YOUR LIFE. YOUR CHOICE. YOUR HEALTH PLAN · YOUR LIFE. YOUR CHOICE. YOUR HEALTH PLAN. Leave school...

YOUR LIFE. YOUR CHOICE. YOUR HEALTH PLAN. Leave school with health plan coverage

Exclusive offer for students previously enrolled in the University of Minnesota-sponsored student health benefit plan

Rates effective January 1, 2015 through December 31, 2015

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CHOOSE THE PLAN THAT MAKES IT EASY TO GO WHERE LIFE TAKES YOU You’re ready for the next stage in your life. You have a lot of exciting opportunities: moving, a new academic challenge or finding a job. The last thing you want to worry about is a gap in your health coverage.

Your student health plan will end soon. Without coverage, you could be vulnerable.

NEw HEALTH LAw. NO wORRIEs. Now that you are choosing a new health plan, you’ll want one that meets requirements of health care overhaul laws. The Affordable Care Act requires everyone to have a qualified plan or face tax penalties. When you choose one of the Blue Cross health plans in this guide, you will not have to worry about tax penalties.

TRAVEL wITH CONFIDENCE Plan on traveling? Or are you an out of state student? No problem. All of our health plans come with the BlueCard® PPO network. That means you’re covered at more than 92 percent of doctors and 96 percent of hospitals nationwide. You also get access to doctors and hospitals in more than 200 countries with BlueCard Worldwide® .

PERSONALIzEd ONLINE ACCESS Your time is valuable. Blue Cross makes it easy to find information to take care of your health. Tools are available to you online 24 hours a day, seven days a week. Get health and wellness tips, learn how to manage health conditions or find a doctor. Visit myBlueCrossmn.com to register.

MObILE CONVENIENCE When you’re on the go, you can tap into your health benefits with the BlueCrossMN mobile app. The app is available for Apple and Android devices. With a touch of a screen, you can look up your member information, find out what’s covered, get access to health discounts and more. Finding a doctor, clinic or hospital near you is quick and convenient. Members can register at myBlueCrossmn.com to download the app.

sAVE TIME AND MONEY wITH THE “FIND A DOCTOR” TOOL It’s easy to compare doctors and shop for the best price on care with the “Find a doctor” web tool. It offers many advanced features:

➜➜ Choose a doctor, hospital, urgent care center or convenience clinic in your plan’s network

➜➜ Compare health care providers based on cost and quality ratings

➜➜ See estimated total costs and your estimated out-of-pocket expense for more than 300 common procedures

➜➜ Read other consumers’ reviews of doctors and write your own

DID YOU kNOw? You’ll get a personalized online account to:

➜➜ Keep track of your claims

➜➜ Manage your accounts

➜➜ Find doctors

➜➜ Get health information and more

1

http://myBlueCrossmn.com

http://myBlueCrossmn.com

For your

TOOLS HEALTH ANd

WELLBEING The best time to think about your health is before you get sick. It’s about taking time for your health every day so you stay well. The chart below lists tools and resources that are included in your health plan. These tools can help you take charge of your health habits. Choose the options that best meet your health goals and desired approach.

lEGEND

Health Habits

Managing Stress

Eating Right

Staying Active

Managing Weight

Quitting Tobacco

Maintaining a Healthy Pregnancy

Making Health Decisions

GEt wEll

Options Description Health Habits Contact

Online Care

Meet face-to-face with a board-certified doctor online, from home or work — or even on vacation with Online Care Anywhere® .

onlinecareanywhereMN.com

Nurse Line Talk to a nurse 24 hours a day, 7 days a week to help you get answers to your health-related questions.

1-800-622-9524

Provider Cost/ Quality

Get recommendations on doctors, hospitals, prescriptions and other information, based on cost and quality.

myBlueCrossmn.com

Care Coordination

Talk with a nurse, social worker or other health professional about managing your (or your family member’s) complex health care needs.

Number on the back of your member ID card

SAVE MONEY


Fitness Membership Discount

Get a $20 discount for working out 12 days per month at a participating fitness center.

myBlueCrossmn.com

Online Marketplace

Get exclusive savings on health and wellbeing products and services not typically covered by plan with CareXtend.

CareXtend.com

Vacation Savings Program

Start saving for your next vacation and receive a 50 percent matching credit with the Adestinn vacation savings program.

adestinn.com

2

FIND ANSwERS


Health Guides

Get answers to your questions about your health plan benefits or get connected to a nurse for questions about your health.


Online Health Assessment

Answer questions that assess your health history and health behaviors to get a snapshot of your current health status.

bluecrossmn.com/ myhealth

Online Health and Wellbeing Resources

Access a library of articles, videos, quizzes and calculators about health conditions, diseases, procedures and prescriptions.

bluecrossmn.com/ healthandwellness

SEEK SUPPORt


Online Health Coaching

Provides personalized online coaching to help address your health goals and concerns.

bluecrossmn.com/ healthandwellness

Stop Smoking Support

Helps you develop and maintain a quit plan with information and support from a Quit Coach. Includes over-thecounter medications to help you quit.

1-888-662-2583 or myBlueCrossmn.com

Chronic Condition Management

Get support from a nurse about managing your chronic condition(s), such as diabetes, cancer or asthma.


3

bLUE CROss HEALTH PLANs — HEALTH COVERAgE FOR AN ACTIVE LIFEsTYLE BlueAccess with the Aware® network — Enjoy easy access to the most health care providers

BlueAccess plans come with the convenience of our biggest and broadest network, which includes 100 percent of hospitals and 98 percent of doctors in Minnesota. Boynton Health Services and University of Minnesota Physicians are in the Aware network. Some BlueAccess plans also let you add a health savings account (HSA). HSAs help you save tax-free money, earn interest on that money and use it to pay for medical expenses. This gives you confidence that wherever you go, Blue Cross is there.

LOOk UP YOUR MONTHLY RATE ➜➜ Use the rating area map to determine the correct

rating area based on where you live

➜➜ Find the appropriate rating area for the plan you want in this book

➜➜ Look up rates for you, your spouse and your dependents based on their age

•For dependents ages 21 to 25, assign a rate based on age

•For dependents ages 0 to 20, assign the flat rate with a limit, or cap, on three dependents. That means families with four or more dependents should only be charged for three of the child dependents.

4

RATING AREA MAP

Dodgesteele

RiceNicollet

watonwan

RedwoodLyon

Yellow Medicine

Lac Qui Parle

Renville

Dakotascott

Carver

sibley

McLeod

Hennepin

Ramsey

washington

Anoka

wright

sherburne

Popestevens Traverse

grant Douglas

Otter Tail wilkin

Clay becker

benton

stearns

Meeker

kandiyohi

Chippewa

swift

big stone

brown

CottonwoodMurray

Pipe-stone

Lincoln

Rock Nobles Jackson Martin Faribault

blue Earth waseca

Le sueur

Olmsted

wabasha

Lake of the woods

winona

Fillmore HoustonFreeborn Mower

goodhue

koochiching

beltrami

Hubbard

Cass

Aitkin

Pine

Crow wing

wadena

Todd

Morrison

Mille Lacs kanabec

Isanti

Chisago

Roseau

st. Louis

Carlton

Lake

Cook

Itasca

Norman Mahnomen

Clearwater

Polk

Red Lake

Pennington

Marshall

kittson

1

2

3

4

5

Dodge, Fillmore, Freeborn, Goodhue, Houston, Mower, Olmsted, Steele, Wabasha, Winona counties and outside of Minnesota

Carlton, Cook, Itasca, Koochiching, Lake, Lake of the Woods, St. Louis counties

Blue Earth, Faribault, Waseca, Le Sueur, Martin, Nicollet, Rice, Watonwan counties

Brown, Cottonwood, Jackson, Lincoln, Murray, Nobles, Pipestone, Redwood, Rock counties

Big Stone, Chippewa, Kandiyohi, Lac Qui Parle, Lyon, McLeod, Meeker, Renville, Sibley, Swift, Yellow Medicine counties

6

7

8

9

Becker, Clay, Douglas, Grant, Otter Tail, Pope, Stevens, Traverse, Wilkin counties

Aitkin, Beltrami, Cass, Chisago, Crow Wing, Hubbard, Isanti, Kanabec, Mille Lacs, Morrison, Pine, Roseau, Todd, Wadena counties

Anoka, Benton, Carver, Dakota, Hennepin, Ramsey, Scott, Sherburne, Stearns, Washington, Wright counties

Clearwater, Kittson, Mahnomen, Marshall, Norman, Pennington, Polk, Red Lake counties

5

BlueAccess HSA Bronze $4,500 Plan 235 Aware® network

Benefit highlights for individuals and families January 1, 2015 – December 31, 2015

Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible Non-embedded: The plan begins paying benefits that require cost sharing when the entire family deductible is met. The deductible can be met by one or a combination of several family members. The single deductible applies to single coverage only.

$4,500 single $9,000 family


Your coinsurance The percent you pay after your deductible is met.

0% 50%

Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles and coinsurance. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum. Non-embedded: The family plan begins paying benefits when the entire family out-of-pocket is met. The out-of-pocket can be met by one or a combination of several family members. The single out-of-pocket applies to single coverage only.


Unlimited

Visits to: • health care provider’s office • specialist • retail health clinic • urgent care • e-visits (Online Care Anywhere®)

0% after deductible 0% after deductible 0%after deductible 0% after deductible 0% after deductible

50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible

Other professional services in the office • lab and diagnostic imaging/X-ray services 0% after deductible 50% after deductible Prescription drugs GenRx with open formulary

0% after deductible 0% after deductible

Preventive care (including vision exam) 0% (no deductible) 50% after deductible Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) 0% after deductible 50% after deductible Emergency care • physician • facility



Ambulance 0% after deductible 0% after deductible Ambulatory surgical center 0% after deductible 50% after deductible Hospital (outpatient) • physician • facility • lab and diagnostic imaging/X-ray services

0% after deductible 0% after deductible 0% after deductible


Hospital visit (inpatient) • physician • facility



Chiropractic, physical, occupational and speech therapy


Eyewear for children ages 18 and under • lenses and one pair of frames or contact lenses 0% after deductible 50% after deductible

6

Your out-of-pocket costs depend on the network status of your provider. To check status, use the “Find a doctor” web tool on bluecrossmn.com. Lowest out-of-pocket costs: in-network providers Higher out-of-pocket costs: out-of-network participating providers Highest out-of-pocket costs: out-of-network nonparticipating providers If you receive services from a nonparticipating provider, you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills. This difference does not apply to your out-of-pocket maximum. This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross’ allowed amount, which is typically lower than the amount billed by the provider. This is only a summary. Your contract will provide a detailed description of what is and is not covered. Services not covered include custodial care or rest cures, bariatric surgery, infertility, adult eyewear, adult dental services, services that are experimental, not medically necessary or received while on military duty and certain services for the treatment of autism. Online Care Anywhere is not available in every state. Check OnlineCareAnywhereMN.com to ensure you are located in a state that is eligible to participate. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

This information is also available in other ways to people with disabilities. To reach customer service, call (651) 662-5040 (voice) or 1-800-711-9875 (toll-free).For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carryover), or 1-877-627-3848 (speech-to-speech).Hours: 7 a.m. to 8 p.m., Central Time, Monday through Friday.Attention. If you want free help translating this information, call the above number.Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba.Blue Cross may change premium rates: on an annual renewal date, when you add or delete a dependent, or if you move to a different Blue Cross plan. Factors that mayaffect changes in premium rates include the age of covered members, where you reside and whether a member uses tobacco.To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov.

YD501, YDU51

AASX

X20363 (8/14)

7

http://bluecrossmn.com/

http://OnlineCareAnywhereMN.com

http://healthcare.gov

BlueAccess HSA Bronze $5,200 Plan 236 Aware® network






0% 50%



Unlimited


















8



YD001, YDU01

AAT3

F10220R02 (8/14)

9




BlueAccess Silver $1,500 Plan 237 Aware® network

Benefit highlights for individuals and families

January 1, 2015 – December 31, 2015

Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible.

$1,500 per person $3,000 family



40% 50%

Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles, coinsurance and copays. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum


Unlimited


$40 copay $60 copay $40 copay $40 copay First 3 visits free (no deductible), then $40 copay



Preferred generic: $10 copay Preferred brand: $50 copay Non-preferred: $90 copay Specialty: 20% to a maximum of $200 per prescription

Preferred generic: $10 copay Preferred brand: $50 copay Non-preferred: $90 copay Specialty: No coverage













10



YD502, YDU52

AATW

X20364 (8/14)

11




BlueAccess HSA Silver $2,000 Plan 238 Aware® network






20% 50%

Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles and coinsurance. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum. The single out-of pocket-maximum applies to single coverage only. Non-embedded: The family plan begins paying benefits when the entire family out-of-pocket is met. The out-of-pocket can be met by one or a combination of several family members. The single out-of-pocket applies to single coverage only.


Unlimited


















12



YD503, YDU53

AATS

X20365 (8/14)

13




BlueAccess HSA Silver $3,000 Plan 239 Aware® network


Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible Embedded: The plan begins paying benefits that require cost sharing for the first family member who meets the per-person deductible. The family deductible must then be met by one or more of the remaining family members and then the plan pays benefits for all covered family members




0% 50%

Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles and coinsurance. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum


Unlimited


















14



YD504, YDU54

AATP

X20366 (8/14)

15




BlueAccess HSA Gold $1,800 Plan 240 Aware® network






0% 50%



Unlimited


















16



YD003, YDU55

AASN

F10219R02 (8/14)

17




BlueAccess Gold No Deductible Plan 241 Aware® network


Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible

$0 per person $0 family



20% 50%

Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles, coinsurance, and copays. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum


Unlimited


$30 copay $50 copay $30 copay $30 copay First 3 visits free (no copay), then $30 copay


Other professional services in the office • lab and diagnostic imaging/X-ray services 20% (no deductible) 50% after deductible Prescription drugs GenRx with open formulary



Preventive care (including vision exam) 0% (no deductible) 50% after deductible Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) 20% (no deductible) 50% after deductible Emergency care • physician • facility

0% (no deductible) $200 copay


Ambulance 20% (no deductible) 20% (no deductible) Ambulatory surgical center 20% (no deductible) 50% after deductible Hospital (outpatient) • physician • facility • lab and diagnostic imaging/X-ray services

20% (no deductible) 20% (no deductible) 20% (no deductible)



20% (no deductible) 20% (no deductible)



20% (no deductible) 50% after deductible

Eyewear for children ages 18 and under • lenses and one pair of frames or contact lenses 20% (no deductible) 50% after deductible

18



YD002, YDU02

AASQ

F10218R02 (8/14)

19




BlueAccess Platinum No Deductible Plan 242 Aware® network


Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible

$0 per person $0 family



10% 50%

Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles, coinsurance, and copays. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum


Unlimited


$20 copay $40 copay $20 copay $20 copay First 3 visits free (no copay), then $20 copay


Other professional services in the office • lab and diagnostic imaging/X-ray services 10% (no deductible) 50% after deductible Prescription drugs GenRx with open formulary



Preventive care (including vision exam) 0% (no deductible) 50% after deductible Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) $200 copay per admission (facility)

10% (no deductible, professional services)

50% after deductible

Emergency care • physician • facility



Ambulance 10% (no deductible) 10% (no deductible) Ambulatory surgical center 10% (no deductible) 50% after deductible Hospital (outpatient) • physician • facility • lab and diagnostic imaging/X-ray services

10% (no deductible) 10% (no deductible) 10% (no deductible)



10% (no deductible) $200 copay per admission



10% (no deductible) 50% after deductible

Eyewear for children ages 18 and under • lenses and one pair of frames or contact lenses 10% (no deductible) 50% after deductible

20


This information is also available in other ways to people with disabilities. To reach customer service, call (651) 662-5040 (voice) or 1-800-711-9875 (toll-free).For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carryover), or 1-877-627-3848 (speech-to-speech).Hours: 7 a.m. to 8 p.m., Central Time, Monday through Friday.Attention. If you want free help translating this information, call the above number.Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba.Blue Cross may change premium rates: on an annual renewal date, when you add or delete a dependent, or if you move to a different Blue Cross plan. Factors that may affect changes in premium rates include the age of covered members, where you reside and whether a member uses tobacco.To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov.

YD004, YDU56

AASS

F10217R02 (8/14)

21




Blue Cross ® and Blue Shield® of M innesota and Blue Plus® are nonpro f i t independent licensees of t h e Blue Cross and Blue Shield Associat ion.

2015 BlueAccess Plan Rates Area 1

Plan Name 32 33 34 35 36 37 38 39 40 41 42 43

BlueAccess Gold No Deductible Plan 241 (AASQ) 366.42 371.07 376.02 378.50 380.98 383.46 385.93 390.89 395.84 403.28 410.40 420.31

BlueAccess HSA Bronze $4500 Plan 235 (AASX) 248.11 251.25 254.61 256.28 257.96 259.64 261.32 264.67 268.03 273.06 277.89 284.60 BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 233.57 236.54 239.69 241.27 242.85 244.43 246.01 249.17 252.33 257.07 261.61 267.93

BlueAccess HSA Gold $1800 Plan 240 (AASN) 326.56 330.70 335.12 337.33 339.54 341.74 343.95 348.37 352.79 359.41 365.76 374.59 BlueAccess HSA Silver $2000 Plan 238 (AATS) 285.02 288.64 292.49 294.42 296.35 298.27 300.20 304.06 307.91 313.69 319.24 326.95

BlueAccess HSA Silver $3000 Plan 239 (AATP) 305.85 309.73 313.86 315.93 318.00 320.07 322.14 326.27 330.41 336.61 342.56 350.83 BlueAccess Platinum No Deductible Plan 242 (AASS) 411.50 416.72 422.29 425.07 427.85 430.63 433.42 438.98 444.55 452.90 460.90 472.03

BlueAccess Silver $1500 Plan 237 (AATW) 305.84 309.72 313.86 315.93 318.00 320.06 322.13 326.27 330.41 336.61 342.56 350.83

Plan Name 0-20 21 22 23 24 25 26 27 28 29 30 31


BlueAccess HSA Bronze $4500 Plan 235 (AASX) 186.66 209.73 209.73 209.73 209.73 210.56 214.76 219.79 227.97 234.68 238.04 243.07

BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 175.72 197.44 197.44 197.44 197.44 198.23 202.18 206.92 214.62 220.94 224.10 228.84

BlueAccess HSA Gold $1800 Plan 240 (AASN) 245.68 276.05 276.05 276.05 276.05 277.15 282.67 289.30 300.06 308.90 313.31 319.94

BlueAccess HSA Silver $2000 Plan 238 (AATS) 214.43 240.93 240.93 240.93 240.93 241.90 246.72 252.50 261.89 269.60 273.46 279.24

BlueAccess HSA Silver $3000 Plan 239 (AATP) 230.10 258.54 258.54 258.54 258.54 259.57 264.74 270.95 281.03 289.30 293.44 299.64

BlueAccess Platinum No Deductible Plan 242 (AASS) 309.58 347.85 347.85 347.85 347.85 349.24 356.19 364.54 378.11 389.24 394.81 403.15


Age

Age

Rates effective January 1, 2015

Rates are sub jec t to benef i t c h a n g e s manda ted by law and annua l a d j u s t m e n t s Note: Y o u r rate may c h a n g e w h e n y o u m o v e into a d i f ferent rate a rea or c h a n g e plans. Y o u r rate wil l a lso c h a n g e on an annua l renewal date based on y o u r age and benef i t plan se lected.

Age

Plan Name 44 45 46 47 48 49 50 51 52 53 54 55

BlueAccess Gold No Deductible Plan 241 (AASQ) 432.70 447.26 464.61 484.12 506.42 528.41 553.19 577.66 604.61 631.86 661.29 690.71 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 292.99 302.84 314.59 327.80 342.90 357.79 374.57 391.14 409.38 427.84 447.76 467.69

BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 275.83 285.11 296.16 308.60 322.82 336.84 352.63 368.23 385.41 402.78 421.54 440.30 BlueAccess HSA Gold $1800 Plan 240 (AASN) 385.64 398.61 414.07 431.46 451.34 470.93 493.02 514.83 538.84 563.13 589.36 615.58

BlueAccess HSA Silver $2000 Plan 238 (AATS) 336.58 347.91 361.40 376.58 393.93 411.03 430.31 449.34 470.30 491.50 514.39 537.28



Age

Plan Name 56 57 58 59 60 61 62 63 64+

BlueAccess Gold No Deductible Plan 241 (AASQ) 722.62 754.83 789.21 806.25 840.63 870.36 889.88 914.35 929.22 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 489.29 511.10 534.38 545.92 569.19 589.33 602.54 619.11 629.19

BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 460.63 481.17 503.08 513.94 535.86 554.81 567.25 582.85 592.32 BlueAccess HSA Gold $1800 Plan 240 (AASN) 644.02 672.72 703.37 718.55 749.19 775.69 793.08 814.89 828.15

BlueAccess HSA Silver $2000 Plan 238 (AATS) 562.10 587.15 613.90 627.15 653.89 677.02 692.20 711.23 722.79 BlueAccess HSA Silver $3000 Plan 239 (AATP) 603.17 630.05 658.75 672.97 701.67 726.49 742.78 763.20 775.62

BlueAccess Platinum No Deductible Plan 242 (AASS) 811.53 847.70 886.31 905.44 944.06 977.45 999.36 1026.84 1043.55 BlueAccess Silver $1500 Plan 237 (AATW) 603.16 630.04 658.74 672.96 701.66 726.48 742.77 763.19 775.59


Rates are subject to benefit changes mandated by law and annual adjustments Note: Your rate may change when you move into a different rate area or change plans. Your rate will also change on an annual renewal date based on your age and benefit plan selected.


Age

Plan Name 0-20 21 22 23 24 25 26 27 28 29 30 31

BlueAccess Gold No Deductible Plan 241 (AASQ) 226.15 254.10 254.10 254.10 254.10 255.12 260.20 266.30 276.21 284.34 288.40 294.50 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 153.13 172.05 172.05 172.05 172.05 172.74 176.18 180.31 187.02 192.53 195.28 199.41 BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 144.16 161.98 161.98 161.98 161.98 162.62 165.86 169.75 176.07 181.25 183.84 187.73




Age

Plan Name 32 33 34 35 36 37 38 39 40 41 42 43



BlueAccess HSA Silver $2000 Plan 238 (AATS) 233.83 236.79 239.95 241.53 243.12 244.70 246.28 249.44 252.60 257.35 261.89 268.22 BlueAccess HSA Silver $3000 Plan 239 (AATP) 250.91 254.09 257.49 259.18 260.88 262.58 264.27 267.67 271.06 276.15 281.03 287.81

BlueAccess Platinum No Deductible Plan 242 (AASS) 337.59 341.87 346.43 348.71 351.00 353.28 355.56 360.13 364.70 371.54 378.11 387.24 BlueAccess Silver $1500 Plan 237 (AATW) 250.91 254.09 257.48 259.18 260.87 262.57 264.27 267.66 271.06 276.15 281.02 287.81



Age

Plan Name 44 45 46 47 48 49 50 51 52 53 54 55





Age

Plan Name 56 57 58 59 60 61 62 63 64+

BlueAccess Gold No Deductible Plan 241 (AASQ) 592.82 619.24 647.45 661.42 689.63 714.02 730.03 750.10 762.30

BlueAccess HSA Bronze $4500 Plan 235 (AASX) 401.40 419.29 438.39 447.85 466.95 483.47 494.31 507.90 516.15 BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 377.89 394.74 412.72 421.62 439.60 455.15 465.36 478.15 485.94

BlueAccess HSA Gold $1800 Plan 240 (AASN) 528.33 551.88 577.02 589.48 614.61 636.35 650.62 668.51 679.38 BlueAccess HSA Silver $2000 Plan 238 (AATS) 461.13 481.68 503.62 514.50 536.44 555.41 567.86 583.48 592.95 BlueAccess HSA Silver $3000 Plan 239 (AATP) 494.82 516.88 540.42 552.09 575.63 595.99 609.35 626.11 636.30

BlueAccess Platinum No Deductible Plan 242 (AASS) 665.75 695.43 727.11 742.80 774.48 801.87 819.85 842.39 856.08

BlueAccess Silver $1500 Plan 237 (AATW) 494.81 516.87 540.41 552.08 575.62 595.98 609.34 626.10 636.27




Age

Plan Name 0-20 21 22 23 24 25 26 27 28 29 30 31





Age

Plan Name 32 33 34 35 36 37 38 39 40 41 42 43







Age

Plan Name 44 45 46 47 48 49 50 51 52 53 54 55





Age

Plan Name 56 57 58 59 60 61 62 63 64+

BlueAccess Gold No Deductible Plan 241 (AASQ) 591.69 618.07 646.22 660.17 688.32 712.67 728.65 748.68 760.86 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 400.64 418.50 437.56 447.01 466.07 482.55 493.37 506.94 515.19 BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 377.17 393.99 411.93 420.82 438.77 454.29 464.48 477.25 485.01

BlueAccess HSA Gold $1800 Plan 240 (AASN) 527.33 550.84 575.93 588.36 613.45 635.15 649.39 667.24 678.09 BlueAccess HSA Silver $2000 Plan 238 (AATS) 460.25 480.77 502.67 513.52 535.42 554.36 566.79 582.37 591.84

BlueAccess HSA Silver $3000 Plan 239 (AATP) 493.88 515.90 539.40 551.04 574.54 594.86 608.20 624.92 635.07 BlueAccess Platinum No Deductible Plan 242 (AASS) 664.49 694.11 725.73 741.39 773.01 800.35 818.30 840.80 854.46





Age

Age

Plan Name 0-20 21 22 23 24 25 26 27 28 29 30 31





Plan Name 32 33 34 35 36 37 38 39 40 41 42 43







Age

Age

Plan Name 44 45 46 47 48 49 50 51 52 53 54 55





Plan Name 56 57 58 59 60 61 62 63 64+









Age

Age

Plan Name 0-20 21 22 23 24 25 26 27 28 29 30 31





Plan Name 32 33 34 35 36 37 38 39 40 41 42 43







Age

Age

Plan Name 44 45 46 47 48 49 50 51 52 53 54 55





Plan Name 56 57 58 59 60 61 62 63 64+

BlueAccess Gold No Deductible Plan 241 (AASQ) 575.96 601.63 629.04 642.62 670.02 693.72 709.27 728.77 740.61 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 389.99 407.37 425.93 435.12 453.67 469.72 480.25 493.46 501.48 BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 367.14 383.51 400.98 409.63 427.10 442.21 452.12 464.56 472.11 BlueAccess HSA Gold $1800 Plan 240 (AASN) 513.31 536.19 560.61 572.71 597.14 618.26 632.12 649.50 660.06 BlueAccess HSA Silver $2000 Plan 238 (AATS) 448.02 467.99 489.30 499.87 521.18 539.62 551.71 566.89 576.09






Age

Age

Plan Name 0-20 21 22 23 24 25 26 27 28 29 30 31





Plan Name 32 33 34 35 36 37 38 39 40 41 42 43



BlueAccess HSA Gold $1800 Plan 240 (AASN) 237.68 240.70 243.91 245.52 247.13 248.74 250.34 253.56 256.77 261.59 266.21 272.64 BlueAccess HSA Silver $2000 Plan 238 (AATS) 207.45 210.08 212.89 214.29 215.69 217.10 218.50 221.30 224.11 228.32 232.35 237.96 BlueAccess HSA Silver $3000 Plan 239 (AATP) 222.61 225.43 228.44 229.95 231.45 232.96 234.46 237.47 240.48 245.00 249.33 255.35




Age

Age

Plan Name 44 45 46 47 48 49 50 51 52 53 54 55





Plan Name 56 57 58 59 60 61 62 63 64+

BlueAccess Gold No Deductible Plan 241 (AASQ) 525.95 549.39 574.42 586.82 611.84 633.48 647.69 665.50 676.32 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 356.12 372.00 388.94 397.34 414.28 428.94 438.55 450.61 457.95

BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 335.27 350.21 366.16 374.07 390.02 403.81 412.87 424.22 431.13 BlueAccess HSA Gold $1800 Plan 240 (AASN) 468.74 489.63 511.94 522.99 545.29 564.58 577.23 593.11 602.76

BlueAccess HSA Silver $2000 Plan 238 (AATS) 409.12 427.35 446.82 456.46 475.93 492.76 503.81 517.66 526.08 BlueAccess HSA Silver $3000 Plan 239 (AATP) 439.01 458.58 479.46 489.81 510.70 528.77 540.62 555.49 564.51 BlueAccess Platinum No Deductible Plan 242 (AASS) 590.66 616.99 645.09 659.02 687.12 711.42 727.37 747.38 759.54





Age

Age

Plan Name 0-20 21 22 23 24 25 26 27 28 29 30 31





Plan Name 32 33 34 35 36 37 38 39 40 41 42 43



BlueAccess HSA Gold $1800 Plan 240 (AASN) 256.98 260.24 263.72 265.46 267.19 268.93 270.67 274.15 277.62 282.83 287.83 294.78 BlueAccess HSA Silver $2000 Plan 238 (AATS) 224.30 227.14 230.17 231.69 233.21 234.72 236.24 239.27 242.31 246.86 251.22 257.29 BlueAccess HSA Silver $3000 Plan 239 (AATP) 240.68 243.74 246.99 248.62 250.25 251.87 253.50 256.76 260.01 264.89 269.57 276.08




Age

Age

Plan Name 44 45 46 47 48 49 50 51 52 53 54 55





Plan Name 56 57 58 59 60 61 62 63 64+

BlueAccess Gold No Deductible Plan 241 (AASQ) 568.65 594.00 621.06 634.46 661.52 684.92 700.28 719.53 731.22 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 385.04 402.20 420.52 429.60 447.92 463.76 474.16 487.20 495.12 BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 362.49 378.65 395.89 404.44 421.69 436.60 446.39 458.66 466.11







Age

Age

Plan Name 0-20 21 22 23 24 25 26 27 28 29 30 31





Plan Name 32 33 34 35 36 37 38 39 40 41 42 43







Age

Age

Plan Name 44 45 46 47 48 49 50 51 52 53 54 55





Plan Name 56 57 58 59 60 61 62 63 64+









Age

Age

Plan Name 0-20 21 22 23 24 25 26 27 28 29 30 31





Plan Name 32 33 34 35 36 37 38 39 40 41 42 43







Age

Age

Plan Name 44 45 46 47 48 49 50 51 52 53 54 55





Plan Name 56 57 58 59 60 61 62 63 64+








WHAT'S NEXT? READY TO APPLY? * Visit the Student Health Benefits Office

* Call (612) 624-0627 (toll free: 1-800-232-9017)

* Online: shb.umn.edu

* Contact Tom Seifert at (612) 373-9878 or [email protected]

Save time, skip the hassle

Automatic payment saves time, stamps and checks. It's a convenient, worry-free way to pay. Blue Cross can deduct your monthly payment from your bank account automatically. That means no checks to write or bills to mail.

http://shb.umn.edu

mailto:[email protected]

NOTES:

This notice required by law

Not ice concerning pol icyholder r ights in an insolvency under the Minnesota Life and Heal th Insurance Guaranty Associat ion Law

If the insurer that issued your life, annuity, or health insurance policy becomes impaired or insolvent, you are enti t led to compensat ion for your policy f rom the assets of that insurer. The amount you recover wi l l depend on the financial condit ion of the insurer.

In addit ion, residents of Minnesota w h o purchase life insurance, annuities, or health insurance f rom insurance companies authorized to do business in Minnesota are protected, subject to l imits and exclusions, in the event the insurer becomes financially impaired or insolvent. This protect ion is provided by the Minnesota Life and Health Insurance Guaranty Associat ion.

Minnesota Life and Heal th Insurance Guaranty Associat ion 4760 W h i t e Bear Parkway Suite 101 W h i t e Bear Lake, M N 55110 Telephone: (651) 407-3149 Fax: (651) 407-3150 Execut ive Director: Gerald C. Backhaus

The m a x i m u m a m o u n t the Guaranty Associat ion wi l l pay for all policies on one life by the same insurer is l imi ted to $500,000. Subject to this $500 ,000 l imit, the Guaranty Associat ion wi l l pay up to $500 ,000 in life insurance death benef i ts, $130,000 in net cash surrender and net cash w i thdrawal values for life insurance, $500 ,000 in health insurance benef i ts, including any net cash surrender and net cash w i thdrawal values, $250 ,000 in annuity net cash surrender and net cash w i thdrawal values, $410,000 in present value of annuity benef i ts for annuit ies wh i ch are part of a st ructured set t lement or for annuit ies in regard to wh i ch periodic annuity benef i ts, for a period of not less than the annuitant 's l i fet ime or for a period certain of not less than ten years, have begun to be paid on or before the date of impairment or insolvency, or if no coverage limit has been speci f ied for a covered policy or benefi t , the coverage limit shall be $500 ,000 in present value. Unallocated annuity contracts issued to ret i rement plans, other than def ined benef i t plans, establ ished under sect ion 401, 403(b) , or 457 of the Internal Revenue Code of 1986, as amended through December 31, 1992, are covered up to $250 ,000 in net cash surrender and net cash w i thdrawal values, for Minnesota residents covered by the plan provided, however, that the Associat ion shall not be responsible for more than $10,000,000 in claims f rom all Minnesota residents covered

For policy years beginning on and after January 1, 2014, monthly rates, or premiums, may vary based upon the plan you select, the ages of covered persons, geographic rating area and tobacco use.

The monthly rate charged may be changed to reflect:

1. Adding or deleting a dependent ;

2. Your move to a di f ferent geographic rating area;

3. Changes in age (on a renewal date);

4. Changes in tobacco use;

5. Your request to transfer to a new health plan; or

6. Other changes required by or o therwise expressly permi t ted by state or federal law or regulations.

To v i ew a listing of all individual health plans actively marketed by Blue Cross and a descript ion of benef i ts and premiums, please go to healthcare.gov.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

X16695R13 (10/14)

by the plan. If total claims exceed $10,000,000, the $10,000,000 shall be prorated among all claimants. These are the max imum claim amounts. Coverage by the Guaranty Associat ion is also subject to other substantial l imitat ions and exclusions and requires cont inued residency in Minnesota. If your claim exceeds the Guaranty Associat ion's l imits, you may still recover a part or all of that amount f rom the proceeds of the l iquidation of the insolvent insurer, if any exist. Funds to pay claims may not be immediately available. The Guaranty Associat ion assesses insurers l icensed to sell life and health insurance in Minnesota after the insolvency occurs. Claims are paid f rom this assessment .

The coverage provided by the Guaranty Association is not a substitute for using care in selecting insurance companies that are well managed and financially stable. In selecting an insurance company or policy you are advised not to rely on coverage by the Guaranty Association.

This notice is required by Minnesota state law to advise policyholders of life, annuity or health insurance policies of their rights in the event their insurance carrier becomes financially impaired or insolvent. This notice in no way implies that the company currently has any type of financial problems. All life, annuity and health insurance policies are required to provide this notice.

To see benef i t and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov.

This information is also available in other ways to people w i t h disabilit ies by calling customer service at (651) 662-5040 (voice), or 1-800-711-9875 (toll free).

For (TTY) call (651) 662-8700, or 1 -888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, Voice, ASCII, Hearing Carry Over), or 1-877-627-3848 (Speech-to-Speech)

Hours: 8 a.m. to 5 p.m., Central Time, Monday through Thursday; 9 a.m. to 5 p.m. Central Time, Friday.

At tent ion. If you wan t free help translating this information, call the above number.

Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba.

This notice required by law

Notice concerning policyholder rights in an insolvency under the Minnesota Life and Health Insurance Guaranty Association Law

If the insurer that issued your life, annuity, or health insurance policy becomes impaired or insolvent, you are entitled to compensation for your policy from the assets of that insurer. The amount you recover will depend on the financial condition of the insurer.

In addition, residents of Minnesota who purchase life insurance, annuities, or health insurance from insurance companies authorized to do business in Minnesota are protected, subject to limits and exclusions, in the event the insurer becomes financially impaired or insolvent. This protection is provided by the Minnesota Life and Health Insurance Guaranty Association.

Minnesota Life and Health Insurance Guaranty Association 4760 White Bear Parkway Suite 101 White Bear Lake, MN 55110 Telephone: (651) 407-3149 Fax: (651) 407-3150 Executive Director: Gerald C. Backhaus

The maximum amount the Guaranty Association will pay for all policies on one life by the same insurer is limited to $500,000. Subject to this $500,000 limit, the Guaranty Association will pay up to $500,000 in life insurance death benefits, $130,000 in net cash surrender and net cash withdrawal values for life insurance, $500,000 in health insurance benefits, including any net cash surrender and net cash withdrawal values, $250,000 in annuity net cash surrender and net cash withdrawal values, $410,000 in present value of annuity benefits for annuities which are part of a structured settlement or for annuities in regard to which periodic annuity benefits, for a period of not less than the annuitant’s lifetime or for a period certain of not less than ten years, have begun to be paid on or before the date of impairment or insolvency, or if no coverage limit has been specified for a covered policy or benefit, the coverage limit shall be $500,000 in present value. Unallocated annuity contracts issued to retirement plans, other than defined benefit plans, established under section 401, 403(b), or 457 of the Internal Revenue Code of 1986, as amended through December 31, 1992, are covered up to $250,000 in net cash surrender and net cash withdrawal values, for Minnesota residents covered by the plan provided, however, that the Association shall not be responsible for more than $10,000,000 in claims from all Minnesota residents covered

by the plan. If total claims exceed $10,000,000, the $10,000,000 shall be prorated among all claimants. These are the maximum claim amounts. Coverage by the Guaranty Association is also subject to other substantial limitations and exclusions and requires continued residency in Minnesota. If your claim exceeds the Guaranty Association’s limits, you may still recover a part or all of that amount from the proceeds of the liquidation of the insolvent insurer, if any exist. Funds to pay claims may not be immediately available. The Guaranty Association assesses insurers licensed to sell life and health insurance in Minnesota after the insolvency occurs. Claims are paid from this assessment.

The coverage provided by the Guaranty Association is not a substitute for using care in selecting insurance companies that are well managed and financially stable. In selecting an insurance company or policy you are advised not to rely on coverage by the Guaranty Association.

This notice is required by Minnesota state law to advise policyholders of life, annuity or health insurance policies of their rights in the event their insurance carrier becomes financially impaired or insolvent. This notice in no way implies that the company currently has any type of financial problems. All life, annuity and health insurance policies are required to provide this notice.

To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov.

This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice), or 1-800-711-9875 (toll free).

For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, Voice, ASCII, Hearing Carry Over), or 1-877-627-3848 (Speech-to-Speech)

Hours: 8 a.m. to 5 p.m., Central Time, Monday through Thursday; 9 a.m. to 5 p.m. Central Time, Friday.

Attention. If you want free help translating this information, call the above number.

Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba.

For policy years beginning on and after January 1, 2014, monthly rates, or premiums, may vary based upon the plan you select, the ages of covered persons, geographic rating area and tobacco use.

The monthly rate charged may be changed to reflect:

1. Adding or deleting a dependent;

2. Your move to a different geographic rating area;

3. Changes in age (on a renewal date);

4. Changes in tobacco use;

5. Your request to transfer to a new health plan; or

6. Other changes required by or otherwise expressly permitted by state or federal law or regulations.

To view a listing of all individual health plans actively marketed by Blue Cross and a description of benefits and premiums, please go to healthcare.gov.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

X16695R13 (10/14)



YOUR LIFE. YOUR CHOICE. YOUR HEALTH PLAN · YOUR LIFE. YOUR CHOICE. YOUR HEALTH PLAN. Leave school...

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