(DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 7
(HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022)
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024
MMCP: Memorial Healthcare System Coverage for: Individual, Individual + Family Plan Type: HMO
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 954-622-
3499. 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 www.cciio.cms.gov or call 954-622-3499 to request a copy.
Important Questions Answers Why This Matters:
What is the overall
deductible?
Individual Family
In
-network: $100 $300
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.
Are there services
covered before you meet
your deductible?
Yes. Preventive Services and
Pharmacy
This plan covers some items and services even if you haven’t yet met the annual deductible
amount.
But a copayment or coinsurance 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
www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific
services?
No. You don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
$4,000 for employee only /
$8,000
for employee plus spouse, employee
plus child(ren),
employee plus family
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.
What is not included in
the out-of-pocket limit?
Premiums and health care services
this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you
use a network provider?
Yes
- The Memorial Health Network
(
MHN). For a list of preferred
provider
s, see the Lawson
website
, email
CCP.CustomerSvc@ccpcares.org,or
call 954-622-3499
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.
Do you need a referral to
see a specialist?
No. You can see the specialist you choose without a referral.
* For more information about limitations and exceptions, call 954 622 3499. Page 2 of 7
All copayment and coinsurance 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
Limitations, Exceptions, & Other
Important Information
Network Provider
(You will pay the least)
Out-of-Network
Provider
(You will pay the
most)
If you visit a health care
provider’s office or
clinic
Primary care visit to treat an
injury or illness
$20 copay / visit after
deductible
Not Covered None
Specialist visit
$30 copay / visit
after
deductible
Not Covered
maximum) – 20% after deductible for
Preventive care/screening/
Immunization
No charge Not Covered
preventive. Ask your provider if the services
you need are preventive. Then check what
If you have a test
Diagnostic test (x-ray, blood
work)
$50 copay after
deductible
Not Covered
Imaging (CT/PET scans,
MRIs)
$100 copay / test after
deductible
Not Covered
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available
from Southern Scripts
at 1-800-710-9341 or
southernscripts.net
Generic drugs
$10 copay / 30 day
retail
supply,
$20 copay 90 day retail
supply*,
$20 copay / 90 day mail-
order supply
Not Covered
$10 copay / 30 day supply
$20 copay / 90 day supply
*One copay per month (3 copays) will apply
for 90 day retail prescriptions outside of the
Preferred brand drugs
$35 copay / 30 day retail
supply,
$70 copay 90 day retail
supply*,
$70 copay / 90 day mail-
order supply
Not Covered
In-house Pharmacy
$20 copay / 30 day supply
$55 copay / 90 day supply
*One copay per month (3 copays) will apply
for 90 day retail prescriptions outside of the
First Choice network
* For more information about limitations and exceptions, call 954 622 3499. Page 3 of 7
Common Medical Event Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Network Provider
(You will pay the least)
Out-of-Network
Provider
(You will pay the
most)
Non-preferred brand drugs
40% ($50 minimum, $150
maximum) / 30 day retail
prescription,
40% ($150 minimum,
$210 maximum 90 day
retail supply*,
40% ($70 minimum, $210
maximum) / 90 day mail-
order supply
Not Covered
40% ($35 min, $135 max) / 30 day supply
40% ($55 min $195 max) / 90 day supply
* The coinsurance maximum applies per 30
day supply for 90 day retail prescriptions
outside of the First Choice network
In the event a Tier 1 equivalent medication
is available the member will be responsible
for a co-pay of 40% (a minimum $50 and a
maximum of $150) plus the cost difference
between the Tier 1 equivalent and the Tier 3
Specialty drugs
40% ($150 minimum
$300 maximum)
Not Covered
If you have outpatient
surgery
Facility fee (e.g., ambulatory
surgery center)
$250 copay after
deductible
Not Covered, except in
an emergency
authorization. – 20% after deductible for
Physician/surgeon fees $0 copay after deductible Not Covered
If you need immediate
medical attention
Emergency room care
$150 copay / visit, waived
if admitted after
deductible
$150 copay / visit,
waived if admitted after
deductible
None
Emergency medical
transportation
$50 copay / event after
deductible
$50 copay / event after
deductible
Urgent care
• CVS Minute Clinic/
Walgreens
•
Memorial Primary
Care
$20 copay / visit
after
deductible
$20 copay / visit
after
deductible
$75 (Non-Memorial
Urgent Care Center)
after deductible
None
* For more information about limitations and exceptions, call 954 622 3499. Page 4 of 7
Common Medical Event Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Network Provider
(You will pay the least)
Out-of-Network
Provider
(You will pay the
most)
• Holy Cross Urgent
Care Centers
• MHS Urgent Care
Centers
• Memorial Pembroke
24/7 Care Center
(Douglas Rd)
• MDNOW Urgent
Care
• Selected Broward
Health locations
$20 copay / visit
after
deductible
$20 copay / visit
after
deductible
$50 copay / visit
after
deductible
$75 copay / visit after
deductible
$75 copay / visit after
deductible
If you have a hospital
stay
Facility fee (e.g., hospital
room)
$150 copay per day (5
day max) after deductible
Not Covered, unless
admitted through an
emergency room
5 day max. Requires Prior Authorization
Physician/surgeon fees $0 copay after deductible Not Covered None
If you need mental
health, behavioral
health, or substance
abuse services
Outpatient services
$20 copay / per visit after
deductible
Not Covered None
Inpatient services
$150 copay per day
(5 day max) after
deductible
Not Covered
Copay applicable to first 5 days of each
admission. Requires Prior
Authorization
If you are pregnant
Office visits
$150 physician copay /
pregnancy
after
deductible
Not Covered
No prior authorization required for
initial
visit, but is required thereafter.
Childbirth/delivery
professional services
$0 copay after deductible Not Covered None
Childbirth/delivery facility
services
$0 copay
after deductible
Not Covered Requires prior authorization.
* For more information about limitations and exceptions, call 954 622 3499. Page 5 of 7
Common Medical Event Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Network Provider
(You will pay the least)
Out-of-Network
Provider
(You will pay the
most)
If you need help
recovering or have
other special health
needs
Home health care
$15 copay / day after
deductible
Not Covered
Rehabilitation services
$20 per day after deductible
Cardiac Rehabilitation
covered in Full
Not Covered
speech therapy visits are limited to sixty (60)
visits per calendar year.
Cardiac rehabilitation is limited to 36 visits
Habilitation services
Not Covered
Not Covered
Skilled nursing care $0 copay after deductible Not Covered
Durable medical equipment $0 copay after deductible Not Covered
authorization. Subject to medical necessity
Hospice services $0 copay after deductible Not Covered
maximum benefit of $10,000. Limited to life
If your child needs
dental or eye care
Children’s eye exam $0 copay after deductible Not Covered
covered children as a preventive service.
A
Children’s glasses Not Covered Not Covered
Children’s dental check-up Not Covered Not Covered
Excluded Services & Other Covered Services:
* For more information about limitations and exceptions, call 954 622 3499. Page 6 of 7
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Cosmetic surgery
•
Dental care
•
Habilitation Services
•
•
Long-term care
•
Non-emergency care when traveling outside the
U.S.
• Private-duty nursing
•
Routine eye care (adult)
•
Routine foot care
•
Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
•
Acupuncture
• Bariatric surgery
• Chiropractic care
•
Hearing aids
• Infertility treatment
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 U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services 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 on how 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: Appeals Coordinator, c/o Community Care Plan 1643 Harrison Parkway, Suite 200, Bldg. H. Sunrise, Florida 33323.
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 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.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 954 622 3499.
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number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy
of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Page 7 of 7
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.
The plan’s overall deductible $100
Specialist copay $30
Hospital (facility) copay $0 for maternity
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)
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles
$100
Copayments
$400
Coinsurance
$0
What isn’t covered
Limits or exclusions
$60
The total Peg would pay is
$560
The plan’s overall deductible $100
Specialist copay $30
Hospital (facility) copay $150 per day
(5 day max)
Other coinsurance 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)
Total Example Cost
$5,600
In this example, Joe would pay:
Cost Sharing
Deductibles
$100
Copayments
$800
Coinsurance
$0
What isn’t covered
Limits or exclusions
$20
The total Joe would pay is
$920
The plan’s overall deductible $100
Specialist copay $30
Hospital (facility) copay $150 per day
(5 day max)
Other coinsurance 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)
Total Example Cost
$2,800
In this example, Mia would pay:
Cost Sharing
Deductibles
$100
Copayments
$500
Coinsurance
$0
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is
$640
The plan would be responsible for the other costs of these EXAMPLE covered services.
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)