Kentucky Health Cooperative Inc.: KY Health Cooperative Silver
Coverage Period: Beginning on January 1, 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual | Plan Type: PPO
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
document at: www.mykyhc.org or by calling: 1-855-OUR-KYHC (687-5942).
Important Questions Answers
Why this Matters:
What is the overall
deductible? Network
$2,500 per person/$7,500
per family
Non-Network
$4,500 per
person/$13,200 per family
You must pay all the costs up to the Deductible amount before this plan begins to pay
for covered services you use. See the chart starting on page 2 to find out how much
you pay for covered services after you have met the Deductible.
Are there other
deductibles for specific
services? YES
$500 Pharmacy
Is there an out–of–pocket
limit on my expenses? YES
Network providers
$6,600 per person/
$13,200 per family
Non-Network providers
$10,000 per person/
$30,000 per family
What is not included in
the out–of–pocket limit? Premiums, Balance-billed Though you may have paid expenses in these areas, they do not count toward the Out-
of-Pocket Limit
charges, Health care
received but not covered
by this plan and Penalties.
*Copayments, other than prescription drug, DO NOT Apply toward the Deductible
You do have to meet a Deductible for Prescription Drug Benefits
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 can help you plan
for health care expenses.
*Copayments, other than prescription drug, DO Apply toward the Out-of-Pocket Limit
Is there an overall annual
NO
limit on what the plan pays? 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 If you use our Network provider, this plan will pay some or all of the costs of covered
services. Any non-Network provider charges, even if used by one of your Network
providers, may not be paid by this plan
Do I need a referral to see a
specialist? NO You can see the Specialist you choose without permission from this plan, though
possible non-payment, by this plan, for services from a Non-Network provider applies.
Form# KYHCSBCIND
Questions: Call 1-855-OUR KYHC (687-5942) or visit us at: www.mykyhc.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at:
www.dol.gov/ebsa/healthreform or call 1-855-OUR KYHC (687-5942) to request a copy.
1 of 8Kentucky Health Cooperative Inc.: KY Health Cooperative Silver
Coverage Period: Beginning on January 1, 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Are there services this plan
doesn’t cover?
YES
Coverage for: Individual | Plan Type: PPO
There are services not covered by this plan. Please consult your policy or plan
documents for the list of Excluded Services.

Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
 Co-insurance 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 co-insurance 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 Network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Your cost if you use an
Common
Medical Event
Services You May Need
Primary care visit to treat an injury or illness
If you visit a health
care provider’s office
or clinic
Specialist visit
In-network
Provider
$35 copay/visit
$50 copay/visit
Diagnostic test (x-ray, blood work)
If you have a test
Imaging (CT/PET scans, MRIs)
Limitations & Exceptions
$35 copay/visit 60% Coinsurance
after deductible Chiropractor: 12 manipulation visits
per benefit period.
$0
35% Coinsurance
after deductible
35% Coinsurance
after deductible 60% Coinsurance
60% Coinsurance
after deductible
60% Coinsurance
after deductible In-Network coinsurance varies based
upon setting where test received.
In-Network coinsurance varies based
upon setting where test received.
Other practitioner office visit-chiropractor
Preventive care/screening/immunization
Out-of-
network
Provider
60% Coinsurance
60% Coinsurance
Form# KYHCSBCIND
Questions: Call 1-855-OUR KYHC (687-5942) or visit us at: www.mykyhc.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at:
www.dol.gov/ebsa/healthreform or call 1-855-OUR KYHC (687-5942) to request a copy.
2 of 8Kentucky Health Cooperative Inc.: KY Health Cooperative Silver
Coverage Period: Beginning on January 1, 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual | Plan Type: PPO
Your cost if you use an
Common
Medical Event
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.mykyhc.org
If you have
outpatient surgery
If you need
immediate medical
attention
Services You May Need
In-network
Provider
Generic drugs $20 after deductible
Preferred brand drugs $40 after deductible
Non-preferred brand drugs $75 after deductible
Specialty drugs
Facility fee (e.g., ambulatory surgery center)
Physician/surgeon fees
35% Coinsurance
after deductible
35% Coinsurance
after deductible
35% Coinsurance
after deductible
Emergency room services $225
Copayment/visit
before deductible +
35% Coinsurance
Emergency medical transportation 35% Coinsurance
after deductible
Urgent care $75 Copay/visit
Facility fee (e.g., hospital room) Physician/surgeon fee
If you have a
hospital stay
Out-of-
network
Provider
$20 after
deductible
$40 after
deductible
$75 after
deductible
35% Coinsurance
after deductible
60% Coinsurance
after deductible
60% Coinsurance
after deductible
$225
Copayment/visit
+ 35%
Coinsurance
before deductible
60% Coinsurance
after deductible
Limitations & Exceptions
No out-of-network mail order
No out-of-network mail order
No out-of-network mail order
No out-of-network mail order
Pre-authorization/Pre-certification
may be required
Pre-authorization/Pre-certification
may be required
May be waived if admitted. Maximum
Allowable Amount applies to Out-of-
Network services.
Waived if admitted and related to
accident/injury
35% Coinsurance
after deductible 60% Coinsurance
after deductible
60% Coinsurance
after deductible Pre-authorization/Pre-certification
may be required
35% Coinsurance
after deductible 60% Coinsurance
after deductible In-Network coinsurance varies based
upon setting where service received.
Form# KYHCSBCIND
Questions: Call 1-855-OUR KYHC (687-5942) or visit us at: www.mykyhc.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at:
www.dol.gov/ebsa/healthreform or call 1-855-OUR KYHC (687-5942) to request a copy.
3 of 8Kentucky Health Cooperative Inc.: KY Health Cooperative Silver
Coverage Period: Beginning on January 1, 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual | Plan Type: PPO
Your cost if you use an
Common
Medical Event
Services You May Need
In-network
Provider
Limitations & Exceptions
$30 copay/visit 60% Coinsurance
after deductible 35% Coinsurance
after deductible 60% Coinsurance
after deductible $30 copay/visit 60% Coinsurance
after deductible Substance use disorder inpatient services 35% Coinsurance
after deductible 60% Coinsurance
after deductible Pre-authorization/Pre-certification
may be required
Prenatal and postnatal care 35% Coinsurance
after deductible 60% Coinsurance
after deductible In-Network coinsurance varies based
upon setting where service received.
Delivery and all inpatient services 35% Coinsurance
after deductible 60% Coinsurance
after deductible In-Network coinsurance varies based
upon setting where service received.
Mental/Behavioral health outpatient services
If you have mental
health, behavioral
health, or substance
abuse needs
Out-of-
network
Provider
Mental/Behavioral health inpatient services
Substance use disorder outpatient services
If you are pregnant
Pre-authorization/Pre-certification
may be required
Form# KYHCSBCIND
Questions: Call 1-855-OUR KYHC (687-5942) or visit us at: www.mykyhc.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at:
www.dol.gov/ebsa/healthreform or call 1-855-OUR KYHC (687-5942) to request a copy.
4 of 8Kentucky Health Cooperative Inc.: KY Health Cooperative Silver
Coverage Period: Beginning on January 1, 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual | Plan Type: PPO
Your cost if you use an
Common
Medical Event
Services You May Need
In-network
Provider
35% Coinsurance
after deductible 60% Coinsurance
after deductible
$35 copay/visit 60% Coinsurance
after deductible
35% Coinsurance
after deductible 60% Coinsurance
after deductible
35% Coinsurance
after deductible 60% Coinsurance
after deductible
35% Coinsurance
after deductible 60% Coinsurance
after deductible
Hospice service Consistent with
Medicare rate Eye exam $50 copay Consistent with
Medicare rate
60% Coinsurance
after deductible
60% Coinsurance
after deductible
Not Covered
Home health care
Rehabilitation services
If you need help
recovering or have
other special health
needs
Habilitation services
Skilled nursing care
Durable medical equipment
If your child needs
dental or eye care
Out-of-
network
Provider
Glasses
Dental check-up
35% Coinsurance
after deductible
Not Covered
Limitations & Exceptions
Pre-authorization/Pre-certification
may be required/100 visits per
calendar year
Pre-authorization/Pre-certification
may be required/ Limit of 20 visits on
certain services (speech therapy,
physical therapy etc.)
Pre-authorization/Pre-certification
may be required/ Limit of 20 visits on
certain services (speech therapy,
physical therapy etc.)
Pre-authorization/Pre-certification
may be required/90 days maximum
combined in and out of network
Pre-authorization/Pre-certification
may be required/Hearing Aid for
those <18 is 1 per 36 month period
Pre-authorization/Pre-certification
may be required
1 per calendar year
1 pair per calendar year + 1
replacement pair if medically necessary
Form# KYHCSBCIND
Questions: Call 1-855-OUR KYHC (687-5942) or visit us at: www.mykyhc.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at:
www.dol.gov/ebsa/healthreform or call 1-855-OUR KYHC (687-5942) to request a copy.
5 of 8Kentucky Health Cooperative Inc.: KY Health Cooperative Silver
Coverage Period: Beginning on January 1, 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual | Plan Type: PPO
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 for Morbid Obesity

Cosmetic Surgery, unless to correct a
functional impairment

Long-Term Care
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.)

Private Duty Nursing
Your Rights to Continue Coverage: If you lose coverage under this plan, then, depending upon the circumstances, Federal and State of KY
laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium,
which may be significantly higher than the premium you pay while covered under this plan. Other limitations on your rights to continue coverage may
also apply. For more information on your rights to continue coverage, please contact the plan at: 1-855-OUR-KYHC or your state department of
insurance, Department of Labor Employee Benefits Security Administration at: 1-866-444-EBSA (3272) or the U.S. Department of Health and Human
Services at 1-877-267-2323 ext. 61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you
may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact:
Kentucky Health Cooperative at www.mykyhc.org or 1-855-OUR-KYHC or your state insurance department, or;
Department of Labor Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
Department of Insurance, P.O. Box 517, Frankfort, KY 40602-0517 PH: 502-564-3630 or 800-595-6053 or TTY: 800-648-6056
Department of Insurance, Consumer Protection Division, P.O. Box 517, Frankfort, KY 40602-0517, website: http://insurance.ky.gov,
Email: DOI.Ombudsman@ky.gov, PH: 877-587-7222
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Form# KYHCSBCIND
Questions: Call 1-855-OUR KYHC (687-5942) or visit us at: www.mykyhc.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at:
www.dol.gov/ebsa/healthreform or call 1-855-OUR KYHC (687-5942) to request a copy.
6 of 8About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Having a baby Managing type 2 diabetes
(normal delivery) (routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $3,590
 Patient pays $3,950  Amount owed to providers: $5,400
 Plan pays $2,660
 Patient pays $2,740
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
Patient pays:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total
**
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$2,700
$30
$1,720
$0
$4,450
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
$3,000
Co-pays
$100
Co-insurance
$140
Limits or exclusions
$0
Total
$3,240
** ASSUMING START OF PLAN YEAR
SO DEDUCTIBLES APPLIED IN FULL
------------------------------------------------------------
** The information for these examples is
incomplete since time and place of service are
key to deductible application.
Form# KYHCSBCIND
Questions: Call 1-855-OUR KYHC (687-5942) or visit us at: www.mykyhc.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at:
www.dol.gov/ebsa/healthreform or call 1-855-OUR KYHC (687-5942) to request a copy.
7 of 8Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?







Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
The patient’s condition was not an
excluded condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from in-
network providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show? Can I use Coverage Examples
to compare plans?
For each treatment situation, the Coverage
Example helps you see how deductibles, co-
payments, and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.  Yes. When you look at the Summary of
Does the Coverage Example
predict my own care needs?
 No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
 No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition.
They are for comparative purposes only.
Your own costs will be different depending
on the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
 Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-of-
pocket costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Form# KYHCSBCIND
Questions: Call 1-855-OUR KYHC (687-5942) or visit us at: www.mykyhc.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at: