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Medical Mutual of Ohio (MMO) – Group #595996

Our Medical Plans

Provide a wide range of health care services.
Provide benefits for covered expenses after you pay a copayment or meet the applicable annual deductible.
Offer network providers whose pre-negotiated rates will save you money.
Allow you to use out-of-network providers, if you wish.

Learning as much as possible about the medical plans can help you make more informed choices regarding you and your covered dependents’ needs. Review the benefits-at-a-glance chart below.

Summary of Benefits & Coverage

The Affordable Care Act (ACA) requires health plans and health insurance issuers to provide a summary of benefits and coverage (SBC) to applicants and enrollees. The SBC requirement applies to both grandfathered and non-grandfathered plans. The SBC is a concise document providing simple and consistent information about health plan benefits and coverage. It must be provided free of charge. Its purpose is to help health plan consumers better understand the coverage they have and to help them make easy comparisons of different options when shopping for new coverage.

IMPORTANT! – You have 30 days from any qualifying event such as marriage, the birth of a child or change in dependent status to make changes to your plan and notify administration. Failure to do so could result in a loss of coverage and having to wait until the annual open enrollment period!

MMO SBC Plan 1Certified

Common Medical Event	Services You May Need	Network Provider	Non-Network Provider	Limitations, Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness Specialist visit Preventive care/ screening/ immunization	20% coinsurance 20% coinsurance No Charge	30% coinsurance 30% coinsurance 30% coinsurance	None None You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.
If you have a test	Diagnostic test (x-ray) Diagnostic test (blood work) Imaging (CT/PET scans, MRls)	20% coinsurance 20% coinsurance 20% coinsurance	30% coinsurance 30% coinsurance 30% coinsurance	None None None
If you need drugs to treat your illness or condition	Prescription Drug Coverage	Not Covered by Medical Carrier	Not Covered	Excluded Service
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center	No charge	No charge	None
If you need immediate medical attention	Emergency room care Emergency medical transportation Urgent care	20% coinsurance 20% coinsurance 20% coinsurance	20% coinsurance 30% coinsurance 30% coinsurance	None None None
If you have a hospital stay	Facility fee (e.g., hospital room) Physician/ surgeon fee (inpatient)	20% coinsurance 20% coinsurance	30% coinsurance 30% coinsurance	None None
If you need mental health, behavioral health, or substance abuse services	Outpatient services Inpatient services	Benefits paid based on corresponding medical benefits		None None
If you are pregnant	Office visits Childbirth/delivery professional services Childbirth/delivery facility services	No charge 20% coinsurance 20% coinsurance	30% coinsurance 30% coinsurance 30% coinsurance	Cost sharing does not apply to certain preventive services. Depending on the type of services, copay, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help recovering or have other special health needs	Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services	20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance	30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance	None 80 visits per benefit period None None None None
If your child needs dental or eye care	Children’s eye exam Children’s glasses Children’s dental check-up	No charge Not covered Not covered	30% coinsurance Not covered Not covered	Inclusive with a preventive child visit Excluded service Excluded service

MMO SBC Plan 2 Support

Common Medical Event	Services You May Need	Network Provider	Non-Network Provider	Limitations, Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness Specialist visit Preventive care/ screening/ immunization	20% coinsurance 20% coinsurance No Charge	30% coinsurance 30% coinsurance 30% coinsurance	None None You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.
If you have a test	Diagnostic test (x-ray) Diagnostic test (blood work) Imaging (CT/PET scans, MRls)	20% coinsurance 20% coinsurance 20% coinsurance	30% coinsurance 30% coinsurance 30% coinsurance	None None None
If you need drugs to treat your illness or condition	Prescription Drug Coverage	Not Covered by Medical Carrier	Not Covered	Excluded Service
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center	No charge	No charge	None
If you need immediate medical attention	Emergency room care Emergency medical transportation Urgent care	20% coinsurance 20% coinsurance 20% coinsurance	30% coinsurance 30% coinsurance 30% coinsurance	None None None
If you have a hospital stay	Facility fee (e.g., hospital room) Physician/ surgeon fee (inpatient)	20% coinsurance 20% coinsurance	30% coinsurance 30% coinsurance	None None
If you need mental health, behavioral health, or substance abuse services	Outpatient services Inpatient services	Benefits paid based on corresponding medical benefits		None None
If you are pregnant	Office visits Childbirth/delivery professional services Childbirth/delivery facility services	No charge 20% coinsurance 20% coinsurance	30% coinsurance 30% coinsurance 30% coinsurance	Cost sharing does not apply to certain preventive services. Depending on the type of services, copay, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help recovering or have other special health needs	Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services	20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance	30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance	None 80 visits per benefit period None None None None
If your child needs dental or eye care	Children’s eye exam Children’s glasses Children’s dental check-up	No charge Not covered Not covered	30% coinsurance Not covered Not covered	Inclusive with a preventive child visit Excluded service Excluded service