Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services McComb Local Schools : HDHP

Coverage Period: 01/01/2024 - 12/301/2024 Coverage for: Single or 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 800-367-3762. 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 MutualHealthServices.com/SBC or call 800-367-3762 to request a copy.

Important Questions

What is the overall deductible?

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

What is the out-of-pocket limit for this plan?

What is not included in the out-of-pocket limit?

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

Answers

$3,200/single,$6,400/family Network $5,000/single,$10,000/family
Non-Network

Yes. Certain preventive care and all services with copayments are covered and paid by the plan before you meet your deductible.

No

$3,200/single,$6,400/family Network $11,000/single,$22,000/family
Non-Network

Premiums, balance-billed charges and health care this plan doesn't cover.

Yes, See MutualHealthServices.com/SBC or call 800-367-3762 for a list of participating providers.

No

Why This Matters:

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply.

You don’t have to meet deductibles for specific services.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

This plan uses a provider network. You will pay less if you use a provider in the plan's 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 pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

You can see the specialist you choose without a referral.

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All coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Services with copayments are covered before you meet your deductible, unless otherwise specified.

Common Medical Event

If you visit a health care provider's office or clinic

Services You May Need

Primary care visit to treat an injury or illness

What You Will Pay

Network Provider	Non-Network Provider (You will pay the least)       (You will pay the most)
No charge after deductible	40% coinsurance

Limitations, Exceptions, & Other Important Information

Physician exam only

If you have a test

If you need drugs to treat your illness or condition

Specialist visit

Preventive care/ screening/ immunization

Diagnostic test (x-ray) Diagnostic test (blood work) Imaging (CT/PET scans, MRIs)
Major Medical Drug Coverage /Rx

No charge after deductible No charge

No charge after deductible No charge after deductible No charge after deductible
No charge after deductible

40% coinsurance 40% coinsurance

40% coinsurance 40% coinsurance 40% coinsurance
Does Not Apply

Physician exam only

You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.
None

None None
None

More information about prescription drug coverage is available at MutualHealthServices.com/SBC

If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)
Physician/surgeon fees (Outpatient)

No charge after deductible

No charge after deductible

40% coinsurance	None

40% coinsurance	None

If you need immediate medical attention

Emergency room care

Emergency medical transportation

No charge after deductible	None

No charge after deductible	40% coinsurance	None

Urgent care

If you have a hospital stay	Facility fee (e.g., hospital room)

Physician/ surgeon fee (inpatient)

No charge after deductible No charge after deductible
No charge after deductible

40% coinsurance 40% coinsurance
40% coinsurance

Includes facility

Pre-Certification is required

None

^[ ^For ^more ^information ^about ^limitations ^and ^exceptions, ^see ^the ^plan ^or ^policy ^document ^at ^MutualHealthServices.com/SBC.]                                                    Page 2 of 5 QHCSMCC
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Common Medical Event

If you need mental health, behavioral health, or substance abuse services

Services You May Need

Outpatient services

Inpatient services

What You Will Pay

Network Provider	Non-Network Provider (You will pay the least)       (You will pay the most) Benefits paid based on corresponding medical benefits

Benefits paid based on corresponding medical benefits

Limitations, Exceptions, & Other Important Information

None

None

If you are pregnant

If you need help recovering or have other special health needs

Office visits

Childbirth/delivery professional services

Childbirth/delivery facility services

Home health care

Rehabilitation services (Physical Therapy)
Habilitation services (Occupational Therapy)
Habilitation services (Speech Therapy)
Skilled nursing care

Durable medical equipment

Hospice services

No charge

No charge after deductible

No charge after deductible

No charge after deductible No charge after deductible

No charge after deductible

No charge after deductible

No charge after deductible No charge after deductible

No charge after deductible

40% coinsurance

40% coinsurance

40% coinsurance

40% coinsurance 40% coinsurance

40% coinsurance

40% coinsurance

40% coinsurance 40% coinsurance

40% coinsurance

Cost sharing does not apply to certain preventive services. Depending on the type of services, copay, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
All females covered on plan (benefits paid are based on corresponding medical benefits) All females covered on plan (benefits paid are based on corresponding medical benefits) None

None

None

None

None

Pre-certification is required for purchases over $1,500 and all rentals
None

If your child needs dental or eye care

Children's eye exam Children's glasses
Children's dental check-up

No charge		40% coinsurance Not Covered
Not Covered

None

Excluded Service

Excluded Service

^[ ^For ^more ^information ^about ^limitations ^and ^exceptions, ^see ^the ^plan ^or ^policy ^document ^at ^MutualHealthServices.com/SBC.]                                                    Page 3 of 5 QHCSMCC
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Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) |

•	Acupuncture	•	Dental Care (Adult)	•	Non-emergency care when traveling outside the U.S. •	Bariatric Surgery	•	Hearing Aids	•	Routine Eye Care (Adult)
•	Children's dental check-up	•	Infertility Treatment	•	Routine Foot Care
•	Children's glasses	•	Long-Term Care	•	Weight Loss Programs •	Cosmetic Surgery

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) |
•	Chiropractic Care	•	Private-Duty Nursing

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends.The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 877-267-2323 x61565 or cciio.cms.gov. Other coverage options may be available to you, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit HealthCare.gov or call

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 your plan at

800-367-3762.

Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet 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.

-------------------------------------To see examples of how this plan might cover costs for sample medical situations, see the next section-----------------------------------The coverage example numbers assume that the patient does not use an HRA or FSA. If you participate in an HRA or FSA and use it to pay for out-of-pocket expenses, then your costs may be lower.

^[ ^For ^more ^information ^about ^limitations ^and ^exceptions, ^see ^the ^plan ^or ^policy ^document ^at ^MutualHealthServices.com/SBC.]                                                    Page 4 of 5 QHCSMCC
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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
(9 months of in-network pre-natal care and a hospital delivery)

Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition)

Mia’s Simple Fracture
(in-network emergency room visit and follow up care)

◼ The plan's overall deductible ◼ Specialist coinsurance
◼ Hospital (facility) coinsurance ◼ Other coinsurance

$3,200	_◼ 0%	_◼ 0%	_◼ 0%	_◼

The plan's overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance

$3,200	_◼ 0%	_◼ 0%	_◼ 0%	_◼

The plan's overall deductible	^$3,200 Specialist coinsurance                             ^0% Hospital (facility) coinsurance                   ^0% Other coinsurance                                   ^0%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

This EXAMPLE event includes services like: Primary care physician office visits (including disease education)
Diagnostic tests (blood work) Prescription drugs
Durable medical equipment (glucose meter)

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray)
Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost

In this example, Peg would pay: Cost Sharing
Deductibles Copayments Coinsurance

What isn’t covered Limits or exclusions

The total Peg would pay is

$12,700

$3,200 $0 $0

$60

$3,260

Total Example Cost	$5,600

In this example, Joe would pay: Cost Sharing
Deductibles	$900 Copayments                                              ^$0 Coinsurance                                              ^$0

What isn’t covered

Limits or exclusions	^$20

The total Joe would pay is	^$920

Total Example Cost	$2,800

In this example, Mia would pay: Cost Sharing
Deductibles	$2,800 Copayments                                             ^$0 Coinsurance                                             ^$0

What isn’t covered

Limits or exclusions	^$0

The total Mia would pay is	^$2,800

Note: These numbers assume the patient does not participate in the plan's wellness program. If you participate in the plan's wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: 800-367-3762.

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

[ For more information about limitations and exceptions, see the plan or policy document at MutualHealthServices.com/SBC.]

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Multi-Language Interpreter Services & Nondiscrimination Notice

This document notifies individuals of how to seek assistance if they speak a language other than English.

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X9859-GHP R11/16

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Mutual Health Services complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex in its operation of health programs and activities. Mutual Health Services does not exclude people or treat them differently because of race, color, national origin, age, disability or sex in its operation of health programs and activities.

^n     Mutual Health Services provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, etc.).

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If you need these services or if you believe Mutual Health Services failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, with respect to your health care benefits or services, you can submit a written complaint to the person listed below. Please include as much detail as possible in your written complaint to allow us to effectively research and respond.

Civil Rights Coordinator Medical Mutual of Ohio 2060 East Ninth Street Cleveland, OH 44115-1355 MZ: 01-10-1900

Email: CivilRightsCoordinator@MedMutual.com

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.

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U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F HHH Building
Washington, DC 20201-0004

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(800) 368-1019 (TDD: (800) 537-7697)

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