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A nonprofit independent licensee of the Blue Cross Blue Shield
Association
Available Counties: Broome County, Cayuga County, Chemung
County, Cortland County, Onondaga County, Schuyler County, Steuben
County, Tioga County, Tompkins County
A five step guide to help you understand your health insurance
and enrollment options for 2018.
CENTRAL NEW YORK REGION
INFORMED CHOICESCONFIDENT DECISIONS
Call today to get your FREE health plan evaluation. Enroll by
December 15th for coverage starting in January. Open Enrollment
ends January 31, 2018.
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To learn more about your plan options, visit
ChooseExcellus.com/2018Coverage
STEP 1: GETTING STARTEDHealth care coverage is one of the most
important decisions you make. How do you choose an insurance plan
without fear or worry? Protect yourself and your family with the
compassion of the cross and the security of the shield. You can
feel confident in your decision when you have the right information
and the right people to guide you. We’ve been here over 80 years
helping people find health insurance that best fits their needs and
budgets.
This 5-step guide will help you shop and compare your coverage
options for 2018. Once you’ve chosen a plan, you can enroll
directly with us, or through the NY State of Health Marketplace
where financial help may be available. Call today to get started
with your free health plan evaluation or to schedule a one-on-one
appointment. We’re here to help you every step of the way.
Here are a few questions to ask yourself before making this
important choice.
1. What are the health care needs of my household?
Take an evaluation of the number of doctor visits, hospital
visits and the prescriptions that you and your family have needed
over the last year.
Doctor Visits ____________________
Hospital Visits ___________________
Prescriptions ____________________
2. How do I want to manage my costs?
Determine if you are comfortable with a deductible and a lower
monthly cost or if you would rather pay more per month for lower
and more predictable costs when getting care.
3. Can I get financial help?You may be eligible for financial
assistance based on your household income and size. Find out how
much at ChooseExcellus.com/2018Coverage or call our dedicated
Insurance Agents.
Estimated Tax Credit $______________
4. How do I know if my doctor accepts the plan I am
choosing?
Ask your doctor if he/she accepts the health insurance company
you’re considering. Excellus BCBS plans are accepted by 100% of
hospitals and 99% of doctors in your area.
5. How often do I travel outside of my town?
Our BlueCard® program* gives you access to care when you travel
in the United States, Canada, Mexico, Puerto Rico, the US Virgin
Islands, Guam, and the Mariana Islands. You can also fill a
prescription while traveling, using our National Pharmacy
Network.
You’ll also have coverage for non- emergency care 24/7 for you
and your family with our telemedicine program powered by MDLIVE.
See a board-certified doctor by phone or video on your schedule,
anytime, anywhere.
5 Questions to Ask Before You Buy.
*BlueCard® applies to metal level plans and Base only. It does
not apply to Essential Plan.
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Want help? We’re here for you. Call our dedicated insurance
agents at: 1-866-613-8506 1
STEP 2: GET HELP PAYING FOR YOUR PLAN.
It’s time to start rethinking affordable health care. You might
be surprised to know that you may be able to get money towards your
monthly payment through something called a tax credit. Eligibility
is based on your household income and size. The chart below shows
estimated eligibility.
Financial help is only available when you buy a plan on the NY
State of Health Marketplace. You may also qualify for cost-sharing
reductions which will reduce how much you’ll pay for out-of-pocket
costs when you get care.
*Source: 2017 Federal Income Guidelines: Department of Health
and Human Services. Full calculator available at
https://aspe.hhs.gov/poverty-guidelines
We can answer your questions and estimate your tax credit:
1-866-613-8506 or ChooseExcellus.com/2018Coverage
Financial Assistance Eligibility by Annual Income Level*
Family Size Annual Income Eligibility for Tax Credits
$24,121 - $48,240
$32,481 - $64,960
$40,841 - $81,680
$49,201 - $98,400
$57,561 - $115,120
$65,921 - $131,840
$74,281 - $148,560
$82,641 - $165,280
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2 To learn more about your plan options, visit
ChooseExcellus.com/2018Coverage
Follow the path and get a first look at the plan that might be
right for you or your family.
Think about everyone for whom you need coverage. Do you or they
frequently
go to the doctor or hospital?
YES
YES YES NO NO
NODo you take prescription drugs? Do you take prescription
drugs?
Consider Platinum or Gold.
Consider Gold or Silver.
Consider Gold.
Consider Silver or Bronze.
ESSENTIALPLAN
BASE (CATASTROPHIC)
BRONZE SILVER GOLD PLATINUM
Monthly cost
Cost when you get care
Good option if you…
need low-cost coverage. Eligibility for this plan is based on
your household income and size*
need low-cost protection in the event of a catastrophic injury
or illness
use health care services infrequently
need to balance your monthly premium with your out-of-pocket
costs
want to save on monthly premiums while keeping your
out-of-pocket costs low
may use a lot of health care services and want predictable,
lower out-of-pocket costs for routine care
STEP 3: LET US HELP YOU FIND THE RIGHT PLAN. Choosing the right
health insurance for you and your family is an important decision.
We understand, and we want you to feel confident in your choice.
Plan levels are Bronze, Silver, Gold and Platinum. There is also a
Base plan available to people under age 30 and people of any age
with a hardship exemption from the requirement to have health
insurance. Eligibility for the Essential Plan is based on your
household size and income. The benefits are essentially the same in
every plan but the monthly and out-of-pocket costs differ.
Preventive care is free no matter which plan you choose.
*other eligibility guidelines apply
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Want help? We’re here for you. Call our dedicated insurance
agents at: 1-866-613-8506 3
We make it easy for you to evaluate your plan options with our
comparison chart. View plan options on pages 4 - 9. Select the
options that may fit your needs and fill in the information in the
chart below. You can use the definitions below to understand some
of the key plan terms.
Words you should know. Deductible The amount of money you have
to pay before the health insurance company will make any payment
towards health care services.
Example: If you have a $500 deductible, you pay 100% of your
first $500 in medical bills before your insurance pays
anything.
Copay This is a fixed amount you pay each time you use a medical
service, like a doctor’s visit or prescription refill.
Example: If your prescription drug coverage includes a $20
copay, you pay $20 for each prescription you fill and your
insurance company pays the balance.
Premium The amount of money you pay to a health insurance
company each month for your coverage.
Coinsurance Coinsurance is similar to a copay, but instead of a
fixed-dollar amount, you pay a percentage of the total bill.
Example: If your coinsurance on a $100 bill is 15%, that means
you pay $15 and your insurance company pays the rest.
Out-of-pocket maximum An annual limit on the amount of money
that you would have to pay for health care costs, not including
your monthly premiums.
Health Savings Account (HSA) An HSA is a tax-free funding
account owned by you that helps you pay for qualified medical
expenses such as lab fees, prescription drugs, contact lenses,
chiropractor visits and more. To learn more about your HSA options
contact your financial advisor.
Find out what your real monthly cost could look like.
Deductible
Copay
Coinsurance
Out-of-Pocket Maximum
Monthly Premium
- Estimated Tax Credit
Estimated Premium
Fill in your plan choice.PLAN 1 PLAN 2 PLAN 3
STEP 4: COMPARE YOUR OPTIONS.
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Certified Health Insurance Plan Options
See more Silver plan options on the next page
All of the Standard plans are required by New York State. The
benefits and out-of-pocket costs for the Standard plans will be the
same for all health insurance companies. Provider networks will
differ by insurance company.
Part of the Affordable Care Act is intended to improve dental
coverage for children, including preventive, routine and some major
dental coverage. Individuals purchasing medical coverage outside of
the NY State of Health Marketplace, are required to purchase a
medical plan with pediatric dental included, or a qualified
stand-alone plan. By purchasing a medical plan with dental
included, you can be sure your children will receive comprehensive
coverage overseen by our staff of medical management experts, and
both medical and pediatric dental services will count towards your
out of pocket maximums.
New York State has identified the fitness facility reimbursement
program as a required essential benefit that must be included for
all plans, therefore the ExerciseRewards™ program cannot be removed
from the plans. The rates shown do not include coverage for
dependents through age 29 or pediatric dental benefits.
* Some benefits, such as pediatric vision and durable medical
equipment may have different coinsurance amounts**An HSA or Health
Savings Account is a tax-free funding account owned by you that
helps you pay for qualified medical expenses such as lab fees,
prescription drugs, contact lenses, chiropractor visits and more.
~Any one person insured on a family plan will not pay more than
$7,350 in compliance with the Affordable Care Act
Dependent through 29 rates available upon request.
4 Need more information or help enrolling? Call our dedicated
insurance agents at 1-866-613-8506.
Get up to $400 or $600 a year toward qualified fitness facility
dues and/or fitness classes with our ExerciseRewards™ Program
Get access to more top-quality doctors, hospitals and pharmacies
locally and nationwide
Plan Benefits & Features
Base (Catastrophic) Must be under age 30
or qualify for a hardship exemption
Bronze Standard HSA (HSA** qualified)
Bronze StandardBronze Select
(HSA** qualified)Silver Standard
Tax Credit Available Not applicable Yes Yes Yes Yes
Single Deductible (the deductible amount must be met first
unless indicated otherwise)
$7,350 $5,500 $4,000 $5,000 $2,000
Family Deductible (the deductible amount must be met first
unless indicated otherwise)
$14,700 $11,000 $8,000 $10,000 $4,000
Coinsurance 0% 50% 50% 50% 0%*
Single Out-of -pocket Maximum $7,350 $6,550 $7,150 $6,550
$6,750
Family Out-of -pocket Maximum $14,700 $13,100 $14,300 $13,100
$13,500
Preventive Care (Immunization, screenings)
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
Doctor Visit
1st three visits are covered in full and not subject to
the ded. Once you meet the deductible amount, visits
are covered in full Once you reach thedeductible amount you
will pay 50% coinsurance(a percentage of cost for
services)
Once you reach thedeductible amount you
will pay 50% coinsurance(a percentage of cost for
services)
Once you reach the deductible amount you
will pay 50% coinsurance (a percentage of cost for
services)
$30
Specialist Visit
Once you meet the deductible amount, then these services are
covered in full
$50
Hospital Services $1,500
Emergency Room $250
Lab Work $30/$50
X-Ray $30/$50
Prescription Drugs
Once you meet the deduct-ible amount, then you pay:
$10 for generic$35 for brand
$70 for preferred brand
Once you meet the deduct-ible amount, then you pay:
$10 for generic$35 for brand
$70 for preferred brand
Once you meet the deduct-ible amount, then you pay:
$10 for generic40% for brand
50% for preferred brand
You pay:$10 for generic$35 for brand
$70 for preferred brand(not subject to the deductible)
Telemedicine - MDLIVE Program Included Included Included
Included Included
Pediatric Vision Covered* Covered* Covered* Covered*
Covered*
Rates Through NY State of Health
Single $262.84 $468.23 $495.86 $458.40 $657.17
Single + Spouse $525.68 $936.47 $991.73 $916.79 $1,314.34
Single + Child(ren) $446.83 $795.99 $842.97 $779.28
$1,117.18
Single + Spouse + Child(ren) $749.10 $1,334.47 $1,413.22
$1,306.43 $1,872.93
Child Only NA $192.91 $204.29 NA $270.75
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Dependent through 29 rates available upon request.
All of the Standard plans are required by New York State. The
benefits and out-of-pocket costs for the Standard plans will be the
same for all health insurance companies. Provider networks will
differ by insurance company.
Part of the Affordable Care Act is intended to improve dental
coverage for children, including preventive, routine and some major
dental coverage. Individuals purchasing medical coverage outside of
the NY State of Health Marketplace, are required to purchase a
medical plan with pediatric dental included, or a qualified
stand-alone plan. By purchasing a medical plan with dental
included, you can be sure your children will receive comprehensive
coverage overseen by our staff of medical management experts, and
both medical and pediatric dental services will count towards your
out of pocket maximums.
New York State has identified the fitness facility reimbursement
program as a required essential benefit that must be included for
all plans, therefore the ExerciseRewards™ program cannot be removed
from the plans. The rates shown do not include coverage for
dependents through age 29 or pediatric dental benefits.
* Some benefits, such as pediatric vision and durable medical
equipment may have different coinsurance amounts**An HSA or Health
Savings Account is a tax-free funding account owned by you that
helps you pay for qualified medical expenses such as lab fees,
prescription drugs, contact lenses, chiropractor visits and
more.
Sign up for email updates and see how much you save at
ChooseExcellus.com/2018Coverage 5
Need help choosing the right plan for you? Call our dedicated
Insurance Agents at 1-866-613-8506.
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Central New York Region:Broome CountyCayuga CountyChemung
County
Cortland County Onondaga CountySchuyler County
Steuben CountyTioga CountyTompkins County
Plan Benefits & FeaturesSilver Select
(HSA** qualified)Gold Standard Gold Select Platinum Standard
Platinum Select
Tax Credit Available Yes Yes Yes Yes Yes
Single Deductible (the deductible amount must be reached first
unless indicated otherwise)
$2,250 $600 $750 $0 $0
Family Deductible (the deductible amount must be reached first
unless indicated otherwise)
$4,500 $1,200 $1,500 $0 $0
Coinsurance 20%* 0%* 0%* 0%* 0%*
Single Out-of -pocket Maximum $6,350 $4,000 $6,350 $2,000
$6,350
Family Out-of -pocket Maximum $12,700 $8,000 $12,700 $4,000
$12,700
Preventive Care (Immunization, screenings)
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
Doctor Visit
Once you meet the deductible amount, then you pay coinsurance or
a
percentage of cost for these services
$25 $25 $15 $15
Specialist Visit $40 $40 $35 $25
Hospital Services $1,000 $750 $500 $750
Emergency Room $150 $250 $100 $150
Lab Work $25/$40 $40 $15/$35 $25
X-Ray $25/$40 $40 $15/$35 $25
Prescription Drugs
Once you meet the deductible amount, then you pay:
$10 for generic$45 for brand
$90 for preferred brand
You pay:$10 for generic$35 for brand
$70 for preferred brand
You pay:$10 for generic$35 for brand
$70 for preferred brand
You pay:$10 for generic$30 for brand
$60 for preferred brand
You pay: $10 for generic $35 for brand
$70 for preferred brand
Telemedicine - MDLIVE Program Included Included Included
Included Included
Pediatric Vision Covered* Covered* Covered* Covered*
Covered*
Rates Through NY State of Health
Single $600.76 $774.52 $750.60 $902.42 $882.56
Single + Spouse $1,201.52 $1,549.05 $1,501.20 $1,804.85
$1,765.13
Single + Child(ren) $1,021.29 $1,316.69 $1,276.02 $1,534.12
$1,500.36
Single + Spouse + Child(ren) $1,712.16 $2,207.40 $2,139.20
$2,571.91 $2,515.30
Child Only NA $319.10 NA $371.80 NA
Plan Benefits & Features
Base (Catastrophic) Must be under age 30
or qualify for a hardship exemption
Bronze Standard HSA (HSA** qualified)
Bronze StandardBronze Select
(HSA** qualified)Silver Standard
Tax Credit Available Not applicable Yes Yes Yes Yes
Single Deductible (the deductible amount must be met first
unless indicated otherwise)
$7,350 $5,500 $4,000 $5,000 $2,000
Family Deductible (the deductible amount must be met first
unless indicated otherwise)
$14,700 $11,000 $8,000 $10,000 $4,000
Coinsurance 0% 50% 50% 50% 0%*
Single Out-of -pocket Maximum $7,350 $6,550 $7,150 $6,550
$6,750
Family Out-of -pocket Maximum $14,700 $13,100 $14,300 $13,100
$13,500
Preventive Care (Immunization, screenings)
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
$0 for most preventive services, not subject to
the deductible
Doctor Visit
1st three visits are covered in full and not subject to
the ded. Once you meet the deductible amount, visits
are covered in full Once you reach thedeductible amount you
will pay 50% coinsurance(a percentage of cost for
services)
Once you reach thedeductible amount you
will pay 50% coinsurance(a percentage of cost for
services)
Once you reach the deductible amount you
will pay 50% coinsurance (a percentage of cost for
services)
$30
Specialist Visit
Once you meet the deductible amount, then these services are
covered in full
$50
Hospital Services $1,500
Emergency Room $250
Lab Work $30/$50
X-Ray $30/$50
Prescription Drugs
Once you meet the deduct-ible amount, then you pay:
$10 for generic$35 for brand
$70 for preferred brand
Once you meet the deduct-ible amount, then you pay:
$10 for generic$35 for brand
$70 for preferred brand
Once you meet the deduct-ible amount, then you pay:
$10 for generic40% for brand
50% for preferred brand
You pay:$10 for generic$35 for brand
$70 for preferred brand(not subject to the deductible)
Telemedicine - MDLIVE Program Included Included Included
Included Included
Pediatric Vision Covered* Covered* Covered* Covered*
Covered*
Rates Through NY State of Health
Single $262.84 $468.23 $495.86 $458.40 $657.17
Single + Spouse $525.68 $936.47 $991.73 $916.79 $1,314.34
Single + Child(ren) $446.83 $795.99 $842.97 $779.28
$1,117.18
Single + Spouse + Child(ren) $749.10 $1,334.47 $1,413.22
$1,306.43 $1,872.93
Child Only NA $192.91 $204.29 NA $270.75
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6 Need more information or help enrolling? Call our dedicated
insurance agents at 1-866-613-8506.
Plan Benefits & Features CNY Preferred Gold** Available in
Onondaga & Lewis Counties Only
CNY Preferred Silver** Available in Onondaga & Lewis
Counties Only
Tax Credit Available Yes Yes
Single Deductible (the deductible amount must be reached first
unless indicated otherwise)
$600 $2,000
Family Deductible (the deductible amount must be reached first
unless indicated otherwise)
$1,200 $4,000
Coinsurance 0%* 0%*
Single Out-of -pocket Maximum $6,350 $6,850
Family Out-of -pocket Maximum $12,700 $13,700
Preventive Care (Immunization, screenings)
$0 for most preventive services, not subject to the deductible
$0 for most preventive services, not subject to the deductible
Doctor Visit $25 $30
Specialist Visit $40 $50
Hospital Services $750 $1,250
Emergency Room $150 $250
Lab Work $40 $50
X-Ray $40 $50
Prescription Drugs
You pay:$5 for generic$35 for brand
$70 for preferred brand
You pay:$10 for generic$45 for brand
$90 for preferred brand(not subject to the deductible)
Telemedicine - MDLIVE Program Included Included
Pediatric Vision Covered* Covered*
Rates Through NY State of Health
Single $688.44 $577.04
Single + Spouse $1,376.89 $1,154.08
Single + Child(ren) $1,170.36 $980.97
Single + Spouse + Child(ren) $1,962.07 $1,644.56
Child Only NA NA
Dependent through 29 rates available upon request.
All of the Standard plans are required by New York State. The
benefits and out-of-pocket costs for the Standard plans will be the
same for all health insurance companies. Provider networks will
differ by insurance company.
Part of the Affordable Care Act is intended to improve dental
coverage for children, including preventive, routine and some major
dental coverage. Individuals purchasing medical coverage outside of
the NY State of Health Marketplace, are required to purchase a
medical plan with pediatric dental included, or a qualified
stand-alone plan. By purchasing a medical plan with dental
included, you can be sure your children will receive comprehensive
coverage overseen by our staff of medical management experts, and
both medical and pediatric dental services will count towards your
out of pocket maximums.
New York State has identified the fitness facility reimbursement
program as a required essential benefit that must be included for
all plans, therefore the ExerciseRewards™ program cannot be removed
from the plans. The rates shown do not include coverage for
dependents through age 29 or pediatric dental benefits.
* Some benefits, such as pediatric vision and durable medical
equipment may have different coinsurance amounts
**Cost share shown applies when a Crouse, St. Joseph’s Hospital
or Lewis County Hospital provider or facility is used. Not all
physicians are in the Tier 1 network. Check our “Find a Provider”
tool to make sure your physician is in the Tier 1 network.
Need help choosing the right plan for you? Call our dedicated
Insurance Agents at 1-866-613-8506.
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Central New York Region:Broome CountyCayuga CountyChemung
County
Cortland County Onondaga CountySchuyler County
Steuben CountyTioga CountyTompkins County
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Plan Benefits & Features Silver StandardSilver Standard
(200-250% FPL**)Silver Select
(HSA*** qualified)Silver Select
(200-250% FPL**)
Tax Credit Available Yes Yes Yes Yes
Single Deductible (the deductible amount must be met first
unless indicated otherwise)
$2,000 $1,650 $2,250 $2,250
Family Deductible (the deductible amount must be met first
unless indicated otherwise)
$4,000 $3,300 $4,500 $4,500
Coinsurance 0%* 0%* 20%* 20%*
Out-of -pocket Maximum $6,750 $5,550 $6,350 $3,750
Family Out-of -pocket Maximum $13,500 $11,100 $12,700 $7,500
Preventive Care (Immunization, screenings)
$0 for most preventive services, not subject to the
deductible
$0 for most preventive services, not subject to the
deductible
$0 for most preventive services, not subject to the
deductible
$0 for most preventive services, not subject to the
deductible
Doctor Visit $30 $30
Once you meet the deductible amount, then you pay
coinsurance or a percentage of cost for these services
Once you meet the deductible amount, then you pay
coinsurance or a percentage of cost for these services
Specialist Visit $50 $50
Hospital Services $1,500 $1,500
Emergency Room $250 $250
Lab Work $30/$50 $30/$50
X-Ray $30/$50 $30/$50
Prescription Drugs
You pay:$10 for generic$35 for brand
$70 for preferred brand(not subject to the deductible)
You pay:$10 for generic$35 for brand
$70 for preferred brand(not subject to the deductible)
Once you meet the deductible amount, then you pay:
$10 for generic$45 for brand
$90 for preferred brand
Once you meet the deductible amount, then you pay:
$5 for generic$45 for brand
$90 for preferred brand
Telemedicine - MDLIVE Program Included Included Included
Included
Pediatric Vision Covered* Covered* Covered* Covered*
Rates Through NY State of Health
Single $657.17 $657.17 $600.76 $600.76
Single + Spouse $1,314.34 $1,314.34 $1,201.52 $1,201.52
Single + Child(ren) $1,117.18 $1,117.18 $1,021.29 $1,021.29
Single + Spouse + Child(ren) $1,872.93 $1,872.93 $1,712.16
$1,712.16
Child Only $270.75 $270.75 NA NA
Below are additional Silver plan options that include
cost-sharing reductions that reduce how much you pay when you get
care. Eligibility is based on your Federal Poverty Level (FPL)
which is determined by household income and size.
Part of the Affordable Care Act is intended to improve dental
coverage for children, including preventive, routine and some major
dental coverage. Individuals purchasing medical coverage outside of
the NY State of Health Marketplace, are required to purchase a
medical plan with pediatric dental included, or a qualified
stand-alone plan. By purchasing a medical plan with dental
included, you can be sure your children will receive comprehensive
coverage overseen by our staff of medical management experts, and
both medical and pediatric dental services will count towards your
out of pocket maximums.
New York State has identified the fitness facility reimbursement
program as a required essential benefit that must be included for
all plans, therefore the ExerciseRewards program cannot be removed
from the plans. The rates shown do not include coverage for
dependents through age 29 or pediatric dental benefits.
Only Silver Select meets the IRS requirements for pairing with a
health savings account. Subsidized health plans are not eligible
for health savings accounts.
* Some benefits, such as pediatric vision and durable medical
equipment may have different coinsurance amounts
** Federal Poverty Level (FPL) is the minimum yearly income that
a person or family needs in order to provide for their basic needs.
The Department of Health and Human Services determines the FPL
annually. Find out your estimated FPL using our tax credit
calculator at ChooseExcellus.com/2018Coverage
***An HSA or Health Savings Account is a tax-free funding
account owned by you that helps you pay for qualified medical
expenses such as lab fees, prescription drugs, contact lenses,
chiropractor visits and more.
All of the Standard plans are required by New York State. The
benefits and out of pocket costs for the Standard plans will be the
same for all health insurance companies. Provider networks will
differ by insurance company.
Sign up for email updates and see how much you save at
ChooseExcellus.com/2018Coverage 7
Dependent through 29 rates available upon request.
Get up to $400 or $600 a year toward qualified fitness facility
dues and/or fitness classes with our ExerciseRewards™ Program
Get access to more top-quality doctors, hospitals and pharmacies
locally and nationwide
-
Part of the Affordable Care Act is intended to improve dental
coverage for children, including preventive, routine and some major
dental coverage. Individuals purchasing medical coverage outside of
the NY State of Health Marketplace, are required to purchase a
medical plan with pediatric dental included, or a qualified
stand-alone plan. By purchasing a medical plan with dental
included, you can be sure your children will receive comprehensive
coverage overseen by our staff of medical management experts, and
both medical and pediatric dental services will count towards your
out of pocket maximums.
New York State has identified the fitness facility reimbursement
program as a required essential benefit that must be included for
all plans, therefore the ExerciseRewards program cannot be removed
from the plans. The rates shown do not include coverage for
dependents through age 29 or pediatric dental benefits.
Only Silver Select meets the IRS requirements for pairing with a
health savings account. Subsidized health plans are not eligible
for health savings accounts.
* Some benefits, such as pediatric vision and durable medical
equipment may have different coinsurance amounts
**Cost share shown applies when a Crouse, St. Joseph’s Hospital
or Lewis County Hospital provider or facility is used. Not all
physicians are in the Tier 1 network. Check our “Find a Provider”
tool to make sure your physician is in the Tier 1 network.† Federal
Poverty Level (FPL) is the minimum yearly income that a person or
family needs in order to provide for their basic needs. The
Department of Health and Human Services determines the FPL
annually. Find out your estimated FPL using our tax credit
calculator at ChooseExcellus.com/2018Coverage
All of the Standard plans are required by New York State. The
benefits and out of pocket costs for the Standard plans will be the
same for all health insurance companies. Provider networks will
differ by insurance company.
8 Need more information or help enrolling? Call our dedicated
insurance agents at 1-866-613-8506.
Dependent through 29 rates available upon request.
Plan Benefits & Features CNY Preferred Silver** Available in
Onondaga & Lewis Counties Only
CNY Preferred Silver** (200-250% FPL†)
Tax Credit Available Yes Yes
Single Deductible (the deductible amount must be reached first
unless indicated otherwise)
$2,000 $2,000
Family Deductible (the deductible amount must be reached first
unless indicated otherwise)
$4,000 $4,000
Coinsurance 0%* 0%*
Single Out-of -pocket Maximum $6,850 $4,850
Family Out-of -pocket Maximum $13,700 $9,700
Preventive Care (Immunization, screenings)
$0 for most preventive services, not subject to the deductible
$0 for most preventive services, not subject to the deductible
Doctor Visit $30 $30
Specialist Visit $50 $50
Hospital Services $1,250 $1,250
Emergency Room $250 $250
Lab Work $50 $30
X-Ray $50 $50
Prescription Drugs
You pay: $10 for Tier 1 $45 for Tier 2 $90 for Tier 3
You pay:$10 for generic$45 for brand
$90 for preferred brand(not subject to the deductible)
Telemedicine - MDLIVE Program Included Included
Pediatric Vision Covered* Covered*
Rates Through NY State of Health
Single $577.04 $577.04
Single + Spouse $1,154.08 $1,154.08
Single + Child(ren) $980.97 $980.97
Single + Spouse + Child(ren) $1,644.56 $1,644.56
Child Only NA NA
Need help choosing the right plan for you? Call our dedicated
Insurance Agents at 1-866-613-8506.
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Central New York Region:Broome CountyCayuga CountyChemung
County
Cortland County Onondaga CountySchuyler County
Steuben CountyTioga CountyTompkins County
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Annual Income Eligibility for Essential Plan
Household Size Essential Plans 1 & 2 (139%-200%FPL)
Essential Plans 3 & 4 (under 100%-138% FPL***)
$16,644 - $24,120 $0 - $16,643
$22,412 - $32,480 $0 - $22,411
$28,181 - $40,840 $0 - $28,180
$33,949 - $49,200 $0 - $33,948
$39,717 - $57,560 $0 - $39,716
$45,486 - $65,920 $0 - $45,485
Plan Benefits & Features
Essential Plan 1(151% - 200% FPL)
Essential Plan 1 Plus Vision and Dental
(151% - 200% FPL)
Essential Plan 2(139% - 150% FPL)
Essential Plan 2 Plus Vision and Dental
(139% - 150% FPL)
Essential Plan 3(100% - 138% FPL)
Essential Plan 4(Below 100% FPL)
Deductible $0 $0 $0 $0 $0 $0
Coinsurance 0% 0% 0% 0% 0% 0%
Out-of -pocket Maximum $2,000 $2,000 $200 $200 $200 $0
Preventive Care (Immunization, screenings)
$0 for most preventive services
$0 for most preventive services
$0 for most preventive services
$0 for most preventive services
$0 for most preventive services
$0 for most preventive services
Doctor Visit $15 $15 $0 $0 $0 $0
Specialist Visit $25 $25 $0 $0 $0 $0
Hospital Services $150 $150 $0 $0 $0 $0
Emergency Room $75 $75 $0 $0 $0 $0
Lab Work $25 $25 $0 $0 $0 $0
X-Ray $25 $25 $0 $0 $0 $0
Adult Vision Exam Not Available $15 Not Available $0 $0 $0
Glasses and Contact Lenses Not Available 10% Not Available $0 $0
$0
Adult Dental Coverage Included Not Available Yes Not Available
Yes Yes Yes
Prescription Drugs
You pay:$6 for generic$15 for brand
$30 for preferred brand
You pay:$6 for generic$15 for brand
$30 for preferred brand
You pay:$1 for generic$3 for brand
$3 for preferred brand
You pay:$1 for generic$3 for brand
$3 for preferred brand
You pay:$1 for generic$3 for brand
$3 for preferred brand
You pay:$0 for generic$0 for brand
$0 for preferred brand
Telemedicine - MDLIVE Program $10 $10 $0 $0 $0 $0
Rates Through NY State of Health
Single $20 $47.62 to $47.79† $0 $32.07 to $32.24† $0 $0
Essential Plans - Rates as low as $0 a month for eligible
individuals Eligibility is based on your household size and
income.** Essential Plan 1 and 2 will now offer packages with and
without vision and dental benefits. If you choose to enroll in a
plan that includes this coverage, there is an added monthly cost.
Vision and dental benefits are always included with Essential Plan
3 and 4. To find out if you qualify for the Essential Plan, call
our dedicated insurance agents.
“New York State has identified the fitness facility
reimbursement program as a required essential benefit that must be
included for all plans, therefore the ExerciseRewards program
cannot be removed from the plans. **Other eligibility requirements
must be met to enroll.***Must be a lawfully present immigrant
(“Qualified non-citizen” immigration status without a waiting
period; Humanitarian statuses or circumstances (including Temporary
Protected Status, Special Juvenile Status, asylum applicants,
Convention Against Torture, victims of trafficking); Valid
non-immigration visas; Legal status conferred by other laws
(temporary resident status, LIFE Act, Family Unity individuals). To
see a full list of eligible immigration statuses, please visit the
web site at www.healthcare.gov/immigrants/immigration-status// or
call the NY State of Health at 1-855-355-5777.) †Rates for this
plan will depend on what county you live in.
The benefits and out of pocket costs for the Essential Plans
will be the same for all health insurance companies.
Sign up for email updates and see how much you save at
ChooseExcellus.com/2018Coverage 9
-
10 To learn more about your plan options, visit
ChooseExcellus.com/2018Coverage
Coverage you can count on. More Access100% of hospitals and 99%
of doctors in your area accept our plans. Plus our BlueCard®
program gives you even more access to care when you travel. Choose
the card that can open doors in all 50 states.
More SecurityProviding quality coverage for 80+ years.
More SavingsFree preventive care — includes routine physicals,
screenings and vaccinations, plus low-cost generic drugs.
ExerciseRewardsTM Program — Fitness facility and individual
fitness class rewards program with reduced fees at participating
facilities, with online interactive fitness and wellness tools
available at no additional cost. Earn up to $400 or $600 annually.
Now you can track your fitness center visits using the
ExerciseRewards CheckIn!TM App.
Blue365® — members enjoy exclusive discounts on health and
wellness products and services
from fitness to healthy eating to personal care, including
vision and dental discounts.
More ConvenienceMobile App — 24/7 access to your member card,
claims, account information, and more.
Online Account — order member cards, track deductibles and
out-of-pocket spending, find a health care provider, and access
your benefits and claims information.
Telemedicine powered by MDLIVE — See a board-certified doctor by
phone or video on your schedule, anytime, anywhere, including from
your own home.
Pharmacy Home DeliverySave time and money by having your
prescriptions delivered right to your home.*
Your enrollment checklist. Get ready to enroll by having the
following information available:
Email address (you are required to provide an email address to
enroll in the NY State of Health Marketplace)
Proof of U.S. citizenship or legal status in the form of birth
certificate, “Green Card” or passport
Social Security card
Information about others you plan to enroll (spouse, children,
their birth dates, Social Security numbers)
Termination letter if you recently lost coverage
Policy number(s) for any current health insurance
Most recently completed tax return and/or your last 30 days of
pay stubs. You will need to project your annual household income
for the year ahead. You can refer to your tax return to help you
estimate that amount.
Savings
9:15 AM 75%
In-Network Out-of-Network
$Deductible
-
Want help? We’re here for you. Call our dedicated insurance
agents at: 1-866-613-8506 11
*Certain prescription drugs may be ordered through pharmacy home
delivery supplier at two and a half copays for a 90 day supply.
The ExerciseRewards Program is provided by American Specialty
Health Fitness, Inc., a subsidiary of American Specialty Health
Incorporated (ASH). ExerciseRewards and ExerciseRewards CheckIn!
are trademarks of ASH and used with permission herein. The
ExerciseRewards CheckIn! App is not available with the Essential
Plan. Consult a physician before beginning or changing your
exercise or fitness routine.
Your enrollment checklist. Get ready to enroll by having the
following information available:
CALL 1-866-613-8506
CLICK ChooseExcellus.com/2018Coverage
VISIT Excellus BCBS Resource Center221 South Warren Street,
Syracuse, NY 13202Call 1-800-234-4781 for hours or to schedule an
appointment
STEP 5: ENROLLING IS QUICK AND EASY.
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https://www.ExcellusBCBS.com/
When you can enroll.
Annual Open Enrollment Period: November 1, 2017 - January 31,
2018
Special Enrollment Period: Certain life events such as a
pregnancy, adopting a baby, aging off a parent’s plan, getting a
divorce or losing coverage through an employer may qualify you for
a Special Enrollment Period (SEP). Generally with an SEP, you have
60 days to get coverage.
Enrollment is available for the Essential Plan, Medicaid and
Child Health Plus all year long.
-
Notice of Nondiscrimination
Our Health Plan complies with federal civil rights laws. We do
not discriminate on the basis of race, color, national origin, age,
disability, or sex. The Health Plan does not exclude people or
treat them differently because of race, color, national origin,
age, disability, or sex.
The Health Plan:
• 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, please refer to the enclosed
document for ways to reach us.
If you believe that the Health Plan 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:
Advocacy DepartmentAttn: Civil Rights CoordinatorPO Box
4717Syracuse, NY 13221Telephone number: 1-800-614-6575TTY number:
1-800-421-1220Fax: 315-671-6656
You can file a grievance in person or by mail or fax. If you
need help filing a grievance, theHealth Plan’s Civil Rights
Coordinator is available to help you.
You can also file a civil rights complaint with the U.S.
Department of Health and HumanServices, Office for Civil Rights,
electronically through the Office for Civil Rights ComplaintPortal,
available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by
mail or phone at:
U.S. Department of Health and Human Services200 Independence
Avenue, SWRoom 509F, HHH BuildingWashington, D.C.
202011-800-368-1019, 800-537-7697 (TDD)Complaint forms are
available at http://www.hhs.gov/ocr/office/file/index.html.
12 To learn more about your plan options, visit
ChooseExcellus.com/2018Coverage
-
B-5495
Attention: If you speak English free language help is available
to you. Please refer to the enclosed document for ways to reach us.
Atención: Si habla español, contamos con ayuda gratuita de idiomas
disponible para usted. Consulte el documento adjunto para ver las
formas en que puede comunicarse con nosotros.
注意:如果您说中文,我们可为您提供免费的语言协助。 请参见随附的文件以获取我们的联系方式。 Внимание! Если ваш
родной язык русский, вам могут быть предоставлены бесплатные
переводческие услуги. В приложенном документе содержится информация
о том, как ими воспользоваться. Atansyon: Si ou pale Kreyòl Ayisyen
gen èd gratis nan lang ki disponib pou ou. Tanpri gade dokiman ki
nan anvlòp la pou jwenn fason pou kontakte nou. 주목해 주세요: 한국어를 사용하시는
경우, 무료 언어 지원을 받으실 수 있습니다. 연락 방법은 동봉된 문서를 참조하시기 바랍니다. Attenzione: Se
la vostra lingua parlata è l’italiano, potete usufruire di
assistenza linguistica gratuita. Per sapere come ottenerla,
consultate il documento allegato.
אויפמערקזאם: אויב איר רעדט אידיש, איז אומזיסטע שפראך הילף
אוועילעבל פאר אייך ביטע רעפערירט צום בייגעלייגטן דאקומענט צו זען
אופנים זיך צו פארבינדן מיט אונז.
নজর দিন: যদি আপদন বাাংলা ভাষায় কথা বললন তাহলল আপনার জনয সহায়তা
উপলভয রলয়লে। আমালির সলে যযাগালযাগ করার জনয অনগু্রহ কলর সাংযুক্ত নদথ
পড়ুন। Uwaga: jeśli mówisz po polsku, możesz skorzystać z bezpłatnej
pomocy językowej. Patrz załączony dokument w celu uzyskania
informacji na temat sposobów kontaktu z nami. تنبيه: إذا كنت تتحدث
اللغة العربية، فإن المساعدة اللغوية المجانية متاحة لك. يرجى الرجوع
إلى الوثيقة
ة كيفية الوصول إلينا.المرفقة لمعرف Remarque : si vous parlez
français, une assistance linguistique gratuite vous est proposée.
Consultez le document ci-joint pour savoir comment nous
joindre.
سے رابطہ کرنے کے نوٹ: اگر آپ اردو بولتے ہيں تو آپ کے ليے زبان کی
مفت مدد دستياب ہے۔ ہم طریقوں کے ليے منسلک دستاویز مالحظہ کریں۔
Paunawa: Kung nagsasalita ka ng Tagalog, may maaari kang kuning
libreng tulong sa wika. Mangyaring sumangguni sa nakalakip na
dokumento para sa mga paraan ng pakikipag-ugnayan sa amin. Προσοχή:
Αν μιλάτε Ελληνικά μπορούμε να σας προσφέρουμε βοήθεια στη γλώσσα
σας δωρεάν. Δείτε το έγγραφο που εσωκλείεται για πληροφορίες
σχετικά με τους διαθέσιμους τρόπους επικοινωνίας μαζί μας. Kujdes:
Nëse flisni shqip, ju ofrohet ndihmë gjuhësore falas. Drejtojuni
dokumentit bashkëlidhur për mënyra se si të na kontaktoni.
Want help? We’re here for you. Call our dedicated insurance
agents at: 1-866-613-8506
-
Call 1-866-613-8506 and get a FREE health plan evaluation. Open
Enrollment ends January 31, 2018!
ChooseExcellus.com/2018Coverage
P.O. Box 22999, Rochester, NY 14692
B-5258Y18 / 11503-17M
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