(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 6
(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: 01/01/2023 – 12/31/2023
C.O.P.S. Trust: Michigan State Police Troopers Association, Plan 1, Group 71792 Coverage for: Individual or Family | Plan Type: PPO
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 1-800-229-
2210. 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.healthcare.gov/sbc-glossary/ or call 1-800-229-2210 to request a copy.
Important Questions Answers Why This Matters:
What is the overall
deductible?
In-Network providers:
$500 individual / $1,000 family
Out-of-Network providers:
$1,000 individual / $2,000 family
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 care and other serv
ices
as noted are covered before you meet
your deductible.
This plan covers some items and services even if you haven’t yet met the 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 https://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?
In-Network providers:
$6,350 individual / $12,700 family
Out-of-Network providers:
$12,700 individual / $25,400 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,
prior authorization penalties,
copayments, and health care 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. See bluewaterbenefitsadmin.com
for a list of 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?
No. You can see the network specialist you choose without a referral.
* For more information about limitations and exceptions, see the plan or policy document at bluewaterbenefitsadmin.com. Page 2 of 6
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
Deductible does not apply
20% coinsurance None
Specialist visit
$20 copay
Deductible does not apply
20% coinsurance None
Preventive
care/screening/
immunization
No charge
Deductible does not apply
20% coinsurance
preventive. Ask your provider if the services
needed are preventive. Then check what
your plan will pay for. No charge Out-of-
Network: annual physical, gynecological
exam, fecal occult blood screening, and
If you have a test
Diagnostic test (x-ray,
blood work)
$20 copay
Deductible does not apply
20% coinsurance None
Imaging (CT/PET
scans, MRIs)
$20 copay +
10% coinsurance
20% coinsurance None
If you need drugs to treat
your illness or condition
More information about
prescription drug
coverage is available at
bluewaterbenefitsadmin.com
Generic drugs
$5 copay (retail)
$10 copay (mail order)
Deductible does not apply
$5 copay (retail) +
25% cost share of
eligible expenses.
Mail order not available.
Covers up to a 31-day supply (retail
prescription); 90-day supply (mail order
prescription). Some prescription drugs are
subject to prior authorization, or benefits will
be reduced by 20%.
Preferred brand drugs
$20 copay (retail)
$40 copay (mail order)
Deductible does not apply
$20 copay (retail) +
25% cost share of
eligible expenses.
Mail order not available.
Non-preferred brand
drugs
$40 copay (retail)
$80 copay (mail order)
Deductible does not apply
$40 copay (retail) +
25% cost share of
eligible expenses.
Mail order not available
* For more information about limitations and exceptions, see the plan or policy document at bluewaterbenefitsadmin.com. Page 3 of 6
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 have outpatient
surgery
Facility fee (e.g.,
ambulatory surgery
center)
10% coinsurance 20% coinsurance
Prior authorization is required, or benefits will
be reduced by 20%.
Physician/surgeon
fees
10% coinsurance 20% coinsurance
If you need immediate
medical attention
Emergency room care
$200 copay
Deductible does not apply
$200 copay
Copay waived if you are admitted to hospital
as inpatient. Emergency Room physician
covered at 100% following In-Network
Deductible.
Emergency medical
transportation
10% coinsurance 10% coinsurance None
Urgent care
$20 copay
Deductible does not apply
No charge None
If you have a hospital stay
Facility fee (e.g.,
hospital room)
10% coinsurance 20% coinsurance
Prior authorization is required, or benefits will
be reduced by 20%.
Physician/surgeon
fees
10% coinsurance 20% coinsurance
be reduced by 20%.
If you need mental health,
behavioral health, or
substance abuse services
Outpatient services
$20 copay
Deductible does not apply
20% coinsurance None
Inpatient services
No charge
20% coinsurance
If you are pregnant
Office visits 10% coinsurance 20% coinsurance
Cost sharing does not apply for preventive
services. Depending on the type of service, a
copayment may apply. Maternity care may
include tests and services described
elsewhere in the SBC (i.e. ultrasound). Prior
authorization is required for vaginal deliveries
requiring more than a 48 hour stay and for
cesarean section deliveries requiring more
than a 96 hour stay or benefits will be
reduced by 20%.
Childbirth/delivery
professional services
No charge
Deductible does not apply
20% coinsurance
Childbirth/delivery
facility services
No charge
Deductible does not apply
20% coinsurance
* For more information about limitations and exceptions, see the plan or policy document at bluewaterbenefitsadmin.com. Page 4 of 6
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 10% coinsurance 20% coinsurance None
Rehabilitation services
Facility setting:
10% coinsurance
Office setting:
$20 copay
20% coinsurance
Limited to 30 visits per plan year for speech
therapy. Limited to 30 visits per plan year
combined for occupational and physical
therapy.
Habilitation services
Facility setting:
10% coinsurance
Office setting:
$20 copay
20% coinsurance
Limited to 30 visits per plan year for speech
therapy. Limited to 30 visits per plan year
combined for occupational and physical
therapy.
Skilled nursing care 10% coinsurance 20% coinsurance Limited to 100 days per plan year.
Durable medical
equipment
No charge No charge None
Hospice services 10% coinsurance 20% coinsurance None
If your child needs dental
or eye care
Children’s eye exam Not covered Not covered Not covered.
Children’s glasses Not covered Not covered Not covered.
Children’s dental
check-up
Not covered Not covered Not covered.
* For more information about limitations and exceptions, see the plan or policy document at bluewaterbenefitsadmin.com. Page 5 of 6
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.)
•
Cosmetic Surgery
• Dental Care (Adult)
•
Long-Term Care
• Non-Emergency Care when travelling outside the
U.S.
•
Routine Eye Care (Adult)
• 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 (Limited to 30 visits per
calendar year)
• Hearing Aids payable once every 36 months
•
Infertility Treatment (except in-vitro)
• Private-Duty Nursing
•
Routine Foot Care
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 plan at 1-800-225-9674, the state insurance department, the U.S. Department of Labor, the Employee Benefits Security Administration at 1-866- 444-
3272 or www.dol.gov/ebsa/healthreform, 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: the plan at 1-800-225-9674. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security
Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or
www.cciio.cms.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance
Program at 1-877-999-6442 or www.michigan.gov/lara or email difs-hicap@michigan.gov.
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 1-800-229-2210.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-229-2210.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-229-2210.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-229-2210.
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control 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 6 of 6
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 $500
Specialist [cost sharing] $20
Hospital (facility) [cost sharing] 10%
Other [cost sharing] 10%
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
$500
Copayments
$50
Coinsurance
$1,200
What isn’t covered
Limits or exclusions
$60
The total Peg would pay is
$1,770
The plan’s overall deductible $500
Specialist [cost sharing] $20
Hospital (facility) [cost sharing] 10%
Other [cost sharing] 10%
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
$500
Copayments
$800
Coinsurance
$0
What isn’t covered
Limits or exclusions
$20
The total Joe would pay is
$1,320
The plan’s overall deductible $500
Specialist [cost sharing] $20
Hospital (facility) [cost sharing] 10%
Other [cost sharing] 10%
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
$500
Copayments
$300
Coinsurance
$60
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is
$860
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)