State of Illinois: State Plan

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2024 - 06/30/2025

State of Illinois: State Plan Coverage for: 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,

www.healthalliance.org/stateofillinois or call 1-800-851-3379. 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

https://www.healthalliance.org/documents/1492 or call 1-800-851-3379 to request a copy.

Important Questions

Answers

Why This Matters:

What is the overall

deductible?

See the Common Medical Events chart below for your costs for services this plan covers.

Are there services

covered before you meet

your deductible?

No.

Are there other

deductibles f

or specific

services?

Yes; $150 Prescription Drugs

You mu

st pay all of the costs for these services up to the specific deductible amount before

this plan begins to pay for these services.

What is the out-of-pocket

limit for this plan?

$3,000 Individual/ $6,000

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, balance billing

charges, healthcare this plan

does not cover.

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

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* For more information about limitations and exceptions, see the plan or policy document at www.healthalliance.org/stateofillinois.

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Will you pay less if you

use a network provider?

Yes. See:

www.healthalliance.org/state

ofillinois or call 1-800-851-3379

for a list of Participating (In-

network) providers.

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?

Yes, this plan may require

referrals to in-network

specialists.

This p

lan will pay some or all of the costs to see a specialist for covered services but

only if you have a referral before you see the specialist.

* For more information about limitations and exceptions, see the plan or policy document at www.healthalliance.org/stateofillinois.

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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

Participating (In-

Network) Provider

(You will pay the least)

Non-Participating (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

$30 copay/visit Not Covered --none--

Specialist visit $40 copay/visit Not Covered --none--

Preventive

care/screening/

immunization

No Charge

Not Covered

You may have to pay for services that aren’t

preventive. Ask your provider if the

services you need are preventive. Then

check what you plan will pay for. Refer to

Wellness Brochure.

If you have a test

Diagnostic test (x-ray, blood

work)

$0 copay/service Not Covered --none--

Imaging (CT/PET scans,

MRIs)

$30 copay/service Not Covered Preauthorization Required

If you need drugs to

treat your illness or

condition

More information about

prescription drug

coverage is available at

https://healthalliance.o

/documents/formulary/

661/2024

Reduced Generic Tier 1

$4 copay /

prescription

Not Covered

Covers up to a 30-day supply (retail

prescription); 90 day supply (mail order)

available for 2.5 copays.

Generic Tier 1

$20 copay /

prescription

Not Covered

Covers up to a 30-day supply (retail

prescription); 90 day supply (mail order)

available for 2.5 copays.

Preferred Brand -

Preferred Specialty Tier 2

$35 copay /

prescription

Not Covered

Covers up to a 30-day supply (retail

prescription); 90 day supply (mail order)

available for 2.5 copays. If you or your

Physician requests a brand name drug

when

a generic drug exists, you pay the

Preferred

Brand or Non-Preferred Brand Deductible

Copayment and/or Coinsurance, plus a

100% coinsurance for the difference in

cost

between the Brand name drug and the

Generic drug. This price difference is

applied

to your Deductible. In no instance will the

total cost you are charged for the drug

exceed the actual cost of the drug.

* For more information about limitations and exceptions, see the plan or policy document at www.healthalliance.org/stateofillinois.

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Non-Preferred Brand -

Non-Preferred Specialty Tier 3

$60 copay /

prescription

Not Covered

Preauthorization may be required. If you or

your Physician requests a brand name drug

when a generic drug exists, you pay the

Preferred Brand or Non-Preferred Brand

Deductible, Copayment and/or

Coinsurance, plus a 100% coinsurance for

the difference in cost between the Brand

name drug and the Generic drug. This price

difference is applied to your Deductible. In

no instance will the total cost you are

charged for the drug exceed the actual cost

of the drug.

Medical Drugs

0% coinsurance Not Covered

Preauthorization is required

If you have outpatient

surgery

Facility fee (e.g., ambulatory

surgery center)

$300 copay/procedure Not Covered

Preauthorization may be required for

certain procedures. Contact customer

Service for detailed information.

Physician/surgeon fees No Charge Not Covered --none--

If you need immediate

medical attention

Emergency room care

$275 copay / visit

Participating Benefit Applies

Emergency medical

transportation

No Charge No Charge Participating Benefit Applies

Urgent care

$30 copay / visit $30 copay / visit --none--

* For more information about limitations and exceptions, see the plan or policy document at www.healthalliance.org/stateofillinois.

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Common

Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important

Information

Participating (In-

Network) Provider

(You will pay the least)

Non-Participating (Out

of Network) Provider

(You will pay the most)

If you have a hospital

stay

Facility

fee

(e.g.,

hospital

room)

$425 copay / stay

Not Covered

Preauthorization is required.

Physician/surgeon fees No Charge Not Covered Preauthorization may be required.

If you need mental

health, behavioral

health, or substance

abuse services

Outpatient services $30 copay/visit Not Covered --none--

Inpatient services $425 copay / stay Not Covered Preauthorization is required.

If you are pregnant

Office visits

$50 copay/pregnancy

Not Covered

--none--

Childbirth/delivery

professional services

No Charge Not Covered --none--

Childbirth/delivery facility

services

$425 copay / stay Not Covered --none--

If you need help

recovering or have other

special health needs

Home health care

$40 copay/visit

Not Covered

--none--

Rehabilitation services $40 copay/visit Not Covered

Preauthorization is required. 60 visits per

condition per plan year maximum.

Habilitation services $40 copay/visit Not Covered

60 visits per condition per plan year

maximum.

Skilled

nursing

care

$0 copay / stay

Not Covered

Preauthorization is required.

Durable medical equipment 20% coinsurance Not Covered

Preauthorization may be required for

certain medical equipment. Contact

Customer Service for detailed information.

Hospice services

$0 copay

Not Covered

--none--

If your child needs

dental or eye care

Children’s

eye

exam

Not Covered

--none--

Children’s

glasses

Not Covered

--none--

Children’s dental check-up

Not Covered

--none--

* For more information about limitations and exceptions, see the plan or policy document at www.healthalliance.org/stateofillinois.

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Excluded Services & Other Covered Services:

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

• Dental Care

• Long Term Care

• Non-Emergency Care When

Traveling Outside the U.S.

• 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

• Hearing Aids

• Infertility Services

• Private Duty Nursing

• Elective Abortion

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: For group health coverage subject to ERISA, Department of Labor’s Employee Benefits Security Administration at 1-866-

444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

For non-federal governmental group health plans, Department of Health and Human

Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not

covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator

regarding their possible rights to continuation coverage under State law.

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 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 non-federal governmental group health plans and church plans that are group health plans, contact Health Alliance at 1-800-851-3379 and

State of Illinois Department of Insurance at 1-877-527-9431 or consumer_complaints@ins.state.il.us.

Additionally, a consumer assistance program can help you file your appeal. Contact 1-800-851-3379. A list of states with Consumer Assistance

Programs is available at: www.dol.gov/ebsa/healthreform and http://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/.

* For more information about limitations and exceptions, see the plan or policy document at www.healthalliance.org/stateofillinois.

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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 1-800-851-3379.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-851-3379.

Chinese (中文): 如果需要中文的帮助，请请打请个号请1-800-851-3379.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-851-3379.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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

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About these Coverage

 The plan’s overall deductible $0

 Specialist $40 copay/visit

 Hospital (facility) $425 copay/stay

 Other 0% coinsurance

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:

 The plan’s overall deductible $0

 Specialist $40 copay/visit

 Hospital (facility) $425 copay/stay

 Other 0% coinsurance

This EXAMPLE event includes services like:

Primary care physician office visits (including

disease education)

Diagnostic tests (bloo

d work)

Prescription drugs

Durable medical equipment (glucose meter)

Total Example Cost

$5,600

In this example, Joe would pay:

 The plan’s overall deductible $0

 Specialist $40 copay/visit

 Hospital (facility) $425 copay/stay

 Other 0% coinsurance

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:

Mia’s Simple Fracture

(in-network emergency room visit and follow

up care)

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well-

controlled condition)

Peg is Having a Baby

(9 months of in-network pre-natal care and a

hospital delivery)

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.

Cost Sharing

Deductibles

Copayments

$900

Coinsurance

What isn’t covered

Limits or exclusions

$60

The total Peg would pay is

$960

Cost Sharing

Deductibles

Copayments

$300

Coinsurance

What isn’t covered

Limits or exclusions

$200

The total Joe would pay is

$500

Cost Sharing

Deductibles

Copayments

$500

Coinsurance

$40

What isn’t covered

Limits or exclusions

The total Mia would pay is

$540

GNCMHA24-CMnondiscrimnt-0623

DISCRIMINATION IS AGAINST THE LAW

Health Alliance

complies with applicable federal civil rights laws and does not discriminate on the basis of race,

color, national origin, age, disability or sex (including pregnancy, sexual orientation or gender identity). Health

Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability or sex

(including pregnancy, sexual orientation or gender identity). Health Alliance:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters.

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:

Qualified interpreters.

Information written in other languages.

If you need these services, contact Customer Service.

If you believe that Health Alliance has failed to provide these services or discriminated in another way on the basis of

race, color, national origin, age, disability or sex (including pregnancy, sexual orientation or gender identity), you can

file a grievance with: Health Alliance, Customer Service, 3310 Fields South Drive, Champaign, IL 61822 or 411 N.

Chelan Ave., Wenatchee, WA 98801; telephone for members in Illinois, Indiana, Iowa and Ohio: (800) 851-3379,

TTY:711; members in Washington call: (877) 750-3515, TTY: 711; fax: (217) 902-9705;

CustomerService@HealthAlliance.org.

You can file a grievance in person or by mail, fax or email. If you need help

filing a grievance, Customer Service 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,

(800) 368-1019, TTY: (800) 537-7697. Complaint forms are available at

http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: Si habla Español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. IA, IL, IN, OH:

Llame (800) 851-3379, WA Llame: (877) 750-3515 (TTY: 711).

注意：如果你講中文，語言協助服務，免費的，都可以給你。IA, IL, IN, OH: 呼叫 (800) 851-3379, WA: 呼叫 (877) 750-

3515(TTY: 711)。

UWAGA: Je

śli mówić Polskie, usługi pomocy języka, bezpłatnie, są dostępne dla Ciebie. IA, IL, IN, OH: Zadzwoń

(800) 851-3379, WA: Zadzwoń (877) 750-3515 (TTY: 711).

Chú ý: Nế

u bạn nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, miễn phí, có sẵn cho bạn. IA, IL, IN, OH: Gọi

(800) 851-3379, WA: Gọi (877) 750-3515 (TTY: 711).

주의 : 당신이

한국어, 무료 언어 지원 서비스를 말하는 경우 사용할 수 있습니다. (800) 851-3379 IA, IL, IN, OH: 전화 WA:

(877) 750-3515 전화 (TTY: 711).

ВНИМАНИЕ: Ес

ли вы говорите русский, вставки услуги языковой помощи, бесплатно, доступны для вас. IA, IL, IN, OH:

Вызов (800) 851-3379, WA: Вызов (877) 750-3515 (TTY: 711).

Pansin: Kung magsalita ka Tagalog, mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. IA, IL, IN, OH:

Tumawag (800) 851-3379, WA: Tumawag (877) 750-3515 (TTY: 711).

هﺎﺒﺘﻧا:

اذإ

ﺖ ﻨ ﻛ

ﻢﻠﻜﺘﺗ

،ﺔﯿﺑﺮﻌﻟا

نﺈﻓ

تﺎﻣﺪﺧ

ةﺪﻋﺎﺴﻤﻟا

ﺔﯾﻮﻐﻠﻟا

ةﺮﻓﻮﺘﻣ

ﻚﻟ

ﺎﻧﺎﺠﻣ.

،يﻮﻨﯿﻠﯾإ

،ﺎﻧﺎﯾﺪﻧإ

ﻮﯾﺎھوأ:

ﻞﺼﺗا

ﻢﻗﺮﻟﺎﺑ

3379-851

(800) ،

ﺔﯿﻟاو

ﻦﻄﻨﺷاو:

ﻞﺼﺗا

ﻢﻗﺮﻟﺎﺑ:

)711 ﻢ ﻗ ﺮ ﻟ ا ﻰﻠﻋ ﻞﺼﺗﺎﻓ ﻊ ﻤ ﺴ ﻟ ا ﻲ ﻓ ﺔﺑﻮﻌﺻ وأ ﻢﻤﺼﻟا ﻦﻣ ﻲﻧﺎﻌﺗ ﺖ ﻨ ﻛ ا ذ إ (

(877) 750-3515

Aufmerksamkeit: Wenn Sie Deutsch sprechen, Sprachassistenzdienste sind kostenlos, zur Verfügung. IA, IL, IN, OH: Anruf (800)

851-3379, WA: Anruf (877) 750-3515 (TTY: 711).

ATTENTION: Si vous parlez français, les services d'assistance linguistique, gratuitement, sont à votre disposition. IA, IL, IN,

OH: Appelez (800) 851-3379, WA: Appelez (877) 750-3515 (TTY: 711).

યાન: તમ

ે વાત તો ગુજરાતી, ભાષા સહાય સેવાઓ, મફત, તમારા માટે ઉપલધ છે. IA, IL, IN, OH: કૉલ (800) 851-3379,

WA: કૉલ (877) 750-3515 (TTY: 711).

注意：あなたは、日本語、無料で言語支援サービスを、話す場合は、あなたに利用可能です。

(800) 851-3379 IA, IL, IN, OH: コール (877) 750-3515 WA: コール（TTY: 711)。

LET OP: Services Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass

dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: IA, IL, IN, OH: Call (800) 851-3379 WA: Call (877) 750-3515

(TTY: 711).

УВАГА: Я

кщо ви говорите український, вставки послуги мовної допомоги, безкоштовно, доступні для вас. IA, IL, IN,

OH: Виклик (800) 851-3379, WA: Виклик (877) 750-3515 (TTY: 711).

ATTENZIONE: Se si p

arla italiano, servizi di assistenza linguistica, a titolo gratuito, sono a vostra disposizione. IA, IL, IN, OH:

Chiamare (800) 851-3379, WA: Chiamare (877) 750-3515 (TTY: 711).