HomeMy WebLinkAbout2021-2022 Group Health Plan Notices for Plan ParticipantsThe following notices provide important information about your employer provided group health
plan. Please read the notices carefully and keep a copy for your records. If you have any questions
regarding these notices, please contact Human Resources or the plan administrator at
benefits@d93.k12.id.us or (208) 525-4444
Bonneville Joint School District 93
Group Health Plan
Notices
Annual Required Legal Notices and Disclosures for Plan Participants
Page 1
This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
Medicare Part D Notice
Important Notice About Your Creditable Prescription Drug Coverage and Medicare
If you or any of your eligible dependents are eligible for Medicare, or will soon become
eligible for Medicare, please read this notice. If not, you can disregard this notice.
Please read this notice carefully and keep it where you can find it. This notice has information about your
current prescription drug coverage and about your options under Medicare’s prescription drug coverage. This
information can help you decide whether or not you want to join a Medicare prescription drug plan. If you are
considering joining, you should compare your current coverage, including which drugs are covered at what cost,
with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information
about where you can get help to make decisions about your prescription drug coverage is at the end of this
notice.
There are two important things you need to know about your current coverage and Medicare’s prescription
drug coverage:
1.Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get
this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an
HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard
level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly
premium.
2.Your employer has determined that the prescription drug coverage offered by Blue Cross of Idaho
(Preferred Blue PPO $3,000 Ded & HSA Blue PPO $6,800 Ded) is expected to pay, on average, as much as
standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage.
Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher
premium (a penalty) if you later decide to join a Medicare drug plan.
When can you join a Medicare drug plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th
to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of
your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare
prescription drug plan.
Please contact Human Resources for more information about what happens to your coverage if you enroll in a
Medicare prescription drug plan.
Individuals who are eligible for Medicare should compare their current coverage, including which drugs are
covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in their area.
Your medical benefits brochure contains a description of your current prescription drug benefits. If you are
eligible for Medicare and do decide to enroll in a Medicare prescription drug plan and drop your employer’s
group health plan prescription drug coverage, be aware that you and your dependents may not be able to get
this coverage back.
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This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
When will you pay a higher premium (penalty) to join a Medicare drug plan?
You should also know that if you drop or lose your current coverage with your employer and don’t join a
Medicare prescription drug plan within 63 continuous days after your current coverage ends, you may pay a
higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium
may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not
have that coverage. For example, if you go nineteen months without creditable coverage, your premium may
consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this
higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have
to wait until the following October to join.
For more information about this notice or your current prescription drug coverage…
Contact Human Resources for further information.
NOTE: You will receive this notice annually, before the next period you can join a Medicare prescription drug
plan, and if this coverage through your employer changes. You also may request a copy of this notice at any
time.
For more information about your options under Medicare prescription drug coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare &
You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be
contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:
•Visit www.medicare.gov
•Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the
“Medicare & You” handbook for their telephone number) for personalized help
•Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available.
For information about this extra help, visit the Social Security Administration (SSA) online at
www.socialsecurity.gov, or call SSA at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: keep this creditable coverage notice. If you decide to join one of the Medicare prescription drug
plans, you may be required to provide a copy of this notice when you join to show whether or not you have
maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a
penalty).
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This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
Women’s Health and Cancer Rights Act 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. If you would like more information on WHCRA benefits, contact the
plan administrator.
Newborns’ and Mother’s Health Protection Act
The Newborns' and Mothers' Health Protection Act (NMHPA) requires that group health plans and health
insurance issuers who offer childbirth coverage 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). Refer to your plan document for specific
information about childbirth coverage or contact your plan administrator.
For additional information about NMHPA provisions and how Self-funded non Federal governmental plans may
opt-out of the NMHPA requirements, visit http://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-
Insurance-Protections/nmhpa_factsheet.html.
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This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
HIPAA Non-Discrimination Requirements
The Health Insurance Portability & Accountability Act (HIPAA) prohibits group health plans and health insurance
issuers from discriminating against individuals in eligibility and continued eligibility for benefits and in
individual premium or contribution rates based on health factors.
These health factors include health status, medical condition (including both physical and mental illnesses),
claims experience, receipt of health care, medical history, genetic information, evidence of insurability
(including conditions arising out of acts of domestic violence and participation in activities such as
motorcycling, snowmobiling, all-terrain vehicle riding, horseback riding, skiing, and other similar activities),
and disability.
Page 5
This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
Notice of HIPAA Special Enrollment Rights
A federal law called HIPAA requires that we notify you of your right to enroll in the plan under its “special
enrollment provision” if you acquire a new dependent, or if you decline coverage under this plan for yourself or
an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying
reasons.
Special Enrollment Provisions
Loss of Other Coverage (Except Medicaid or a State Children's Health Insurance Program). If you decline
enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or
group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if
you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward
your or your dependents' other coverage). However, you must request enrollment within 30 days after your or
your dependents' other coverage ends (or after the employer stops contributing toward the other coverage).
Loss of Eligibility Under Medicaid or a State Children's Health Insurance Program. If you decline enrollment for
yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state
children's health insurance program is in effect, you may be able to enroll yourself and your dependents in this
plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment
within 60 days after your or your dependents' coverage ends under Medicaid or a state children's health
insurance program.
New Dependent by Marriage, Birth, Adoption, or Placement for Adoption. 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 new
dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or
placement for adoption.
Eligibility for Medicaid or a State Children's Health Insurance Program. If you or your dependents (including your
spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children's
health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your
dependents in this plan. However, you must request enrollment within 60 days after your or your dependents'
determination of eligibility for such assistance.
Other mid-year election changes may be permitted under your plan (refer to “Permitted Midyear Election
Changes” section below).
To request special enrollment or obtain more information, contact Human Resources.
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This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
Permitted Midyear Election Changes
Due to Internal Revenue Service (IRS) regulations, in order to be eligible to take your premium contribution
using pre-tax dollars, your election generally must be irrevocable for the entire plan year (with the exception of
HSA benefit elections, for which prospective election changes generally are allowed). As a result, your
enrollment in the medical, dental, and vision plans or declination of coverage when you are first eligible, will
generally remain in place until the next open enrollment period, unless you have an approved election change
event and certain other conditions are met as outlined in IRS Code Section 125. See your Section 125 premium
conversion plan summary plan description (SPD) for further details and a complete listing of permitted change in
election events.
Examples of permitted change in election events include:
•Change in legal marital status (e.g., marriage, divorce, annulment, or legal separation)
•Change in number of dependents (e.g., birth, adoption, or death)
•Change in your employment status or your spouse’s or covered child’s change in employment (e.g.,
reduction in hours affecting eligibility or change in employment)
•Your child satisfies or ceases to satisfy the requirements for coverage due to attainment of age, student
status, or any similar circumstance as provided in the plan under which you receive coverage
•You and/or your spouse or covered child has a change of residence
•Your spouse or covered child makes an election change during an open enrollment period under his or
her employer’s cafeteria plan, but only if the change under this Plan is consistent with and on account of
your spouse’s or covered child’s change.
•Enrollment in state-based insurance Exchange
•Medicare Part A or B enrollment
These are just some examples of permitted mid-year change in election events. Consult with Human Resources
for other circumstances that may be permissible mid-year change in election events.
You must notify Human Resources within 30 days of the above change in status, with the exception of the loss of
eligibility or enrollment in Medicaid or state health insurance programs - which requires notice within 60 days.
Page 7
This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
HIPAA Privacy Notice
Notice of Health Information Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can
obtain access to this information. Please review it carefully.
This notice is required by law under the federal Health Insurance Portability and Accountability Act of 1996
(HIPAA). One of its primary purposes is to make certain that information about your health is handled with
special respect for your privacy. HIPAA includes numerous provisions designed to maintain the privacy and
confidentiality of your protected health information (PHI). PHI is health information that contains identifiers,
such as your name, address, social security number, or other information that identifies you.
Our Pledge Regarding Health Information
•We understand that health information about you and your health is personal.
•We are committed to protecting health information about you.
•This notice will tell you the ways in which we may use and disclose health information about you.
•We also describe your rights and certain obligations we have regarding the use and disclosure of health
information.
We are Required by Law to
•Make sure that health information that identifies you is kept private.
•Give you this notice of our legal duties and privacy practices with respect to health information about
you.
•Follow the terms of the notice that are currently in effect.
The Plan Will Use Your Health Information for
Treatment: The plan may use your health information to assist your health care providers (doctors,
pharmacies, hospitals and others) to assist in your treatment. For example, the plan may provide a treating
physician with the name of another treating provider to obtain records or information needed for your
treatment.
Regular Operations: We may use information in health records to review our claims experience and to
make determinations with respect to the benefit options that we offer to employees.
Business Associates: There are some services provided in our organization through contracts with business
associates. Business associate agreements are maintained with insurance carriers. Business associates with
access to your information must adhere to a contract requiring compliance with HIPAA privacy and security
rules.
As Required by Law: We will disclose health information about you when required to do so by federal,
state or local law.
Workers’ Compensation: We may release health information about you for Workers’ Compensation or
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This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
similar programs. These programs provide benefits for work-related injuries or illness.
Law Enforcement: We may disclose your health information for law enforcement purposes, or in response
to a valid subpoena or other judicial or administrative request.
Public Health: We may also use and disclose your health information to assist with public health activities
(for example, reporting to a federal agency) or health oversight activities (for example, in a government
investigation).
Your Rights Regarding Your Health Information
Although your health record is the physical property of the entity that compiled it, the information belongs to
you. You have the right to:
•Request a restriction on certain uses and disclosures of your information, where concerning a service
already paid for.
•Obtain a paper copy of the Notice of Health Information Practices by requesting it from the plan privacy
officer.
•Inspect and obtain a copy of your health information.
•Request an amendment to your health information.
•Obtain an accounting of disclosures of your health information.
•Request communications of your health information be sent in a different way or to a different place
than usual (for example, you could request that the envelope be marked "Confidential" or that we send it
to your work address rather than your home address);
•Revoke in writing your authorization to use or disclose health information except to the extent that
action has already been taken, in reliance on that authorization.
The Plan’s Responsibilities
The plan is required to:
•Maintain the privacy of your health information.
•Provide you with a notice as to our legal duties and privacy practices with respect to information we
•collect and maintain about you.
•Abide by the terms of this notice.
•Notify you if we are unable to agree to a requested restriction, amendment or other request.
•Notify you of any breaches of your personal health information within 60 days or 5 days if conducting
business in California.
•Accommodate any reasonable request you may have to communicate health information by alternative
means or at alternative locations.
The plan will not use or disclose your health information without your consent or authorization, except as
provided by law or described in this notice. The plan reserves the right to change our health privacy practices.
Should we change our privacy practices in a material way, we will make a new version of our notice available to
you.
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This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
For More Information or to Report a Problem
•If you have questions or would like additional information, or if you would like to make a request to
inspect, copy, or amend health information, or for an accounting of disclosures, contact Human
Resources and the plan privacy officer. All requests must be submitted in writing.
•If you believe your privacy rights have been violated, you can file a formal complaint with the plan privacy
officer, or with the U.S. Department of Health and Human Services. You will not be penalized for filing a
complaint.
Other Uses of Health Information
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be
made only with your written authorization. If you authorize us to use or disclose health information about you,
you may revoke that authorization, in writing, at any time. If you revoke your authorization we will no longer use
or disclose health information about you for the reasons covered by your written authorization. You understand
that we are unable to take back any disclosures we have already made with your authorization, and that we are
required to retain our records of the payment activities that we provided to you.
Page 10
This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
Important Information on How Health Care
Reform Impacts Your Plan
Prohibition on Excess Waiting Periods
Group health plans may not apply a waiting period that exceeds 90 days. A waiting period is defined as the
period that must pass before coverage for an eligible employee or his or her dependent becomes effective
under the Plan.
Prohibition on Preexisting Condition Exclusions
Effective for Plan Years on or after January 1, 2014, Group health plans are prohibited from denying coverage or
excluding specific benefits from coverage due to an individual’s preexisting condition, regardless of the
individual’s age. A preexisting condition includes any health condition or illness that is present before the
coverage effective date, regardless of whether medical advice or treatment was actually received or
recommended.
New Health Insurance Marketplace Coverage Options and Your Health Coverage
General Information. When key parts of the health care law took 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 and employment-based health
coverage offered by your employer.
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
for coverage starting as early as January.
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.
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,
Page 11
This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
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? For more information about your coverage offered by your employer, please
check your summary plan description or contact the plan administrator. 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.
Page 12
This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
Employee Rights & Responsibilities under the
Family Medical Leave Act (FMLA)
The FMLA only applies to employers that meet certain criteria. A covered employer is a:
•Private-sector employer with 50 or more employees in 20 or more workweeks in the current or preceding
calendar year (including a joint employer or successor in interest).
•Public agency (including a local, state, or Federal government agency) regardless of number of employees.
•Public or private elementary or secondary school, regardless of number of employees.
Leave Entitlement
Family Medical Leave Act (FMLA) requires covered employers to provide up to 12 weeks of unpaid, job
protected leave in a 12-month period to eligible employees for the following reasons:
•The birth of a child or placement of a child for adoption or foster care.
•To bond with a child (leave must be taken within one year of the child’s birth or placement).
•To care for the employee’s spouse, child, or parent who has a qualifying serious health condition.
•For the employee’s own qualifying serious health condition that makes the employee unable to perform
the employee’s job.
•For qualifying exigencies related to the foreign deployment of a military member who is the employee’s
spouse, child, or parent.
An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to
26 weeks of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or
illness.
An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted,
employees may take leave intermittently or on a reduced schedule.
Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an
employee substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s
normal paid leave policies.
Benefits & Protections
While employees are on FMLA leave, employers must continue health insurance coverage as if the employees
were not on leave.
Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it
with equivalent pay, benefits, and other employment terms and conditions.
An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying
to use FMLA leave, opposing any practice made unlawful by the FMLA, or being involved in any proceeding
under or related to the FMLA.
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This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
Eligibility Requirements
An employee who works for a covered employer must meet three criteria to be eligible for FMLA leave. The
employee must:
•Have worked for the employer for at least 12 months.
•Have at least 1,250 hours of service in the 12 months before taking leave; * and
•Work at a location where the employer has at least 50 employees within 75 miles of the employee’s
worksite.
*Special “hours of service” requirements apply to airline flight crew employees.
Requesting Leave
Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give
30-days’ notice, an employee must notify the employer as soon as possible and, generally, follow the employer’s
usual procedures.
Employees do not have to share a medical diagnosis but must provide enough information to the employer so it
can determine if the leave qualifies for FMLA protection. Sufficient information could include informing an
employer that the employee is or will be unable to perform his or her job functions, that a family member
cannot perform daily activities, or that hospitalization or continuing medical treatment is necessary. Employees
must inform the employer if the need for leave is for a reason for which FMLA leave was previously taken or
certified.
Employers can require a certification or periodic recertification supporting the need for leave. If the employer
determines that the certification is incomplete, it must provide a written notice indicating what additional
information is required.
Employer Responsibilities
Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the
FMLA, the employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also
provide a notice of rights and responsibilities under the FMLA. If the employee is not eligible, the employer must
provide a reason for ineligibility.
Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be
designated as FMLA leave.
Enforcement
Employees may file a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a
private lawsuit against an employer.
The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law
or collective bargaining agreement that provides greater family or medical leave rights.
For additional information or to file a complaint:
(866) 4US-WAGE ((866) 487-9243) TYY: (877) 889-5627
www.wagehour.dol.gov
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This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
Notice of Right to Continued Coverage under
Uniformed Services Employment &
Reemployment Rights Act (USERRA)
Right to Continue Coverage
If you leave your job to perform military service, you have the right to elect to continue your existing employer-
based health plan coverage for you and your dependents for up to 24 months while in the military.
USERRA continuation group health plan coverage is considered alternative group health plan coverage for
purposes of COBRA. Therefore, if a you elect USERRA continuation coverage, COBRA continuation group health
plan coverage will not be available.
Even if you don’t elect to continue coverage during your military service, you have the right to be reinstated in
your employer’s health plan when you are reemployed, generally without any waiting periods or exclusions
(e.g., pre-existing condition exclusions) except for service-connected illnesses or injuries.
How to Continue Coverage
If the conditions are met, you (or your authorized representative) may elect to continue your coverage (and the
coverage of your covered dependents, if any) under the Plan by completing and returning an Election Form 60
days after date that USERRA election notice is mailed, and by paying the applicable premium for your coverage
as described below.
What Happens if You Do Not Elect to Continue Coverage?
If you fail to submit a timely, completed Election Form as instructed or do not make a premium payment within
the required time, you will lose your continuation rights under the Plan, unless compliance with these
requirements is precluded by military necessity or is otherwise impossible or unreasonable under the
circumstances.
If you do not elect continuation coverage, your coverage (and the coverage of your covered dependents, if any)
under the Plan ends effective the end of the month in which you stop working due to your leave for uniformed
service.
Premium for Continuing Your Coverage
The premium that you must pay to continue your coverage depends on your period of service in the uniformed
services. Contact Human Resources for more details.
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This information is only a summary and does not supersede the carrier provided contracts and
general provisions found in your plan documents should there be a conflict.
Medicare and Health Savings Accounts (HSAs)
If you are approaching Medicare eligibility and you currently contribute to a Health Savings Account (HSA) that is
integrated with a High Deduction Health Plan (HDHP), it is important to understand how HSA eligibility rules and
Medicare enrollment interact.
An individual is not eligible to make HSA contributions (nor eligible to have employer contributions made to
their HSA) if the individual has other coverage including being enrolled in Medicare. An individual who is
enrolled in Medicare is not eligible for continued HSA contributions, however, funds that existed in the HSA
prior to Medicare enrollment may continue to be used for ongoing medical expenses.
It is important to be aware that Medicare enrollment based on age or disability cannot be waived by individuals
who are receiving Social Security benefits. However, Medicare enrollment may be delayed by delaying the
receipt of Social Security benefits. For those that delay applying for Medicare, enrollment is generally
retroactive for up to six months (that is, Medicare coverage will begin up to six months prior to the month in
which they applied). Because the first month of Medicare enrollment will be retroactive for individuals who
delay applying for Medicare, those individuals should use extra care when determining the amount of their HSA
contributions to avoid excess contributions and possible adverse tax consequences.
Idaho School Benefit Trust PPO
Summary of Benefits and Coverage: What this Plan Covers & What You
Pay For Covered Services
Coverage Period: 9/1/2021 - 8/31/2022
Coverage for: Enrollee + Eligible Dependents | 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 the plan (called the contribution) 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, visit
https://members.bcidaho.com/my-account/my-account-my-contract.page. For general definitions of common terms, such as allowed amount, balance
billing, cost sharing, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at
www.healthcare.gov/sbc-glossary or call 1-800-627-1188 to request a copy.
Important Questions Answers Why This Matters:
What is the overall
Deductible?
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.
$3,000 person/$6,000 family.
Are there services
covered before you meet
your Deductible?
This Plan covers some items and services even if you haven't yet met the Deductible amount. But a Copayment or Cost
Sharing may apply. For example, this Plan covers certain Preventive Services without Cost Sharing and before you meet
your Deductible. See a list of covered Preventive Services at
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Yes. Pharmacy, services that require Copays,
immunizations or In-Network hospice care and
Preventive Care are covered before you meet
your Deductible.
Are there other
Deductibles for specific
services ?
You don't have to meet Deductibles for specific services.No. There are no other specific Deductibles.
What is the Out-of-pocket
Limit for this Plan?
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.
For In-Network Provider $5,500 person
/$11,000 family, For Out-of-Network Provider
$8,000 person /$16,000 family For
Prescription Drugs $2,000 person/$4,000
family
What is not included in
the Out-of-pocket Limit ?
Even though you pay these expenses, they don't count toward the Out-of-pocket Limit.Contributions, Balance-Billing charges and
health care this Plan doesn't cover.
Will you pay less if you
use a Network Provider?
You pay the least if you use a Provider on the ChoiceDocs In-Network Provider list. You pay more if you use all other
Providers on the In-Network Provider list. 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 Providers 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.
Yes. See www.bcidaho.com or call
1-800-627-1188 for a list of Network
Providers.
Do you need a Referral to
see a Specialist?
You can see the Specialist you choose without a Referral.No.
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust PPO | 3000 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 80725
Page 1 of 9
All copayments and cost sharing costs shown in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event Services You May Need
What You Will Pay
Out-of-Network
Provider
(You will pay the
most)
Network
Provider
(You will pay the
least)
Limitations, Exceptions, & Other Important Information
If you visit a health
care provider's
office or clinic
Primary care visit to treat an injury or illness ChoiceDocs = $10
Copay/visit; All other
In-Network = $30
Copay/visit, Deductible
does not apply
70% Cost Sharing after
Deductible
Copay does not apply to additional services. Cost Sharing may not
apply for pediatric physician office visit. $0 Copay/visit for qualifying
non-emergency telehealth services provided by MDLIVE. Additional
telehealth services may be provided by your Provider.
Specialist visit ChoiceDocs = $30
Copay/visit; All other
In-Network = $50
Copay/visit, Deductible
does not apply
70% Cost Sharing after
Deductible
Copay does not apply to additional services. Cost Sharing may not
apply for pediatric physician office visit.
Preventive Care/Screening/immunization No charge for listed
preventive, Screening and
immunization services.
Deductible does not
apply.
No charge for listed
immunizations, 70% Cost
Sharing after Deductible
for preventive and
Screening.
You may have to pay for services that aren't preventive. Ask your
Provider if the services needed are preventive. Then check what your
Plan will pay for.
If you have a test ------------------------------------------ none -------------------------------------Diagnostic Test (x-ray, blood work)No charge up to a
combined $100, then 50%
Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Imaging (CT/PET scans, MRIs)No charge up to a
combined $100, then 50%
Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Preauthorization required.
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust PPO | 3000 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 80725
Page 2 of 9
Common
Medical Event Services You May Need
What You Will Pay
Out-of-Network
Provider
(You will pay the
most)
Network
Provider
(You will pay the
least)
Limitations, Exceptions, & Other Important Information
If you need drugs
to treat your illness
or condition
More information
about prescription
drug coverage is
available at
www.bcidaho.com
Generic drugs $15 Copay/prescription
(retail and mail order)
$15 Copay/prescription
(retail and mail order)
Covers up to a 90 day supply with multiple Copays. Additional
Out-of-Network charges may apply.
Preferred brand drugs $30 Copay/prescription
(retail and mail order)
$30 Copay/prescription
(retail and mail order)
Covers up to a 90 day supply with multiple Copays. Additional
Out-of-Network charges may apply.
Non-preferred brand drugs $45 Copay/prescription
(retail and mail order)
$45 Copay/prescription
(retail and mail order)
Covers up to a 90 day supply with multiple Copays. Additional
Out-of-Network charges may apply.
Specialty Drugs Refer to generic,
preferred brand and
non-preferred brand
drugs above.
Refer to generic,
preferred brand and
non-preferred brand
drugs above.
Coverage may include limitations and Preauthorization may be
required. Additional Out-of-Network charges may apply.
If you have
outpatient surgery
Facility fee (e.g., ambulatory surgery center)50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Preauthorization required.
Physician/surgeon fees 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Preauthorization required.
If you need
immediate medical
attention
Emergency Room Care $100 Copay/visit, 50%
Cost Sharing after
Deductible
$100 Copay/visit, 70%
Cost Sharing after
Deductible
Out-of-Network services paid at In-Network if Emergency Medical
Condition. Copay waived if admitted.
------------------------------------------ none -------------------------------------Emergency Medical Transportation 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Urgent Care $30 Copay/visit;
Specialist: $50
Copay/visit; Deductible
does not apply
70% Cost Sharing after
Deductible
Copay does not apply to additional services. Cost Sharing may vary
based on physician and may not apply to pediatric physician office
visit.
If you have a
hospital stay
Facility fee (e.g., hospital room)50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Preauthorization required.
Physician/surgeon fee 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Preauthorization required.
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust PPO | 3000 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 80725
Page 3 of 9
Common
Medical Event Services You May Need
What You Will Pay
Out-of-Network
Provider
(You will pay the
most)
Network
Provider
(You will pay the
least)
Limitations, Exceptions, & Other Important Information
If you have mental
health, behavioral
health, or
substance abuse
services
Outpatient services $30 Copay/visit, 50%
Cost Sharing after
Deductible for facility and
other services
70% Cost Sharing after
Deductible
Cost Sharing may not apply for pediatric outpatient psychotherapy. $0
Copay/visit for qualifying non-emergency telehealth services provided
by MDLIVE. Additional telehealth services may be provided by your
Provider.
Inpatient services 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Preauthorization required.
If you are pregnant Office Visits 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
For pregnancy services, Cost Sharing does not apply to certain
Preventive Services. Depending on the type of services, a Copay, Cost
Sharing or Deductible may apply. Maternity care may include tests and
services described elsewhere in the SBC (i.e. ultrasound).
------------------------------------------ none -------------------------------------Childbirth/delivery professional services 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
------------------------------------------ none -------------------------------------Childbirth/delivery facility services 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
If you need help
recovering or have
other special
health needs
Home Health Care 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Preauthorization required.
ReHabilitation Services 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Coverage is limited to 20 visit annual max for outpatient physical,
speech and occupational; 36 visit annual max for outpatient cardiac
rehabilitation.
Habilitation Services 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Coverage is limited to 20 visit annual max for outpatient physical,
speech and occupational.
Skilled Nursing Care 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Coverage is limited to 30 day annual max.
Durable Medical Equipment 50% Cost Sharing after
Deductible
70% Cost Sharing after
Deductible
Preauthorization required.
------------------------------------------ none -------------------------------------Hospice Services No charge. Deductible
does not apply.
50% Cost Sharing after
Deductible
If your child needs
dental or eye care
------------------------------------------ none -------------------------------------Children's eye exam Not covered Not covered
------------------------------------------ none -------------------------------------Children's glasses Not covered Not covered
------------------------------------------ none -------------------------------------Children's dental check-up Not covered Not covered
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust PPO | 3000 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 80725
Page 4 of 9
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 other excluded
services.)
Routine eye care (Adult)•Acupuncture•
Cosmetic surgery••Routine foot care
Dental care (Adult)••Weight loss programs
Dental check-up (Child)•
Eye exam (Child)•
Glasses (Child)•
•Hearing aids
Infertility treatment•
•Long-term care
Private-duty nursing•
Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)
Bariatric surgery•
Chiropractic care•
Non-emergency care when traveling outside the
U.S.
•
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust PPO | 3000 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 80725
Page 5 of 9
Does this plan provide Minimum Essential Coverage? Yes.
Your Rights to Continue Coverage:
Does this plan meet the 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.
** Group health coverage -
There are agencies that can help if you want to continue coverage after it ends. The contact information for those agencies is: Department of Labor's Employee
Benefits Security Administration at 1-866-4444-EBSA(3272) or www.dol.gov/ebsa/healthreform or the 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 through Your Health Idaho. For more information about Your Health Iadho, visit www.YourHealthIdaho.org or call
1-855-944-3246.
Your Grievance and Appeals Rights:
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
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.
There are agencies that can help if you have a complaint against your plan for a denial of 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:
For any inital questions concerning a claim, or to appeal a claim or benefit decision, please contact Customer Service at 1-208-331-7347 Or 1-800-627-1188,
www.bcidaho.com or at P.O. Box 7408, Boise, ID 83707.
If your plan is subject to ERISA, you may contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA or
www.dol.gov/ebsa/healthreform.
If your plan Is fully insured or self-funded and subject to the Idaho Insurance Code, you may also receive assistance from the Idaho Department of
Insurance at 1-800-721-3272 or www.DOI.Idaho.gov
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust PPO | 3000 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 80725
Page 6 of 9
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)
n The plan's overall deductible
n Specialist copay
n Hospital (facility) cost sharing
n Other cost sharing
Total Example Cost $12,690
In this example, Peg would pay:
Copayments
Limits or exclusions $60
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 cost sharing) 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.
$3,000
$40
$2,500
$3,000
$50
50%
50%
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)
The total Peg would pay is
Cost Sharing
What isn't Covered
Total Example Cost $5,830
In this example, Joe would pay:
Deductibles
Copayments
$3,000
$50
50%
50%
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)
Cost Sharing
What isn't Covered
The total Joe would pay is
Limits or exclusions
Mia's Simple Fracture
(in-network emergency room visit and follow up
care)
Total Example Cost $2,800
In this example, Mia would pay:
Copayments
Limits or exclusions
$3,000
$50
50%
50%
This EXAMPLE event includes services like:
Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
The total Mia would pay is
Cost Sharing
What isn't Covered
$0 $0
$1,510 $5,600 $2,150
$130
$1,360
$1,930
$220
$20 $0
About these Coverage Examples:
n The plan's overall deductible
n Specialist copay
n Hospital (facility) cost sharing
n Other cost sharing
n The plan's overall deductible
n Specialist copay
n Hospital (facility) cost sharing
n Other cost sharing
cost sharingcost sharing
The plan would be responsible for the other costs of these EXAMPLE covered services.
Deductibles Deductibles
cost sharing
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust PPO | 3000 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 80725
Page 7 of 9
DISCRIMINATION IS AGAINST THE LAW
Blue Cross of Idaho and Blue Cross of Idaho Care Plus, Inc., (collectively referred to as Blue Cross of Idaho) complies with applicable Federal civil rights
laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho does not exclude people or treat
them differently because of race, color, national origin, age, disability or sex.
Blue Cross of Idaho:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats
(large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Blue Cross of Idaho Customer Service Department. Call
1-800-627-1188 (TTY: 711), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho has failed to
provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex,
you can file a grievance with Blue Cross of Idaho’s Grievances and Appeals Department at:
Manager, Grievances and Appeals 3000 E. Pine Ave., Meridian, ID 83642 Telephone:
1-800-274-4018
Fax: 208-331-7493
Email: grievances&appeals@bcidaho.com TTY: 711
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Grievances and Appeals team is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office
for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.
jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC
20201, 1-800-368-1019, 800-537-7697 (TTY). Complaint forms are available at <http://www.hhs.gov/ocr/office/file/index.html>
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust PPO | 3000 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 80725
Page 8 of 9
ATTENTION: If you speak Arabic, Bantu, Chinese, Farsi, French, German, Japanese, Korean, Nepali, Romanian,
Russian, Serbo-Croatian, Spanish, Tagalog, or Vietnamese, language assistance services, free of charge, are
available to you. Call 1-800-627-1188 (TTY: 711).
Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust PPO | 3000 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 80725
Page 9 of 9
Idaho School Benefit Trust HSA PPO
Summary of Benefits and Coverage: What this Plan Covers & What You
Pay For Covered Services
Coverage Period: 9/1/2021 - 8/31/2022
Coverage for: Enrollee + Eligible Dependents | 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 the plan (called the contribution) 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, visit
https://members.bcidaho.com/my-account/my-account-my-contract.page. For general definitions of common terms, such as allowed amount, balance
billing, cost sharing, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at
www.healthcare.gov/sbc-glossary or call 1-800-627-1188 to request a copy.
Important Questions Answers Why This Matters:
What is the overall
Deductible?
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.
$6,800 person/$13,600 family.
Are there services
covered before you meet
your Deductible?
This Plan covers some items and services even if you haven't yet met the Deductible amount. But a Copayment or Cost
Sharing may apply. For example, this Plan covers certain Preventive Services without Cost Sharing and before you meet
your Deductible. See a list of covered Preventive Services at
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Yes. Services that require Copays,
immunizations and In-Network Preventive Care
are covered before you meet your Deductible.
Are there other
Deductibles for specific
services ?
You don't have to meet Deductibles for specific services.No. There are no other specific Deductibles.
What is the Out-of-pocket
Limit for this Plan?
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.
$6,800 person/$13,600 family
What is not included in
the Out-of-pocket Limit ?
Even though you pay these expenses, they don't count toward the Out-of-pocket Limit.Contributions, Balance-Billing charges and
health care this Plan doesn't cover.
Will you pay less if you
use a Network Provider?
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
Providers 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.
Yes. See www.bcidaho.com or call
1-800-627-1188 for a list of Network
Providers.
Do you need a Referral to
see a Specialist?
You can see the Specialist you choose without a Referral.No.
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust HSA PPO | 6800 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 79646
Page 1 of 9
All copayments and cost sharing costs shown in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event Services You May Need
What You Will Pay
Out-of-Network
Provider
(You will pay the
most)
Network
Provider
(You will pay the
least)
Limitations, Exceptions, & Other Important Information
If you visit a health
care provider's
office or clinic
Primary care visit to treat an injury or illness No charge after
Deductible
No charge after
Deductible
After Deductible, Cost Sharing may not apply for pediatric physician
office visit. Deductible applies to qualifying non-emergency telehealth
services provided by MDLIVE. Additional telehealth services may be
provided by your Provider.
Specialist visit No charge after
Deductible
No charge after
Deductible
After Deductible, Cost Sharing may not apply for pediatric physician
office visit.
Preventive Care/Screening/immunization No charge for listed
preventive, Screening and
immunization services.
Deductible does not
apply.
No charge for listed
preventive, Screening and
immunization services.
Deductible does not
apply.
You may have to pay for services that aren't preventive. Ask your
Provider if the services needed are preventive. Then check what your
Plan will pay for.
If you have a test ------------------------------------------ none -------------------------------------Diagnostic Test (x-ray, blood work)No charge after
Deductible
No charge after
Deductible
Imaging (CT/PET scans, MRIs)No charge after
Deductible
No charge after
Deductible
Preauthorization required.
If you need drugs
to treat your illness
or condition
More information
about prescription
drug coverage is
available at
www.bcidaho.com
Generic drugs No charge after
Deductible.
No charge after
Deductible.
Covers up to a 90 day supply.
Preferred brand drugs No charge after
Deductible.
No charge after
Deductible.
Covers up to a 90 day supply.
Non-preferred brand drugs No charge after
Deductible.
No charge after
Deductible.
Covers up to a 90 day supply.
Specialty Drugs No charge after
Deductible.
No charge after
Deductible.
Coverage may include limitations and Preauthorization may be
required.
If you have
outpatient surgery
Facility fee (e.g., ambulatory surgery center) No charge after
Deductible
No charge after
Deductible
Preauthorization required.
Physician/surgeon fees No charge after
Deductible
No charge after
Deductible
Preauthorization required.
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust HSA PPO | 6800 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 79646
Page 2 of 9
Common
Medical Event Services You May Need
What You Will Pay
Out-of-Network
Provider
(You will pay the
most)
Network
Provider
(You will pay the
least)
Limitations, Exceptions, & Other Important Information
If you need
immediate medical
attention
Emergency Room Care $100 Copay/visit, No
charge after Deductible
$100 Copay/visit, No
charge after Deductible
Copay waived if admitted.
------------------------------------------ none -------------------------------------Emergency Medical Transportation No charge after
Deductible
No charge after
Deductible
Urgent Care No charge after
Deductible
No charge after
Deductible
After Deductible, Cost Sharing may not apply for pediatric physician
office visit.
If you have a
hospital stay
Facility fee (e.g., hospital room)No charge after
Deductible
No charge after
Deductible
Preauthorization required.
Physician/surgeon fee No charge after
Deductible
No charge after
Deductible
Preauthorization required.
If you have mental
health, behavioral
health, or
substance abuse
services
Outpatient services No charge after
Deductible
No charge after
Deductible
After Deductible, Cost Sharing may not apply for pediatric outpatient
psychotherapy. Deductible applies to qualifying non-emergency
telehealth services provided by MDLIVE. Additional telehealth services
may be provided by your Provider.
Inpatient services No charge after
Deductible
No charge after
Deductible
Preauthorization required.
If you are pregnant Office Visits No charge after
Deductible
No charge after
Deductible
For pregnancy services, Cost Sharing does not apply to certain
Preventive Services. Depending on the type of services, a Copay, Cost
Sharing or Deductible may apply. Maternity care may include tests and
services described elsewhere in the SBC (i.e. ultrasound).
------------------------------------------ none -------------------------------------Childbirth/delivery professional services No charge after
Deductible
No charge after
Deductible
------------------------------------------ none -------------------------------------Childbirth/delivery facility services No charge after
Deductible
No charge after
Deductible
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust HSA PPO | 6800 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 79646
Page 3 of 9
Common
Medical Event Services You May Need
What You Will Pay
Out-of-Network
Provider
(You will pay the
most)
Network
Provider
(You will pay the
least)
Limitations, Exceptions, & Other Important Information
If you need help
recovering or have
other special
health needs
Home Health Care No charge after
Deductible
No charge after
Deductible
Preauthorization required.
ReHabilitation Services No charge after
Deductible
No charge after
Deductible
Coverage is limited to 20 visit annual max for outpatient physical,
speech and occupational; 36 visit annual max for outpatient cardiac
rehabilitation.
Habilitation Services No charge after
Deductible
No charge after
Deductible
Coverage is limited to 20 visit annual max for outpatient physical,
speech and occupational.
Skilled Nursing Care No charge after
Deductible
No charge after
Deductible
Coverage is limited to 30 day annual max.
Durable Medical Equipment No charge after
Deductible
No charge after
Deductible
Preauthorization required.
------------------------------------------ none -------------------------------------Hospice Services No charge after
Deductible
No charge after
Deductible
If your child needs
dental or eye care
------------------------------------------ none -------------------------------------Children's eye exam Not covered Not covered
------------------------------------------ none -------------------------------------Children's glasses Not covered Not covered
------------------------------------------ none -------------------------------------Children's dental check-up Not covered Not covered
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust HSA PPO | 6800 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 79646
Page 4 of 9
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 other excluded
services.)
Private-duty nursing•Acupuncture•
Bariatric surgery••Routine eye care (Adult)
Cosmetic surgery••Routine foot care
Dental care (Adult)••Weight loss programs
Dental check-up (Child)•
Eye exam (Child)•
•Glasses (Child)
Hearing aids•
•Infertility treatment
Long-term care•
Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)
Chiropractic care•
Non-emergency care when traveling outside the
U.S.
•
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust HSA PPO | 6800 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 79646
Page 5 of 9
Does this plan provide Minimum Essential Coverage? Yes.
Your Rights to Continue Coverage:
Does this plan meet the 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.
** Group health coverage -
There are agencies that can help if you want to continue coverage after it ends. The contact information for those agencies is: Department of Labor's Employee
Benefits Security Administration at 1-866-4444-EBSA(3272) or www.dol.gov/ebsa/healthreform or the 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 through Your Health Idaho. For more information about Your Health Iadho, visit www.YourHealthIdaho.org or call
1-855-944-3246.
Your Grievance and Appeals Rights:
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
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.
There are agencies that can help if you have a complaint against your plan for a denial of 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:
For any inital questions concerning a claim, or to appeal a claim or benefit decision, please contact Customer Service at 1-208-331-7347 Or 1-800-627-1188,
www.bcidaho.com or at P.O. Box 7408, Boise, ID 83707.
If your plan is subject to ERISA, you may contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA or
www.dol.gov/ebsa/healthreform.
If your plan Is fully insured or self-funded and subject to the Idaho Insurance Code, you may also receive assistance from the Idaho Department of
Insurance at 1-800-721-3272 or www.DOI.Idaho.gov
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust HSA PPO | 6800 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 79646
Page 6 of 9
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)
n The plan's overall deductible
n Specialist cost sharing
n Hospital (facility) cost sharing
n Other cost sharing
Total Example Cost $12,690
In this example, Peg would pay:
Copayments
Limits or exclusions $60
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 cost sharing) 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.
$6,800
$0
$0
$6,800
0%
0%
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)
The total Peg would pay is
Cost Sharing
What isn't Covered
Total Example Cost $5,830
In this example, Joe would pay:
Deductibles
Copayments
$6,800
0%
0%
0%
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)
Cost Sharing
What isn't Covered
The total Joe would pay is
Limits or exclusions
Mia's Simple Fracture
(in-network emergency room visit and follow up
care)
Total Example Cost $2,800
In this example, Mia would pay:
Copayments
Limits or exclusions
$6,800
0%
0%
0%
This EXAMPLE event includes services like:
Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
The total Mia would pay is
Cost Sharing
What isn't Covered
$0 $0
$4,810 $6,860 $2,800
$4,790
$0
$2,700
$100
$20 $0
About these Coverage Examples:
n The plan's overall deductible
n Specialist cost sharing
n Hospital (facility) cost sharing
n Other cost sharing
n The plan's overall deductible
n Specialist cost sharing
n Hospital (facility) cost sharing
n Other cost sharing
cost sharingcost sharing
The plan would be responsible for the other costs of these EXAMPLE covered services.
Deductibles Deductibles
cost sharing
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust HSA PPO | 6800 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 79646
Page 7 of 9
DISCRIMINATION IS AGAINST THE LAW
Blue Cross of Idaho and Blue Cross of Idaho Care Plus, Inc., (collectively referred to as Blue Cross of Idaho) complies with applicable Federal civil rights
laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho does not exclude people or treat
them differently because of race, color, national origin, age, disability or sex.
Blue Cross of Idaho:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats
(large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Blue Cross of Idaho Customer Service Department. Call
1-800-627-1188 (TTY: 711), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho has failed to
provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex,
you can file a grievance with Blue Cross of Idaho’s Grievances and Appeals Department at:
Manager, Grievances and Appeals 3000 E. Pine Ave., Meridian, ID 83642 Telephone:
1-800-274-4018
Fax: 208-331-7493
Email: grievances&appeals@bcidaho.com TTY: 711
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Grievances and Appeals team is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office
for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.
jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC
20201, 1-800-368-1019, 800-537-7697 (TTY). Complaint forms are available at <http://www.hhs.gov/ocr/office/file/index.html>
Questions: Call 1-800-627-1188 or visit us at www.bcidaho.com/SBC.Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust HSA PPO | 6800 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 79646
Page 8 of 9
ATTENTION: If you speak Arabic, Bantu, Chinese, Farsi, French, German, Japanese, Korean, Nepali, Romanian,
Russian, Serbo-Croatian, Spanish, Tagalog, or Vietnamese, language assistance services, free of charge, are
available to you. Call 1-800-627-1188 (TTY: 711).
Bonneville Joint School District 93 | 10014646 | Idaho School Benefit Trust HSA PPO | 6800 | 09/01/21 | PPO | 2021 | AHCR |
SBC ID: 79646
Page 9 of 9