PacifiCare SignatureFreedomSM

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PacifiCare SignatureFreedomSM
The Self Directed Health Plan
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What is a Self Directed Health Plan?

• Traditional High Deductible PPO Plan

PLUS

• Self Directed AccountEmployee controlled
  account that is used to pay for a select set of
  health care expenses

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SDHP Plan Design
FULLY INSURED
Example of employee only coverage
Rx 10 g 30 b 50NF
100 After Coinsurance Maximum
PPO Benefit Plan
Out-of-Network 60
In-Network 80
AnnualDeductible2,500

• Covered Services (apply to deductible)
• Physician Office Visits
• Wellness Preventive Care
• Office-based Diagnostic Tests

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Self Directed Account

• Limited set of covered services under fully
  insured design
• SDA balance rolls over year to year
• Expenses paid from the SDA count toward
  satisfying the PPO deductible
• Physician Office Home Visits
• Diagnostic Testing (office based)
• Consultations
• Office Radiology / Pathology / Lab
• Preventive Care
• Physical Exams
• Well Baby
• Well Woman
• Immunizations

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Self Directed Account

• What is not covered?
• Some Examples
• Chiro
• Colonoscopy (unless preventative)
• Hospital
• Therapies
• Mental Health
• Rehabilitative Services
• Allergy Testing
• Physician Services (other than physician office
  visits)
• Emergency room
• Urgent care
• Ambulance

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• Maria Smith - Employee Only coverage
• Self Directed Account 1,000
• PPO Deductible 2,500

Fully Insured
On September 01, 2003, Maria enrolls in
PacifiCares SignatureFreedom Plan (SDHP). On
September 15, Maria visits her doctor for her
annual physical exam. Total Cost of this visit
is 275.00. On February 22, 2004, Maria visits
the doctor for a rash. The Doctor prescribes
medication. Total cost of office visit 100.00.
Prescription cost 18.50. What is Marias
total out-of-pocket expense? How much money is
left in her SDA account to roll over?
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• Maria Smith - Employee Only coverage
• Self Directed Account 1,000
• PPO Deductible 2,500

Fully Insured
SDA Balance 1,000 Annual Exam (
275.00) SDA Balance 725.00 Office Visit
( 100.00) SDA Account rollover (as of Sept.
1, 2004) 625.00
Prescription 18.50 Less co-pay 10.00
Total out-of-pocket for Maria 10.00
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• Cindy Jones - Family Coverage
• Self Directed Account 1,833.32
• PPO Deductible 5,000.00

Fully Insured
On September 01, 2003, Plan renews. On October
01, Cindy Jones and family (sons Jake and Luke)
enroll in PacifiCares SignatureFreedom Plan
(SDHP). SDA account is prorated for 11 mos. due
to off anniversary enrollment. On October 31,
2003 , Jake visits doctor for strep throat
symptoms. Total cost of visit 185.00. On
November 15, Cindy visits for annual physical.
Total cost of visit 300.00. On March 18, both
Cindy and Jake visit the doctor for ear
infections. Cost for visit 370.000 (185 x 2).
What is the Sept. 01, 2004 SDA Balance? What is
the total out of pocket expense for Cindy?
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• Cindy Jones - Family Coverage
• Self Directed Account 1,833.32
• PPO Deductible 5,000.00

Fully Insured
SDA Balance 1,833.32 Jakes Strep Throat
Visit 185.00 SDA Balance 1,648.32 Cindy
s Annual Physical 300.00 SDA Balance
1,348.32 Jake Cindy Office Visit
370.00 SDA Balance 978.32 September 01,
2004 SDA Balance 2,978.32 Total Out of Pocket
for Cindy 0.00
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• Jack Smith - Employee Only coverage
• Self Directed Account 1,000
• PPO Deductible 2,500

Fully Insured
On September 01, 2003, Jack enrolls in
PacifiCares SignatureFreedom Plan (SDHP). On
December 13, 2003, Jack breaks his leg and wrist
skiing. He has not used any of his SDA account
to date. The In-Network Hospital bill for
breaking his leg totals 15,000. On February
20, 2004, Jack visits the a contracted provider
for an ear infection. The cost of the visit
140. What is Jacks total out of pocket expense?
How much money is left in his SDA account?
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• Jack Smith - Employee Only coverage
• Self Directed Account 1,000
• PPO Deductible 2,500

Fully Insured
Total Amount due for Hospital
15,000.00 Amount covered in Self Directed
Account 00.00 Amount of out-of-pocket
for Jack (deductible) 2,500.00 PPO Coverage at
80 (12,500 x .80 10,000) 2,500.00 SDA
Balance 1,000.00 Office visit- PPO Coverage
at 80 (140 x .80112) 28.00 Since Jack
met his deductible, his 20 responsibility for
the flu visit will be deducted from the SDA
funds. This is only done for eligible expenses
and if funds are available. Out of Pocket for
Jack 5,000.00 SDA Balance
972.00
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• Steve Wilson - Employee Only coverage
• Self Directed Account 1,000
• PPO Deductible 2,500

Fully Insured
On September 01, 2003, Steve enrolls in
PacifiCares SignatureFreedom Plan (SDHP). On
December 01, 2003, Steve visits for annual
physical. Total cost of visit 300.00. On
December 13, 2003, Steve breaks his leg and wrist
while skiing with Jack. The In-Network
Hospital bill for breaking his leg totals
15,000. What is Steves total out of pocket
expense? How much money is left in his SDA
account?
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• Steve Wilson - Employee Only coverage
• Self Directed Account 1,000
• PPO Deductible 2,500

Fully Insured
SDA Balance 1,000.00 Annual
Physical 300.00 SDA Balance
700.00 Total Amount due for Hospital
15,000.00 Amount covered by Self Directed
Account 00.00 Amount of
out-of-pocket for Steve (remaining deductible
2,500 - 300) 2,200.00 PPO Coverage at 80
(12,800 x .80 10,240) 2,560.00 Out of
Pocket for Steve 4,760.00 SDA Balance
700.00