Aegis Freedom Plan (FP) Self-Funded Pre-Paid Certificate Janulary 1, - December 2016

Schedule of Benefits and Contributions for Employee Health and Welfare Benefit Plan

For further questions call 1-888-881-2307

**An NAFM Claim Form must be submitted to NAFM within 60 days of service date. All covered claims are paid within 30 days upon receipt of the Explanation of Benefits.
**Only claims that are considered a covered expense by your ACA compliant plan will be considered for reimbursement.
**If you have an HMO plan that offers no out of network coverage, then NAFM will not reimburse medical expenses on an HMO out of network claim.
**Out of network claims paid by NAFM will be based off the “reasonable and customary” amount.

Important Questions Answers Why this Matters:
What is the overall deductible? No Deductible There is no deductible, but you must submit the claim to your major medical carrier first then submit your claim with your EOB for your disbursement of 75% of eligible unpaid medical expenses per the pre-paid certificate. This plan is considered secondary to your current employer sponsored major medical plan.
Are there other deductibles for specific services? No There are no other deductibles.
Is there an out–of–pocket limit on my expenses? No There is no out of pocket limit.
What is not included in the out–of–pocket limit? There is no out of pocket limit. This plan is designed to pay 75% what your major medical plan does not. You are required to have a major medical plan in conjunction with The Freedom Plan. Your current major medical plan more than likely has an out of pocket limit.
Is there an overall annual limit on what the plan pays? Yes The plan will only pay up to what is in your Freedom Plan pre-paid certificate account value at the time of claim and only what is considered a covered expense by your existing major medical plan and this Summary of Benefits.
Does this plan use a network of providers? Yes The plan will follow the network provided by your current major medical plan. If your current major medical plan is an HMO, it is recommended that you stay in network.
Do I need a referral to see a specialist? No, for PPO plans, Yes for HMO plans If your current major medical provider requires you to receive a referral to see a specialist, then follow their requirements in order to receive your reimbursement from your Freedom Plan.
Are there services this plan doesn’t cover? Yes Some of the services this plan does not cover are listed on page 5. See your policy or plan document for additional information about excluded services.

Freedom Plan (FP) Self-Funded Pre-Paid Certificate Janulary 1, - December 2016

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.

Common Medical Event Services You May Need Your Cost If You Use an In-network Provider Your Cost If You Use an Out-of-network Provider on a PPO or POS network Limitations & Exceptions
Hospital Stay Room and Board 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Intensive Care 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Skilled Nursing Facility
Eligible only if immediately following a hospital stay and only up to 30 days per year.
75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Surgery and Recovery Room 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Physician Services Inpatient visits 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Office visits (office charge only) 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Lab Charges 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Surgery (non-elective) 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Allergy testing 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Home Health Care Home Health (Up to 30 visits per year) 75% of out of Pocket Expense 75% of In-Network Rate (Up to 30 visits per year)
Outpatient Private Duty Nursing Outpatient private duty nursing 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Hospice Care Hospice Care 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Ambulance Services Ground Ambulance 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Air Ambulance 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Mental Disorders Mental/Behavioral health outpatient services 75% of out of Pocket Expense 75% of In-Network Rate 1 per week (per individual) 20 days per year for Individual 25 days for Family
Mental/Behavioral health inpatient services 75% of out of Pocket Expense 75% of In-Network Rate Up to 20 days per year
Mental/Behavioral health partial Hospitalization 75% of out of Pocket Expense 75% of In-Network Rate 2 Partial hospitalizations days equals 1 inpatient day and is subject to the inpatient limit.
Substance Abuse Substance use disorder outpatient services 75% of out of Pocket Expense 75% of In-Network Rate Up to 20 days per year
Substance use disorder inpatient services 75% of out of Pocket Expense 75% of In-Network Rate Up to 20 days per year
Pregnancy Prenatal and postnatal care 75% of out of Pocket Expense 75% of In-Network Rate Dependent daughters not covered and pre-existing pregnancies are not covered.
Delivery and all inpatient services 75% of out of Pocket Expense 75% of In-Network Rate Dependent daughters not covered and pre-existing pregnancies are not covered.
Therapy Speech 75% of out of Pocket Expense 75% of In-Network Rate Up to $500 per year for family.
Therapy Occupational 75% of out of Pocket Expense 75% of In-Network Rate 20 visits per year for Individual 25 visits for Family
Chiropractor Physical 75% of out of Pocket Expense 75% of In-Network Rate 20 visits per year for family for each of physical, pulmonary rehabilitation and cardiac rehabilitation.
Spinal manipulation 75% of out of Pocket Expense 75% of In-Network Rate 12 visits per year for family/1 per month
Outpatient Surgery Surgery Room 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Recover and Prep Room 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Outpatient Tests Outpatient tests, diagnostics and lab work 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Outpatient Radiation and Chemotherapy Radiation and Chemotherapy 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Wigs Wigs (after chemotherapy) 75% of out of Pocket Expense 75% of In-Network Rate Lifetime subsidy of $250
Organ Transplants Transplants 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Preventive Preventive Care/Screenings/Immunizations 75% of out of Pocket Expense 75% of In-Network Rate –––––––––––none–––––––––––
Services Your Plan Does NOT Cover
Prescriptions Vision (Eye Exam, Glasses, Contacts and elective eye surgery) Dental
Cosmetic Surgery Elective Surgery Weight Reduction Surgery
Private Duty Nursing Infertility Treatments Medical Equipment
Assistant Surgeon Prosthetics
Your Rights to Continue Coverage:

Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:

You Commit Fraud The insurer stops offering services in the State You move outside the coverage area.

For more information on your rights to continue coverage, contact:

Aegis at 1-888-881-2307. You may also contact your state insurance department.

OR

** Group health coverage sample –

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage.

Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan.

Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-866-617-NAFM. You may also contact your stateinsurance department, the U.S. Department ofLabor, Employee Benefits SecurityAdministration at 1-866-444-3272 orwww.dol.gov/ebsa, or the U.S. Department ofHealth and Human Services at 1-877-267-2323x61565 or www.cciio.cms.gov.