Section 5420

Section 5420.EXHIBIT B Description of Coverage - Worksheet

	Plan:
	Name:
	Address:
	Toll Free Telephone Number:
	Web site (optional)

Description of Coverage

Basics

Your Doctor (description of process for selection of physician, PCP and/or WPHCP)

Annual Deductible (if applicable)

Out-of-Pocket

Individual

Maximum

Family

Lifetime Maximums

(if applicable)

Preexisting Condition Limitations

Description

Health Care

Of Coverage

Plan Covers

You Pay

In the

Number of Days of Inpatient Care

Hospital

Room & Board

Surgeon's Fees

Doctor's Visits

Medications

Other Miscellaneous Charges

Emer-gency Care

Emergency Services - (medical conditions of sufficient severity such that a prudent layperson could reasonably expect the absence of immediate medical attention to result in serious jeopardy of the person's health, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.)

Emergency Post-stabilization services

In the

Doctor's Office Visits

Doctor's

Routine Physical Exams

Office

Diagnostic Tests and X-rays

Immunizations

Allergy Treatment & Testing

Wellness Care

Medical

Outpatient Surgery

Services

Maternity Care

Hospital Care

Physician Care

Infertility Services

Mental Health

Outpatient

Inpatient

Substance Abuse

Outpatient

Inpatient

Outpatient Rehabilitation Services

Other

Durable Medical Equipment

Services*

Hospice

Home Health Care

Prescription Drugs

Dental Services

Vision Care

*Copayments and deductibles for these services may not apply to your out of pocket maximums.

Service Area (Boldface Type)

[A summary description of the area to be served by the health care plan.]

Exclusions and Limitations (Boldface Type)

[A summary description of all contract exclusions, exceptions and limitations.]

Pre-certification and Utilization Review (Boldface Type)

[A summary description of the procedures and requirements for pre-certification and other utilization review procedures.]

Emergency Care (Boldface Type)

[A summary description of requirements for and coverage of pre and post emergency care.]

Primary Care Physician Selection (Boldface Type)

[A summary description of procedures and requirements for primary care physician selection.]

Access to Specialty Care (Boldface Type)

[A summary description of referral policies, including standing referrals, and any limitation on access to specialists. This should include access to, and limitations on access to, out of network specialists.]

Out-of-Area Coverage (Boldface Type)

[A summary description of benefits available to the enrollee for out-of-area coverage.]

Financial Responsibility (Boldface Type)

[A summary description to the enrollee of all out-of-pocket expenses, including copayments, deductibles and premiums payable under the policy. When the entire premium is not paid directly by the enrollee, then the enrollee may need to contact the benefit administrator for the level of contribution.]

Continuity of Treatment (Boldface Type)

[A summary description of the health care plan's provision for continuity of treatment in the event that the enrollee's health care provider terminates from the plan during a course of care, including time frames for requesting transitional services.]

Appeals Process (Boldface Type)

[A summary description of the process for health care service appeals, complaints, external independent reviews, administrative complaints and utilization review complaints, including time frames and a phone number to call to receive more information from the health care plan concerning the enrollee's appeal process.]

Any enrollee not satisfied with the health care plan's resolution of any complaint may appeal the final plan decision to the Department of Insurance, through the Consumer Services Section, at one of the following locations:

320 West Washington Street

Springfield, Illinois 62767-0001

100 West Randolph Street

Suite 15-100

Chicago, Illinois 60601-3251

You may also contact the Department electronically at http: //www.state.il.us/ins.

Note: External grievance determinations in most cases are not appealable through the Department of Insurance.

IMPORTANT: In the event of any inconsistency between your Description of Coverage and contract or certificate, the terms of the contract or certificate will control.