Community Care of Oklahoma Plan and Cost – Transport Workers Union Local 514

CommunityCare

Your Monthly Contributions

AA Plans	Full Time
	Employee Only	Employee + Spouse	Employee + Child(ren)	Family
Community Care of Oklahoma	$95.20	$244.96	$170.07	$329-19

Summary of Benefits and Coverage: What this Plan Covers & What it Costs.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage For: Family | Plan Type: HMO document at www.ccok.com or by calling 1-800-777-4890.

Important Questions	Answers	Why this Matters:
What is the overall deductible?	$250 person/$750 family. Doesn’t apply to preventive care or pharmacy.	You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Are there other deductibles for specific services?	No.	You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.
Is there an out-of-pocket limit on my expenses?	Yes. In-network $2,500 person/$7,500 family	The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out-of-pocket limit?	Premiums, balance-billed charges and health care this plan doesn’t cover.	Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall annual limit on what the plan pays?	No.	The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a network of providers?	Yes. Foralistofin-network providers, see www.ccok.com or call 1-800-777-4890.	If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to see a specialist?	No.	You can see the specialist you choose without permission from this plan.
Are there services this plan doesn’t cover?	Yes.	Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

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 in-network 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	Limitations & Exceptions
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	20% co-insurance	Not covered	Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
If you have outpatient surgery	Physician/surgeon fees	20% co-insurance	Not covered	Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
If you need immediate medical attention	Emergency room services	20% co-insurance	20% co-insurance	———-none————
	Emergency medical transportation	20% co-insurance	20% co-insurance	———-none————
	Urgent care	$50 / visit	Not covered	Not subject to the deductible.
If you have a hospital stay	Facility fee (e.g., hospital ro om)	20% co-insurance	Not covered	Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
If you have a hospital stay	Physician/surgeon fees	20% co-insurance	Not covered	Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
If you have mental health, behavioral health, or substance abuse needs	Mental/Behavioral health outpatient services	$25 / visit	Not covered	Not subject to the deductible.
	Mental/Behavioral health inpatient services	20% co-insurance	Not covered	Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
	Substance use disorder outpatient services	$25 / visit	Not covered	Not subject to the deductible.
	Substance use disorder inpatient services	20% co-insurance	Not covered	Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
If you are pregnant	Prenatal and postnatal care	No charge	Not covered	Not subject to the deductible.
If you are pregnant	Delivery and all inpatient services	20% co-insurance	Not covered	———-none————
If you need help recovering or have other special health needs	Home health care	20% co-insurance	Not covered	Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
	Rehabilitation services	20% co-insurance	Not covered	Up to 60 treatment days per disability, per calendar year. Combination of physical, occupational, and speech therapy. Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
	Habilitation services	Not covered	Not covered	Not covered
	Skilled nursing care	20% co-insurance	Not covered	Up to 60 consecutive treatment days per disability, per calendar year. Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
	Durable medical equipment	20% co-insurance	Not covered	Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
	Hospice service	20% co-insurance	Not covered	Requires pre-authorization. Failure to receive pre-authorization will result in non-payment of benefits.
If your child needs dental or eye care	Eye Exam	No charge	Not covered	Limited to one exam in 365 days. Not subject to the deductible.
	Glasses	Not covered	Not covered	Not covered
	Dental check-up	Not covered	Not covered	Not covered

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Bariatric surgery
Cosmetic surgery
Dental care (Adult)
Infertility treatment
Long-term care
Non-emergency care when traveling outside the U.S.
Private-duty nursing
Routine foot care
Weight loss programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Acupuncture
Hearing aids (Except age 19 and over)
Routine eye care (Adult)
Chiropractic care (Limited to 12 visits per month and 30 visits per year. Chiropractic maintenance therapy not covered.)

Get the PDF with even More details HERE

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