, or other licensed health
condition severe enough to risk serious danger to your care providers. Home health care usually doesn’t include
health if you didn’t get medical attention right away. If help with non-medical tasks, such as cooking, cleaning, or
you didn’t get immediate medical attention you could driving.
reasonably expect one of the following: 1) Your health
would be put in serious danger; or 2) You would have Hospice Services
serious problems with your bodily functions; or 3) You
would have serious damage to any part or organ of your Services to provide comfort and support for persons in
body. the last stages of a terminal illness and their families.

Emergency Medical Transportation Hospitalization

Ambulance services for an emergency medical condition. Care in a hospital that requires admission as an inpatient
Types of emergency medical transportation may include and usually requires an overnight stay. Some plans may
transportation by air, land, or sea. Your plan may not consider an overnight stay for observation as outpatient
cover all types of emergency medical transportation, or care instead of inpatient care.
may pay less for certain types.
Hospital Outpatient Care
Emergency Room Care / Emergency Services
Care in a hospital that usually doesn’t require an
Services to check for an emergency medical condition and overnight stay.
treat you to keep an emergency medical condition from
getting worse. These services may be provided in a Page 2 of 6
licensed hospital’s emergency room or other place that
provides care for emergency medical conditions.
Glossary of Health Coverage and Medical Terms

Individual Responsibility Requirement Minimum Essential Coverage

Sometimes called the “individual mandate”, the duty you Health coverage that will meet the individual
may have to be enrolled in health coverage that provides responsibility requirement. Minimum essential coverage
minimum essential coverage. If you don’t have minimum generally includes plans, health insurance available
essential coverage, you may have to pay a penalty when through the Marketplace or other individual market
you file your federal income tax return unless you qualify policies, Medicare, Medicaid, CHIP, TRICARE, and
for a health coverage exemption. certain other coverage.

In-network Coinsurance Minimum Value Standard

Your share (for example, 20%) of the allowed amount A basic standard to measure the percent of permitted
for covered healthcare services. Your share is usually costs the plan covers. If you’re offered an employer plan
lower for in-network covered services. that pays for at least 60% of the total allowed costs of
benefits, the plan offers minimum value and you may not
In-network Copayment qualify for premium tax credits and cost sharing
reductions to buy a plan from the Marketplace.
A fixed amount (for example, $15) you pay for covered
health care services to providers who contract with your Network
health insurance or plan. In-network copayments usually
are less than out-of-network copayments. The facilities, providers and suppliers your health insurer
or plan has contracted with to provide health care
Marketplace services.

A marketplace for health insurance where individuals, Network Provider (Preferred Provider)
families and small businesses can learn about their plan
options; compare plans based on costs, benefits and other A provider who has a contract with your health insurer or
important features; apply for and receive financial help plan who has agreed to provide services to members of a
with premiums and cost sharing based on income; and plan. You will pay less if you see a provider in the
choose a plan and enroll in coverage. Also known as an network. Also called “preferred provider” or
“Exchange”. The Marketplace is run by the state in some “participating provider.”
states and by the federal government in others. In some
states, the Marketplace also helps eligible consumers Orthotics and Prosthetics
enroll in other programs, including Medicaid and the
Children’s Health Insurance Program (CHIP). Available Leg, arm, back and neck braces, artificial legs, arms, and
online, by phone, and in-person. eyes, and external breast prostheses after a mastectomy.
These services include: adjustment, repairs, and
Maximum Out-of-pocket Limit replacements required because of breakage, wear, loss, or
a change in the patient’s physical condition.
Yearly amount the federal government sets as the most
each individual or family can be required to pay in cost Out-of-network Coinsurance
sharing during the plan year for covered, in-network
services. Applies to most types of health plans and Your share (for example, 40%) of the allowed amount
insurance. This amount may be higher than the out-of- for covered health care services to providers who don’t
pocket limits stated for your plan. contract with your health insurance or plan. Out-of-
network coinsurance usually costs you more than in-
Medically Necessary network coinsurance.

Health care services or supplies needed to prevent, Out-of-network Copayment
diagnose, or treat an illness, injury, condition, disease, or
its symptoms, including habilitation, and that meet A fixed amount (for example, $30) you pay for covered
accepted standards of medicine. health care services from providers who do not contract
with your health insurance or plan. Out-of-network
copayments usually are more than in-network
copayments.

Glossary of Health Coverage and Medical Terms Page 3 of 6

Out-of-network Provider (Non-Preferred Premium

Provider) The amount that must be paid for your health insurance
or plan. You andor your employer usually pay it
A provider who doesn’t have a contract with your plan to monthly, quarterly, or yearly.
provide services. If your plan covers out-of-network
services, you’ll usually pay more to see an out-of-network Premium Tax Credits
provider than a preferred provider. Your policy will
explain what those costs may be. May also be called Financial help that lowers your taxes to help you and
“non-preferred” or “non-particiapting” instead of “out- your family pay for private health insurance. You can get
of-network provider”. this help if you get health insurance through the
Marketplace and your income is below a certain level.
Out-of-pocket Limit Advance payments of the tax credit can be used right
The most you could away to lower your monthly premium costs.
pay during a coverage
period (usually one year) Prescription Drug Coverage

for your share of the Coverage under a plan that helps pay for prescription
costs of covered drugs. If the plan’s formulary uses “tiers” (levels),
prescription drugs are grouped together by type or cost.
services. After you Jane pays Her plan pays The amount you'll pay in cost sharing will be different
meet this limit the 0% 100% for each "tier" of covered prescription drugs.
plan will usually pay
100% of the (See page 6 for a detailed example.) Prescription Drugs

allowed amount. This limit helps you plan for health Drugs and medications that by law require a prescription.

care costs. This limit never includes your premium, Preventive Care (Preventive Service)
balance-billed charges or health care your plan doesn’t
cover. Some plans don’t count all of your copayments, Routine health care, including screenings, check-ups, and
deductibles, coinsurance payments, out-of-network patient counseling, to prevent or discover illness, disease,
payments, or other expenses toward this limit. or other health problems.

Physician Services Primary Care Physician

Health care services a licensed medical physician, A physician, including an M.D. (Medical Doctor) or
including an M.D. (Medical Doctor) or D.O. (Doctor of D.O. (Doctor of Osteopathic Medicine), who provides
Osteopathic Medicine), provides or coordinates. or coordinates a range of health care services for you.

Plan Primary Care Provider

Health coverage issued to you directly (individual plan) A physician, including an M.D. (Medical Doctor) or
or through an employer, union or other group sponsor D.O. (Doctor of Osteopathic Medicine), nurse
(employer group plan) that provides coverage for certain practitioner, clinical nurse specialist, or physician
health care costs. Also called "health insurance plan", assistant, as allowed under state law and the terms of the
"policy", "health insurance policy" or "health plan, who provides, coordinates, or helps you access a
insurance". range of health care services.

Preauthorization Provider

A decision by your health insurer or plan that a health An individual or facility that provides health care services.
care service, treatment plan, prescription drug or durable Some examples of a provider include a doctor, nurse,
medical equipment (DME) is medically necessary. chiropractor, physician assistant, hospital, surgical center,
Sometimes called prior authorization, prior approval or skilled nursing facility, and rehabilitation center. The
precertification. Your health insurance or plan may plan may require the provider to be licensed, certified, or
require preauthorization for certain services before you accredited as required by state law.
receive them, except in an emergency. Preauthorization
isn’t a promise your health insurance or plan will cover
the cost.

Glossary of Health Coverage and Medical Terms Page 4 of 6

Reconstructive Surgery UCR (Usual, Customary and Reasonable)

Surgery and follow-up treatment needed to correct or The amount paid for a medical service in a geographic
improve a part of the body because of birth defects, area based on what providers in the area usually charge
accidents, injuries, or medical conditions. for the same or similar medical service. The UCR
amount sometimes is used to determine the allowed
Referral amount.

A written order from your primary care provider for you Urgent Care
to see a specialist or get certain health care services. In
many health maintenance organizations (HMOs), you Care for an illness, injury, or condition serious enough
need to get a referral before you can get health care that a reasonable person would seek care right away, but
services from anyone except your primary care provider. not so severe as to require emergency room care.
If you don’t get a referral first, the plan may not pay for
the services.

Rehabilitation Services

Health care services that help a person keep, get back, or
improve skills and functioning for daily living that have
been lost or impaired because a person was sick, hurt, or
disabled. These services may include physical and
occupational therapy, speech-language pathology, and
psychiatric rehabilitation services in a variety of inpatient
andor outpatient settings.

Screening

A type of preventive care that includes tests or exams to
detect the presence of something, usually performed
when you have no symptoms, signs, or prevailing medical
history of a disease or condition.

Skilled Nursing Care

Services performed or supervised by licensed nurses in
your home or in a nursing home. Skilled nursing care is
not the same as “skilled care services”, which are services
performed by therapists or technicians (rather than
licensed nurses) in your home or in a nursing home.

Specialist

A provider focusing on a specific area of medicine or a
group of patients to diagnose, manage, prevent, or treat
certain types of symptoms and conditions.

Specialty Drug

A type of prescription drug that, in general, requires
special handling or ongoing monitoring and assessment
by a health care professional, or is relatively difficult to
dispense. Generally, specialty drugs are the most
expensive drugs on a formulary.

Glossary of Health Coverage and Medical Terms Page 5 of 6

How You and Your Insurer Share Costs - Example

Jane’s Plan Deductible: $1,500 Coinsurance: 20% Out-of-Pocket Limit: $5,000

January 1st December 31st
Beginning of Coverage Period End of Coverage Period

more more
costs costs

Jane pays Her plan pays Jane pays Her plan pays Jane pays Her plan pays

100% 0% 20% 80% 0% 100%

Jane hasn’t reached her Jane reaches her $1,500 Jane reaches her $5,000

$1,500 deductible yet deductible, coinsurance begins out-of-pocket limit
Her plan doesn’t pay any of the costs. Jane has seen a doctor several times and Jane has seen the doctor often and paid
paid $1,500 in total, reaching her $5,000 in total. Her plan pays the full
Office visit costs: $125 deductible. So her plan pays some of the cost of her covered health care services
Jane pays: $125 costs for her next visit. for the rest of the year.
Her plan pays: $0
Office visit costs: $125 Office visit costs: $125
Jane pays: 20% of $125 = $25 Jane pays: $0
Her plan pays: 80% of $125 = $100 Her plan pays: $125

Glossary of Health Coverage and Medical Terms Page 6 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020– 12/31/2020 Coverage
Health & Rehab Solutions Medical Plan: H.S.A. Option for: Individual, Family | Plan Type: HDHP

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. 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 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, call 1-866-887-4113 or visit
www.ebms.com. 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 1-866-487-2365 to request a copy.

Important Questions Answers Why This Matters:
What is the overall Participating Providers: $3,000 per Generally, you must pay all of the costs from providers up to the deductible amount before
deductible? covered person, $6,000 per family unit. this plan begins to pay. If you have other family members on the plan, each family member
Non-Participating Providers: $6,000 per must meet their own individual deductible until the total amount of deductible expenses
Are there services covered person, $12,000 per family unit. paid by all family members meets the overall family deductible.
covered before you meet Yes. Well-baby/Well child care, routine This plan covers some items and services even if you haven’t yet met the deductible
your deductible? mammograms, and Participating amount, however a copayment or coinsurance may apply. For example, this plan covers
Are there other Provider preventive care services are certain preventive services without cost sharing and before you meet your deductible. See
deductibles for specific covered before you meet your a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-
services? deductible. care-benefits/.
What is the out-of-pocket
limit for this plan? No. You don’t have to meet deductibles for specific services.

What is not included in Participating Providers: $3,000 per The out-of-pocket limit is the most you could pay in a year for covered services. If you have
the out-of-pocket limit? covered person, $6,000 per family unit. other family members in this plan, they have to meet their own out-of-pocket limits until the
Non-Participating Providers: $6,000 per overall family out-of-pocket limit has been met.
Will you pay less if you covered person, $12,000 per family unit.
use a network provider? Premiums, balance-billing charges Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
(unless balanced billing is prohibited),
Do you need a referral to and health care this plan doesn’t cover. This plan uses a provider network. You will pay less if you use a provider in the plan’s
see a specialist? network. You will pay the most if you use an out-of-network provider, and you might receive
Yes. See www.ebms.com or call 1-866- a bill from a provider for the difference between the provider’s charge and what your plan
887-4113 for a list of Participating pays (balance billing). Be aware, your network provider might use an out-of-network
Providers. provider for some services (such as lab work). Check with your provider before you get
services.
No.
You can see the specialist you choose without a referral.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 1 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: H.S.A. Option Coverage for: Individual, Family | Plan Type: HDHP

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Services You May Need What You Will Pay Limitations, Exceptions, &
Medical Event Participating Provider Non-Participating Provider Other Important Information
Primary care visit to treat an (You will pay the least) (You will pay the most)
If you visit a health injury or illness
care provider’s Specialist visit 0% coinsurance 0% coinsurance None
office or clinic 0% coinsurance 0% coinsurance
Preventive care/screening/ Deductible may apply to services that aren’t
immunization No charge 0% coinsurance preventive. Ask your provider if the services needed
are preventive, then check what your plan will pay
for. Deductible does not apply to Non-Participating
Provider Well baby/Well child care or Non-
Participating Provider routine mammograms.

If you have a test Diagnostic test (x-ray, blood 0% coinsurance 0% coinsurance None
work)
If you need drugs to Imaging (CT/PET scans, MRIs) 0% coinsurance 0% coinsurance An expanded list of certain 30-day supply preventive
treat your illness or Generic drugs care drugs may be available at no cost to the
condition Preferred brand drugs 0% coinsurance (retail or mail order) member. Retail and mail order drugs are available
More information Non-preferred brand drugs up to a 90-day supply per prescription.
about prescription 0% coinsurance (retail or mail order) Specialty drugs are limited up to a 30-day supply per
drug coverage is Specialty drugs prescription and must be obtained through the
available at 0% coinsurance (retail or mail order) Specialty Pharmacy Program. Only the first fill will
www.ebms.com Facility fee (e.g., ambulatory be available through the retail pharmacy benefit.
surgery center) 0% coinsurance (retail or mail order)
If you have Physician/surgeon fees
outpatient surgery 0% coinsurance 0% coinsurance None
0% coinsurance 0% coinsurance

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 2 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020– 12/31/2020
Health & Rehab Solutions Medical Plan: H.S.A. Option Coverage for: Individual, Family | Plan Type: HDHP

Common Services You May Need What You Will Pay Limitations, Exceptions, &
Medical Event Participating Provider Non-Participating Provider Other Important Information
Emergency room care (You will pay the least) (You will pay the most)
Medical emergency
Covered Persons admitted to a non-participating

0% coinsurance hospital due to an emergency must be transferred to
a participating facility once stable to continue

Non-medical emergency 0% coinsurance 0% coinsurance receiving benefits at the participating provider benefit
level.

If you need Emergency medical 00% coinsurance None
immediate medical transportation
attention
Medically necessary
emergency transport

Non-medically necessary 0% coinsurance 0% coinsurance

transport 0% coinsurance 0% coinsurance
0% coinsurance 0% coinsurance
Urgent care 0% coinsurance 0% coinsurance None
0% coinsurance 0% coinsurance Coverage is limited to the semi-private room rate.
If you have a Facility fee (e.g., hospital room) 0% coinsurance None
0% coinsurance 0% coinsurance
hospital stay Physician/surgeon fees 0% coinsurance None
0% coinsurance 0% coinsurance
If you need mental Outpatient services 0% coinsurance None
health, behavioral 0% coinsurance
health, or substance Office visits 0% coinsurance 0% coinsurance Cost sharing does not apply to certain preventive
abuse services services. Maternity care may include tests and
Inpatient services 0% coinsurance 0% coinsurance services described elsewhere in the SBC (e.g.
ultrasound).
Office visits 0% coinsurance 0% coinsurance
Coverage limited to 180 visits per calendar year.
Childbirth/delivery professional Inpatient services are limited to 30 days per calendar
year; the limit for services related to head or spinal
If you are pregnant services cord injury is 60 visits per condition when necessary.
Outpatient services are limits to 30 (combined) visits
Childbirth/delivery facility per calendar year and includes physical,
services occupational, and speech therapies. Additional
benefits may be available for treatment of head or
Home health care spinal cord injury, stroke, & problems associated with
pervasive developmental disorders.
If you need help Rehabilitation services 0% coinsurance
recovering or have Habilitation services 0% coinsurance
other special health
needs

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 3 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: H.S.A. Option Coverage for: Individual, Family | Plan Type: HDHP

Common Services You May Need What You Will Pay Limitations, Exceptions, &
Medical Event Skilled nursing care Participating Provider Non-Participating Provider Other Important Information
Durable medical equipment (You will pay the least) (You will pay the most)

0% coinsurance 0% coinsurance Coverage is limited to 60 days per calendar year.

Pre-notification is strongly recommended for charges

0% coinsurance 0% coinsurance exceeding $800 for the purchase, rental, repair or
replacement of equipment.

Hospice services 0% coinsurance 0% coinsurance Inpatient/outpatient services have a lifetime limit of
80 visits.
Children’s eye exam
Children’s glasses Not covered Routine vision services may be available through a

If your child needs Children’s dental check-up Not covered separate Plan election.
dental or eye care
Not covered Dental care may be available through a separate
Plan election.

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.)

 Bariatric surgery  Infertility treatment  Routine eye care (Adult)
 Cosmetic surgery
 Dental care (Adult)  Long-term care  Routine foot care
 Hearing aids
 Non-emergency care when traveling outside the U.S.  Weight loss programs

 Private-duty nursing

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

 Acupuncture  Chiropractic care

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 4 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: H.S.A. Option Coverage for: Individual, Family | Plan Type: HDHP

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. For more information, contact EBMS at
1-800-777-3575 or these agencies: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/agencies/ebsa/ or
Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.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 plan documents also
provide complete information 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: EBMS at 1-800-777-3575 or the DOL’s Employee Benefits Security Administration at 1-866-444-EBSA (3272). Additionally, a consumer assistance program
can help you file your appeal. Contact your state’s program if available at: http://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/.

Does this plan provide Minimum Essential Coverage? Yes.
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet 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 (Español): Para obtener asistencia en Español, llame al 1-866-887-4113.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-887-4113.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-866-887-4113.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-887-4113.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 5 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: H.S.A. Option Coverage for: Individual, Family | Plan Type: HDHP

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 plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture

(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)

 The plan’s overall deductible $3,000  The plan’s overall deductible $3,000  The plan’s overall deductible $3,000
 Specialist coinsurance 0%  Specialist coinsurance 0%
 Hospital (facility) coinsurance 0%  Primary care physician coinsurance 0%  Hospital (facility) coinsurance 0%
 Other coinsurance 0%  Hospital (facility) coinsurance 0%  Other coinsurance 0%

 Other coinsurance 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)
Durable medical equipment (crutches)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Rehabilitation services (physical therapy)
Diagnostic tests (ultrasounds and blood work) Prescription drugs
Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

In this example, Peg would pay: $3,000 In this example, Joe would pay: $3,000 In this example, Mia would pay: $1,900
Cost Sharing $0 Cost Sharing $0 Cost Sharing $0
$0 $0 $0
Deductibles Deductibles Deductibles
Copayments $60 Copayments $55 Copayments $0
Coinsurance $3,060 Coinsurance $3,055 Coinsurance $1,900

What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions Limits or exclusions Limits or exclusions
The total Peg would pay is The total Mia would pay is
The total Joe would pay is

The plan would be responsible for the other costs of these EXAMPLE covered services.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 6 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: H.S.A. Option Coverage for: Individual, Family | Plan Type: HDHP

NOTICE OF NONDISCRIMINATION
MONTANA

Your health plan complies with applicable Federal You can file a grievance in person or by mail, fax, CHINESE
civil rights laws and does not discriminate on the or email. If you need help filing a grievance, the 注意：如果您使用繁體中文，您可以免費
basis of race, color, national origin, age, disability, Civil Rights Coordinator is available to help you. 獲得語言援助服務。請致電1-406-756-1128。
or sex. Your health plan does not exclude people or
treat them differently because of race, color, You can also file a civil rights complaint with the JAPANESE
national origin, age, disability, or sex. U.S. Department of Health and Human Services, 注意事項：日本語を話される場合、無料
Office for Civil Rights, electronically through the の言語支援をご利用いただけます1-406-756-
Your health plan: Office for Civil Rights Complaint Portal, available 1128 まで、お電話にてご連絡ください。
at:
Provides free aids and services to people with TAGALOG
disabilities to communicate effectively with us, such https://ocrportal.hhs.gov/ocr/portal/lobby.jsf PAUNAWA: Kung nagsasalita ka ng Tagalog,
as: or by mail or phone at: maaari kang gumamit ng mga serbisyo ng tulong
sa wika nang walang bayad. Tumawag sa 1-406-
 Qualified sign language interpreters U.S. Department of Health and Human Services
 Written information in other formats (large 200 Independence Avenue, 756-1128.

print, audio, accessible electronic formats, SW Room 509F, HHH Building FRENCH
other formats) Washington, D.C. 20201 ATTENTION: Si vous parlez français, des services
d'aide linguistique-vous sont proposés
Provides free language services to people whose 1-800-368-1019, 800-537-7697 (TDD) gratuitement. Appelez le 1-406-756-1128.
primary language is not English, such as: Complaint forms are available at:
RUSSIAN
 Qualified interpreters http://www.hhs.gov/ocr/office/file/index.html. ВНИМАНИЕ: Если вы говорите на русском
 Information written in other languages языке, то вам доступны бесплатные услуги
SPANISH перевода. Звоните 1-406-756-1128.
If you need these services, contact your Human ATENCIÓN: si habla español, tiene a su
Resources Department. If you believe that your disposición servicios gratuitos de asistencia
health plan has failed to provide these services or lingüística. Llame al 1-406-756-1128.
discriminated in another way on the basis of race,
color, national origin, age, disability, or sex, you GERMAN
can file a grievance with the Civil Rights ACHTUNG: Wenn Sie Deutsch sprechen, stehen
Coordinator in the Human Resources Department, Ihnen kostenlos sprachliche Hilfsdienstleistungen
690 N. Meridian, Suite 201, Kalispell, MT 59901, zur Verfügung. Rufnummer: 1-406-756-1128.
Phone: 1-406-756-1128, Fax: 1-406-257-7811,
Email: [email protected].

APPENDIX A Notice of Non-Discrimination Page 1 of 2

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: H.S.A. Option Coverage for: Individual, Family | Plan Type: HDHP

KOREAN NORWEGIAN PENNSYLVANIA DUTCH
주의: 한국어를 사용하시는 경우, 언어 MERK: Hvis du snakker norsk, er gratis Wann du [Deitsch (Pennsylvania German / Dutch)]
지원 서비스를 무료로 이용하실 수 språkassistansetjenester tilgjengelige for deg. Ring schwetzscht, kannscht du mitaus Koschte ebber
있습니다. 1-406-756-1128 번으로 전화해 1-406-756-1128. gricke, ass dihr helft mit die englisch Schprooch.
주십시오. Ruf selli Nummer uff: Call 1-406-756-1128.
VIETNAMESE
ARABIC CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ ITALIAN
‫ فإن خدمات المساعدة‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ملحوظة‬ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số ATTENZIONE: In caso la lingua parlata sia
1128-756-406-1 ‫ اتصل برقم‬.‫اللغوية تتوافر لك بالمجان‬ 1-406-756-1128. l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero 1-406-756-
THAI UKRAINIAN
เรียน: УВАГА! Якщо ви розмовляєте українською 1128.
ถา้ คุณพดู ภาษาไทยคุณสามารถใชบ้ ริการช่วยเหลือทางภาษาไดฟ้ รี โทร мовою, ви можете звернутися до безкоштовної
1-406-756-1128. служби мовної підтримки. Телефонуйте за
номером 1-406-756-1128.

APPENDIX A Notice of Non-Discrimination Page 2 of 2

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: Standard PPO Option Coverage for: Individual, Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. 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 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, call 1-866-887-4113 or visit
www.ebms.com. 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 1-866-487-2365 to request a copy.

Important Questions Answers Why This Matters:
What is the overall Participating Providers: $1,000 per Generally, you must pay all of the costs from providers up to the deductible amount before
deductible? covered person, $2,000 per family unit. this plan begins to pay. If you have other family members on the plan, each family member
Non-Participating Providers: $2,000 per must meet their own individual deductible until the total amount of deductible expenses
Are there services covered person, $4,000 per family unit. paid by all family members meets the overall family deductible.
covered before you meet Yes. Well-baby/Well child care, routine
your deductible? mammograms, prescription drugs, and This plan covers some items and services even if you haven’t yet met the deductible
the following Participating Provider amount, however a copayment or coinsurance may apply. For example, this plan covers
Are there other services: preventive care, physician’s certain preventive services without cost sharing and before you meet your deductible. See
deductibles for specific office visits, urgent care visits, and a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-
services? chiropractic care, are covered before care-benefits/.
What is the out-of-pocket you meet your deductible.
limit for this plan? You don’t have to meet deductibles for specific services.
No.
What is not included in The out-of-pocket limit is the most you could pay in a year for covered services. If you have
the out-of-pocket limit? Participating Providers: $3,000 per other family members in this plan, they have to meet their own out-of-pocket limits until the
covered person, $6,000 per family unit. overall family out-of-pocket limit has been met.
Will you pay less if you Non-Participating Providers: $6,000 per
use a network provider? covered person, $12,000 per family unit. Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Premiums, balance-billing charges
Do you need a referral to (unless balanced billing is prohibited), This plan uses a provider network. You will pay less if you use a provider in the plan’s
see a specialist? and health care this plan doesn’t cover. network. You will pay the most if you use an out-of-network provider, and you might receive
a bill from a provider for the difference between the provider’s charge and what your plan
Yes. See www.ebms.com or call 1-866- pays (balance billing). Be aware, your network provider might use an out-of-network
887-4113 for a list of Participating provider for some services (such as lab work). Check with your provider before you get
Providers. services.
You can see the specialist you choose without a referral.
No.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 1 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: Standard PPO Option Coverage for: Individual, Family | Plan Type: PPO

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Services You May Need What You Will Pay Limitations, Exceptions, &
Medical Event Participating Provider Non-Participating Provider Other Important Information
(You will pay the least) (You will pay the most)

Primary care visit to treat an $35 copayment per visit; 25% coinsurance The office visit copayment applies to the visit
injury or illness deductible does not apply 25% coinsurance charge only. All other services are payable per
normal Plan provisions.
Specialist visit $50 copayment per visit;
deductible does not apply

If you visit a health You may have to pay for services that aren’t
care provider’s
office or clinic preventive. Ask your provider if the services
needed are preventive, then check what your plan
Preventive care/screening/
immunization No charge 25% coinsurance will pay for. Deductible does not apply to Non-
Participating Provider Well baby/Well child care.

Non-Participating Provider routine mammograms
are No charge.

If you have a test Diagnostic test (x-ray, blood 20% coinsurance 45% coinsurance None
work) 20% coinsurance 45% coinsurance
If you need drugs Imaging (CT/PET scans,
to treat your MRIs) $10 copayment per prescription (retail) Deductible does not apply to prescription drugs.
illness or Generic drugs $20 copayment per prescription (mail order) Retail drugs are limited to a 30-day supply per
condition prescription; mail order drugs are available up to a
More information Preferred brand drugs $35 copayment per prescription (retail) 90-day supply per prescription.
about prescription $105 copayment per prescription (mail order) Specialty drugs are limited up to a 30-day supply
drug coverage is Non-preferred brand drugs per prescription and must be obtained through the
available at $60 copayment per prescription (retail) Specialty Pharmacy Program. Only the first fill will
www.ebms.com Specialty drugs $180 copayment per prescription (mail order) be available through the retail pharmacy benefit.

If you have Facility fee (e.g., ambulatory $250 copayment per prescription
outpatient surgery surgery center)
Physician/surgeon fees 20% coinsurance 45% coinsurance None
If you need Emergency room care 20% coinsurance 45% coinsurance
immediate medical Covered Persons admitted to a non-participating
attention Medical emergency 20% coinsurance hospital due to an emergency must be transferred
to a participating facility once stable to continue
Non-medical emergency 20% coinsurance 45% coinsurance receiving benefits at the participating provider
benefit level.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 2 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: Standard PPO Option Coverage for: Individual, Family | Plan Type: PPO

Common Services You May Need What You Will Pay Limitations, Exceptions, &
Medical Event Participating Provider Non-Participating Provider Other Important Information
Emergency medical (You will pay the least) (You will pay the most)
transportation
20% coinsurance None
Medically necessary
emergency transport

Non-medically necessary 20% coinsurance 20% coinsurance
transport
$35 copayment per visit; 25% coinsurance
Urgent care deductible does not apply The urgent care copayment applies to the visit
45% coinsurance charge only. All other services are payable per
If you have a Facility fee (e.g., hospital 20% coinsurance 45% coinsurance normal Plan provisions.
hospital stay room) 20% coinsurance 45% coinsurance
Physician/surgeon fees 20% coinsurance 25% coinsurance Coverage is limited to the semi-private room rate.
If you need mental Outpatient services $35 copayment per visit; 45% coinsurance
health, behavioral deductible does not apply 25% coinsurance None
health, or Office visits 20% coinsurance 45% coinsurance
substance abuse $35 copayment /visit; 45% coinsurance None
services Inpatient services deductible does not apply 45% coinsurance
20% coinsurance 45% coinsurance None
Office visits
20% coinsurance 45% coinsurance Cost sharing does not apply to certain preventive
If you are pregnant Childbirth/delivery 20% coinsurance services. Depending on the type of services,
professional services coinsurance may apply. Maternity care may include
20% coinsurance tests and services described elsewhere in the SBC
Childbirth/delivery facility (e.g. ultrasound).
services 20% coinsurance
Coverage limited to 180 visits per calendar year.
Home health care Inpatient services are limited to 30 days per
calendar year; the limit for services related to head
If you need help Rehabilitation services or spinal cord injury is 60 visits per condition when
recovering or have Habilitation services necessary. Outpatient services are limits to 30
other special (combined) visits per calendar year and includes
health needs physical, occupational, and speech therapies.
Additional benefits may be available for treatment of
head or spinal cord injury, stroke, & problems
associated with pervasive developmental disorders.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 3 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020– 12/31/2020
Health & Rehab Solutions Medical Plan: Standard PPO Option Coverage for: Individual, Family | Plan Type: PPO

Common Services You May Need What You Will Pay Limitations, Exceptions, &
Medical Event Skilled nursing care Participating Provider Non-Participating Provider Other Important Information
Durable medical equipment (You will pay the least) (You will pay the most)

20% coinsurance 45% coinsurance Coverage is limited to 60 days per calendar year.

Pre-notification is strongly recommended for

20% coinsurance 45% coinsurance charges exceeding $800 for the purchase, rental,
repair or replacement of equipment.

Hospice services 20% coinsurance 45% coinsurance Inpatient/outpatient services have a lifetime limit of
80 visits.
Children’s eye exam
Children’s glasses Not covered Routine vision services may be available through a

If your child needs Children’s dental check-up Not covered separate Plan election.
dental or eye care
Not covered Dental care may be available through a separate
Plan election.

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.)

 Bariatric surgery  Infertility treatment  Routine eye care (Adult)
 Cosmetic surgery
 Dental care (Adult)  Long-term care  Routine foot care
 Hearing aids
 Non-emergency care when traveling outside the U.S.  Weight loss programs

 Private-duty nursing

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

 Acupuncture  Chiropractic care

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 4 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: Standard PPO Option Coverage for: Individual, Family | Plan Type: PPO

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. For more information, contact EBMS at
1-800-777-3575 or these agencies: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/agencies/ebsa/ or
Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.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 plan documents also
provide complete information 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: EBMS at 1-800-777-3575 or the DOL’s Employee Benefits Security Administration at 1-866-444-EBSA (3272). Additionally, a consumer assistance program
can help you file your appeal. Contact your state’s program if available at: http://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/.

Does this plan provide Minimum Essential Coverage? Yes.
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet 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 (Español): Para obtener asistencia en Español, llame al 1-866-887-4113.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-887-4113.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-866-887-4113.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-887-4113.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 5 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: Standard PPO Option Coverage for: Individual, Family | Plan Type: PPO

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 plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture

(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)

 The plan’s overall deductible $1,000  The plan’s overall deductible $1,000  The plan’s overall deductible $1,000
 Specialist copayment $50  Primary care physician copayment $35  Specialist copayment $50
 Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%
 Other coinsurance 20%  Other coinsurance 20%  Other coinsurance 20%

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)
Durable medical equipment (crutches)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Rehabilitation services (physical therapy)
Diagnostic tests (ultrasounds and blood work) Prescription drugs
Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

In this example, Peg would pay: $1,000 In this example, Joe would pay: $1,000 In this example, Mia would pay: $1,000
Cost Sharing $0 Cost Sharing $1,145 Cost Sharing $150
$326
Deductibles $2,000 Deductibles $372 Deductibles
Copayments Copayments Copayments $0
Coinsurance $60 Coinsurance $55 Coinsurance $1,476
$3,060 $2,572
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions Limits or exclusions Limits or exclusions
The total Peg would pay is The total Mia would pay is
The total Joe would pay is

The plan would be responsible for the other costs of these EXAMPLE covered services.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146, Released on April 6, 2016 Page 6 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: Standard PPO Option Coverage for: Individual, Family | Plan Type: PPO

NOTICE OF NONDISCRIMINATION CHINESE
MONTANA 注意：如果您使用繁體中文，您可以免費
獲得語言援助服務。請致電1-406-756-1128。
Your health plan complies with applicable Federal You can file a grievance in person or by mail, fax,
civil rights laws and does not discriminate on the or email. If you need help filing a grievance, the JAPANESE
basis of race, color, national origin, age, disability, Civil Rights Coordinator is available to help you. 注意事項：日本語を話される場合、無料
or sex. Your health plan does not exclude people or の言語支援をご利用いただけます1-406-756-
treat them differently because of race, color, You can also file a civil rights complaint with the 1128 まで、お電話にてご連絡ください。
national origin, age, disability, or sex. U.S. Department of Health and Human Services,
Office for Civil Rights, electronically through the TAGALOG
Your health plan: Office for Civil Rights Complaint Portal, available PAUNAWA: Kung nagsasalita ka ng Tagalog,
at: maaari kang gumamit ng mga serbisyo ng tulong
Provides free aids and services to people with sa wika nang walang bayad. Tumawag sa 1-406-
disabilities to communicate effectively with us, such https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
as: or by mail or phone at: 756-1128.

 Qualified sign language interpreters U.S. Department of Health and Human Services FRENCH
 Written information in other formats (large 200 Independence Avenue, ATTENTION: Si vous parlez français, des services
d'aide linguistique-vous sont proposés
print, audio, accessible electronic formats, SW Room 509F, HHH Building gratuitement. Appelez le 1-406-756-1128.
other formats) Washington, D.C. 20201
RUSSIAN
Provides free language services to people whose 1-800-368-1019, 800-537-7697 (TDD) ВНИМАНИЕ: Если вы говорите на русском
primary language is not English, such as: Complaint forms are available at: языке, то вам доступны бесплатные услуги
перевода. Звоните 1-406-756-1128.
 Qualified interpreters http://www.hhs.gov/ocr/office/file/index.html.
 Information written in other languages
SPANISH
If you need these services, contact your Human ATENCIÓN: si habla español, tiene a su
Resources Department. If you believe that your disposición servicios gratuitos de asistencia
health plan has failed to provide these services or lingüística. Llame al 1-406-756-1128.
discriminated in another way on the basis of race,
color, national origin, age, disability, or sex, you GERMAN
can file a grievance with the Civil Rights ACHTUNG: Wenn Sie Deutsch sprechen, stehen
Coordinator in the Human Resources Department, Ihnen kostenlos sprachliche Hilfsdienstleistungen
690 N. Meridian, Suite 201, Kalispell, MT 59901, zur Verfügung. Rufnummer: 1-406-756-1128.
Phone: 1-406-756-1128, Fax: 1-406-257-7811,
Email: [email protected]

APPENDIX A Notice of Non-Discrimination Page 1 of 2

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020
Health & Rehab Solutions Medical Plan: Standard PPO Option Coverage for: Individual, Family | Plan Type: PPO

KOREAN NORWEGIAN PENNSYLVANIA DUTCH
주의: 한국어를 사용하시는 경우, 언어 MERK: Hvis du snakker norsk, er gratis Wann du [Deitsch (Pennsylvania German / Dutch)]
지원 서비스를 무료로 이용하실 수 språkassistansetjenester tilgjengelige for deg. Ring schwetzscht, kannscht du mitaus Koschte ebber
있습니다. 1-406-756-1128 번으로 전화해 1-406-756-1128. gricke, ass dihr helft mit die englisch Schprooch.
주십시오. Ruf selli Nummer uff: Call 1-406-756-1128.
VIETNAMESE
ARABIC CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ ITALIAN
‫ فإن خدمات المساعدة‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ملحوظة‬ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số ATTENZIONE: In caso la lingua parlata sia
1128-756-406-1 ‫ اتصل برقم‬.‫اللغوية تتوافر لك بالمجان‬ 1-406-756-1128. l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero 1-406-756-
THAI UKRAINIAN
เรียน: УВАГА! Якщо ви розмовляєте українською 1128.
ถา้ คุณพดู ภาษาไทยคุณสามารถใชบ้ ริการช่วยเหลือทางภาษาไดฟ้ รี โทร мовою, ви можете звернутися до безкоштовної
1-406-756-1128. служби мовної підтримки. Телефонуйте за
номером 1-406-756-1128.

APPENDIX A Notice of Non-Discrimination Page 2 of 2