Summary of Benefits and Coverage

What Your Plan Covers and What it Costs
Draft Instruction Guide for Group Policies
Edition Date: July 2011
Purpose of the form: Beginning in March 2012, the Patient Protection and Affordable Care Act
(PPACA) requires all health insurance issuers offering group health insurance coverage to
provide enrollees and potential enrollees an accurate summary of benefits and coverage
explanation. This form does not apply to excepted benefits as defined by the Public Health
Services Act (PHSA). Federal law requires this document so eligible employees will find it
easier to compare policies and understand their coverage.
Requirements to provide/deliver the form: As set forth below, this form must be provided to
the employer or eligible employees at the time of issuance of the policy or at renewal, as
applicable.
While it is the insurer’s, or a representative of the insurer’s, responsibility to accurately fill out
and deliver the form, these instructions acknowledge that eligible employees receive information
about their health insurance primarily through their employer. The following are the permitted
methods of delivery:
a.

When an insurer, or a representative of an insurer, meets in person with the eligible
employee, the insurer or a representative of the insurer may hand-deliver the completed
form to the eligible employee. Alternatively, the insurer, or representative of the insurer,
may offer the eligible employee the following options, and shall provide the form to be
delivered in the manner selected by the eligible employee:
1)
A printed copy deposited in the United States mail, postage pre-paid, within seven
(7) days of the request;
2)
An electronic copy delivered to an e-mail address provided by the eligible
employee;
3)
An electronic copy delivered via a link on the Internet;
4)
A copy delivered by any other means acceptable to both the insurer and the
eligible employee.

b.

For an eligible employee who conducts their enrollment electronically, the insurer, or a
representative of the insurer, must make the form available on the electronic site and the
insurer must require the eligible employee to acknowledge receipt of the form as a
necessary step to completing the enrollment application.

c.

For an enrollment application that is completed over the phone or through the mail, the
insurer, or a representative of the insurer, shall offer a printed copy of the completed form
within seven (7) days to the address provided by the eligible employee. Alternatively, the
insurer, or representative of the insurer, may offer the eligible employee the following

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options, and shall provide the form to be delivered in the manner selected by the eligible
employee:
1)
An electronic copy delivered to an e-mail address provided by the eligible
employee;
2)
An electronic copy delivered via a link on the Internet;
3)
A copy delivered by any other means acceptable to both the insurer and the
eligible employee.
d.

When an insurer issues a policy or delivers a certificate the form shall be included with
the policy or certificate and provided in the manner selected by the policy holder or
certificate holder.

e.

When the policy or certificate is renewed, the insurer shall provide the form in the same
manner in which the policy or certificate were provided along with the renewal
documents.

An oral description of the form is not sufficient. An insurer, or a representative of the insurer,
may not provide the form solely by orally explaining the form and its contents either in person or
over the telephone.
Unless otherwise required by law, this form is a freestanding document and may not be
incorporated into any other document that an insurer, or an insurer’s representative, provides to
an applicant, policy holder or certificate holder.
General Instructions: Read all instructions carefully before completing the form.
 This form must be filled out accurately and by the insurer in good faith.
 Form language and formatting must be precisely reproduced, unless instructions allow or
instruct otherwise. Unless otherwise instructed, the insurer must use 12-point (as
required by federal law) Times New Roman font, and replicate all symbols, formatting,
bolding, colors, and shading exactly. Attached is an example of a blank form.
 Insurers must customize all identifiable company information throughout the document,
including websites and telephone numbers.
 If there is a different amount for in-network and out-of-network expenses (such as annual
deductible, additional deductibles, or out-of-pocket limits), list both amounts and indicate
as such, using the terms to describe provider networks used by the insurer. For example,
if the policy uses the terms “preferred provider” and “non-preferred provider” and the
annual deductible is $2,000 for a preferred provider and $5,000 for a non-preferred
provider, then the Answer column should show “$2000 preferred provider, $5,000 nonpreferred provider”.
 The items shown on Page 1 must always appear on Page 1, and the rows of the chart must
always appear in the same order. The chart starting on page 2 shown in the example must
always begin on Page 2, and the rows shown on this chart must always appear in the
same order. However, the chart rows shown on Page 2 may extend to Page 3 if space
requires, and the chart rows on Page 3 may extend to the beginning of Page 4 if space
requires. The Excluded Services and Other Covered Services section may appear on
Page 3 or Page 4, but must always immediately follow the chart starting on page 2. The
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




Excluded Services and Other Covered Services section must be followed by the Your
Rights to Continue Coverage section, the Your Grievance and Appeals Rights section,
and the Coverage Examples section, in that order.
Footer: The footer must appear at the bottom left of every page. The insurer must insert
the appropriate telephone number and website information.
For initial forms (provided to employees in the pre-selection stage), insurers may provide
both single and family information for each category, where applicable (e.g. premium,
deductible, out-of-pocket limit and annual limit). For example, for the deductible
category, the Answer column may show “$2,000 Individual” in the first line, and $3,000
Family” in the second line”. For final forms (provided to employees after selection),
insurers should only include information for the relevant plan.
For all form sections to be filled out by the insurer (particularly in the Answers column on
page 1, and the Your Cost and Limitations and Exceptions columns in the chart that starts
on page 2), the insurer should use plain language and present the information in a
culturally and linguistically appropriate manner and utilize terminology understandable
by the average individual.

Filling out the form:
Top Left Header (Page 1):
On the top left hand corner of the first page, the insurer must show the following information:
 First line: Show the plan name and insurance company name in 16 point font and bold.
Example: “Maximum Health Plan: Alpha Insurance Group”.
o Insurers have the option to use their logo instead of the typing in the company
name if the logo includes the name of the entity issuing the coverage.
o The insurer must use the commonly known company name.
Top Right Header (Page 1):
On the top right hand corner of the first page, the insurer must show the following information:
 First line: After Policy Period, the insurer must show the beginning and end dates for the
applicable policy period in the following format: “MM/DD/YYYY – MM/DD/YYYY”.
For example: “Policy Period: 09/15/2010 - 09/14/2011”.
 Second line:
o After the words “Coverage For”, indicate who the policy is for (such as
Individual, Individual + Spouse, Family). The insurer will use the terms used by
the policy, but should ensure that the term used will make it easy for the eligible
employee to compare similar types of plans.
o After the words “Plan Type”, indicate the type of insurance plan, such as HMO,
PPO, POS, Indemnity, or High-deductible.
Disclaimer (Page 1):
The disclaimer should be replicated and the insurer may not vary the font size, graphic or
formatting. The insurer should insert the plan’s website and telephone number.
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Important Questions/Answers/ Why This Matters Chart
General Instructions for the Important Questions chart:
 This chart must always appear on Page 1, and the rows must always appear in the same
order. Insurers must complete the Answers column for each question on this chart, using
the instructions below.
 Insurers must show the appropriate language in the Why This Matters box as instructed in
the instructions below. Insurers must replicate the language given for the Why This Matters
box exactly, and may not alter the language.
 When responding with a list of items, use words such as “and”, “or”, or “plus” rather than
using a semi-colon. For example: “Yes, $5,000 deductible for prescription drugs and
$2,000 for occupational therapy” rather than “Yes, $5,000 for prescription drugs; $2,000
for occupational therapy”.
1.

What Is The Premium?:
Answers column:
a.
Instructions for the Initial Form (provided before the employee selects a plan):
1)
Insurers will include the following statement: “Please contact your
employer for your share of the premium amount.”
2)
Employers will provide an addendum that defines the monthly premiums
for each coverage level for each plan to support the evaluation of plans by
eligible employees during the open enrollment period. This addendum
should include the following premium information:
a
For small groups whose premiums are based on table rates, the
complete rate table should be attached with a reference in the
Premium box to refer to the attached rates. This will allow eligible
employees to identify the premiums they would pay based on their
combination of age, gender, and coverage level/tier.
b)
For groups whose premiums are not based on age factors,
premiums for each coverage level/tier available for the plan should
be displayed. This will allow eligible employees to identify the
premiums they would pay based on their coverage level/tier.
b.
Final Form for Group Plans (provided after the employee selects a plan)
1)
Insurers will include the following statement: “Please contact your
employer for your share of the premium amount.”
2)
Employers will provide an addendum with the following premium
information:
a
For small groups whose premiums are based on table rates, the
premiums they will pay based on their combination of age, gender,
and coverage level/tier should be displayed. For example:
Male/Female, Age xx – xx, Coverage Tier - $xxx per month
b
For groups whose premiums are not based on age factors,
premiums for each coverage level/tier available for the plan should
be displayed. This will allow eligible employees to identify the

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premiums they would pay based on their coverage level/tier. For
example: Coverage Level - $xxx per month
Why This Matters column:
c.
The insurer must always insert the following language: “The premium is the
amount paid for health insurance.”
2.

What Is The Overall Deductible?:
Answers column:
a.
If there is no calendar year or policy period deductible, answer “$0”.
b.
If there is a calendar year or policy period deductible, answer with the dollar
amount and indicate whether it is based on a calendar year, or policy period. For
example: “$5,000 for calendar year” or “$5,000 for policy period”.
c.
If there is a calendar year or policy period deductible, underneath the dollar
amount insurers must include language specifying major categories of covered
services that are NOT subject to this deductible. For example, “Does not apply to
preventive care and generic drugs”.
d.
If there is a calendar year or policy period deductible, underneath the dollar
amount insurers must include language listing major exceptions, such as out-ofnetwork coinsurance, deductibles for specific services and copayments, which do
not count toward the deductible. For example, “Out-of-network coinsurance and
copayments don’t count toward the deductible.”
e.
Show the answer for the type of policy only. For example, if this is an individual
policy, show answers only for individual. If a family policy and there is a single
deductible amount for the family, show answers only for family.
f.
If portraying a family policy for which there is a separate deductible amount for
each individual and the family, show the individual deductible on the first line,
and the family deductible on the second line. For example, the first line may
show “Individual $2,000” and the second line may show “Family $3,000”.
Why This Matters column:
g.
If there is no calendar year or policy period deductible, show the following
language: “See the chart starting on page 2 for your other costs for services this
plan covers”.
h.
If there is a calendar year or policy period deductible, show the following
language: “You must pay all the costs up to the deductible amount before this
health insurance plan begins to pay for covered services you use. Check your
policy 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.”

3.

Are There Other Deductibles for Specific Services?:
Answers column:
a.
If the calendar year or policy period deductible is the only deductible, answer with
the phrase “No, there are no other deductibles.” Do not answer with just one
word.
b.
If there are other deductibles, answer “Yes”, then list the names and deductible
amounts of the three most significant deductibles other than the annual deductible.
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Significance of deductibles are determined by the insurer based on two factors:
probability of use and financial impact on the employee. Examples of other
deductibles include deductibles for Prescription Drug, Hospital, and Mental
Health). For example: “Yes, $2,000 for prescription drug expenses and $2,000
for occupational therapy services”.
c.
If the plan has more than three other deductibles and not all deductibles are
shown, the following statement must appear at the end of the list: “There are other
deductibles.”
d.
If the plan has less than three other deductibles, the following statement must
appear at the end of the list: “There are no other deductibles.”
e.
Show the answer for the type of policy only. For example, if this is an individual
policy, show answers only for individual. If this is a family policy and there is a
single deductible amount for the family, show answers only for family.
f.
If portraying a family policy for which there is a separate deductible amount for
each individual and the family, show both the individual and family deductible.
For example: “Prescription drugs -- Individual $200, Family $500”
Why This Matters column:
g.
If there are no other deductibles, the insurer must show the following language:
“Because you don’t have to meet deductibles for specific services, this plan starts
to cover costs sooner.”
h.
If there are other deductibles, the insurer must show the following language:
“You must pay all the costs for these services up to the specific deductible amount
before this plan begins to pay for these services.”
4.

Is There An Out-of-Pocket Limit On My Expenses?
Answers column
a.
If there are no out-of-pocket limits, respond “No. There’s no out-of-pocket limit
on your expenses” on the first line. Do not respond with a one-word answer.
b.
If there is an out-of-pocket limit, respond “Yes”, along with a specific dollar
amount that applies in each plan year, and to each charge with a separate out-ofpocket limit on the first line. For example: “Yes. $5,000”.
c.
If there are other types of annual limits, such as annual or plan year limits on
visits, services or drugs, then the insurer must show the following language on the
second line: “Other limits apply – see the chart that starts on page 2.”
d.
If an individual policy, show answers only for individual. If a family policy and
there is a single out-of-pocket limit for the family, show answers only for family.
e.
If a family policy, and there is a single out-of-pocket limit for each individual and
a separate out-of-pocket limit for the family, show the individual out-of-pocket
limit on the first line, and the family out-of-pocket limit on the second line. For
example, the first line may show “Individual $1,000” and the second line may
show “Family $3,000”.
Why This Matters column:
f.
If there is an out-of-pocket limit, the insurer must show the following language:
“The out-of-pocket limit is the most you could pay during a policy period for
your share of the cost of covered services. This limit helps you plan for health
care expenses.”
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g.

If there is no out-of-pocket limit, the insurer must show the following language:
“There’s no limit on how much you could pay during a policy period for your
share of the cost of covered services.”

5.

What Is Not Included In The Out-of-Pocket Limit?
Answers column
a.
If there is no out-of-pocket limit, indicate “This question doesn’t apply to this
plan.”
b.
If there is an out-of-pocket limit, the insurer must list any major exceptions. This
list must always include: premium, balance-billed charges, and health care this
plan doesn’t cover. Depending on the policy, the list could also include:
copayments, out of network coinsurance, deductibles, and penalties for failure to
obtain pre-authorization for services. The insurer must state that these items do
not count toward the limit. For example: “Copayments, premium, balance-billed
charges, and health care this plan doesn’t cover.”
Why This Matters column:
c.
If there is an out-of-pocket limit, the insurer must show the following language:
“Even though you pay these expenses, they don’t count toward the out-of-pocket
limit. So, a longer list of expenses means you have less coverage.”
d.
If there is no out-of-pocket limit, the insurer must show “Not applicable because
there’s no out-of-pocket limit on your expense.”

6.

Is There An Overall Annual Limit On What The Insurer Pays?
Answers column
a.
The insurer should respond “Yes” or “No” based on whether the policy has an
overall annual limit.
b.
If the answer is “Yes”, the insurer should include a brief description and dollar
amount of the overall annual limit. For example: “Yes. This policy has an overall
annual limit of $750,000”.
c.
If the answer is “No”, the insurer should state, “No. This policy has no overall
annual limit on the amount it will pay each year.”
Why This Matters column:
d.
If there is an overall annual limit, the insurer must show the following language:
“This plan will pay for covered services only up to this limit during each policy
period, even if your own need is greater. You’re responsible for all expenses
above this limit. The chart starting on page 2 describes specific coverage limits
such as limits on the number of office visits.”
e.
If there is no overall annual limit, the insurer must show the following language:
“The chart starting on page 2 describes any limits on what the insurer will pay for
specific covered services, such as office visits.”

7.

Does This Plan Use A Network of Providers?:
Answers column
a.
If this plan does not use a network, the insurer must respond, “No. This plan
doesn’t use a network”. Do not use a one-word response.

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b.

If the plan does use a network, the insurer must briefly explain its network policy.
For example “Yes, this plan uses preferred providers. You may use health care
providers that aren’t preferred providers, but you may pay more.”
c.
Insurers have the ability to use plan specific language when distinguishing
between preferred provider and non-preferred provider or in-network and out-ofnetwork out-of-pocket limits, etc.
d.
Include information on where to find a list of preferred providers or in-network
providers, etc. For example “For a list of preferred providers, see
www.insurancecompany.com or call 1-888-123-4567.”
e.
ER and other exceptions to non-preferred provider requirements should add that
information to answer field.
f.
Plans should highlight that some out-of-network specialists are often used by
network providers (e.g., anesthesiologists).
Why This Matters column:
g.
If this plan uses a network, the insurer must show the following language: “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. Plans use the terms in-network, preferred, or
participating to refer to providers in their network.”
h.
If this plan does not use a network, the insurer must show the following language:
“The providers you choose won’t affect your costs.”
8.

Do I Need A Referral To See A Specialist?:
Answers column:
a.
Insurers have the ability to use plan specific language when distinguishing
between preferred provider and non-preferred specialists or in-network and outof-network out-of-pocket limits, etc.
b.
Insurers should specify whether a written or verbal approval is required to see a
specialist.
c.
Insurers should specify whether specialist approval is different for different plan
benefits.
Why This Matters column:
d.
If there is a referral required, the insurer must show the following language: “This
plan will pay some or all of the costs to see a specialist but only if you have the
plan’s permission before you see the specialist for covered services.”
e.
If there is no referral required, the insurer must show the following language:
“You can see the specialist you choose without permission from this plan”.

9.

Are there services this plan doesn’t cover?:
Answers column:
a.
If there are any items in the Services Your Plan Does Not Cover box in the on
page 3 or 4, the insurer should answer “Yes”. See the instructions for the
Excluded Services and Other Covered Services section for more related
information.
Why This Matters column:
b.
If there are no excluded services shown in the Services Your Plan Does Not Cover
box on page 3 or 4, then the insurer must show the language: “This plan also
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c.

covers many other common health care services listed on page [3 or 4].” The
insurer should note the correct page (3 or 4) depending on where the Services
Your Plan Does Not Cover box appears on the form.
If there are excluded services shown in the Services Your Plan Does Not Cover
box on page 3 or 4, then the insurer must show the language: “Some of the
services this plan doesn’t cover are listed on page [3 or 4].” The insurer should
insert the correct page (3 or 4) depending on where the Services Your Plan Does
Not Cover box appears on the form.
Covered Services, Cost Sharing, Limitations and Exceptions

Information Box:
 The information box at the top of Page 2 should be replicated with the same text,
formatting, graphic, bolded words, and bullet points. Only the fourth bullet may change.
 The fourth bullet will change depending on the plan:
o For most plans that use a network, the insurer should fill in the blank on the 4th
bullet, using the terminology that the insurer uses for “in-network” or “preferred
provider”. This should be the same term as used in the heading of the far-left subcolumn under the Your Cost column.
o For plans that have the same cost-sharing percentage for in-network services as
out-of-network services, the insurer should delete the 4th bullet and replace it
with: “Your costs for [in-network] providers will be lower than [out-of-network]
providers.” Insert the term used for in-network and out-of-network shown on the
sub-column headers under the Your Cost column.
o For non-networked plans, the insurer should delete the 4th bullet and replace it
with: “Your costs are the same no matter which provider you see.”
 If any of the explanations in this box are inaccurate for the plan, then the insurer should
use the chart below (in either the Your Cost column or the Limitations and Exceptions
column) to show that information. For instance, if cost-sharing is not subject to the
deductible (and therefore the second bullet is not accurate for this plan), then the insurer
should indicate in the Your Cost column next to each cost-sharing charge that the charge
is “not subject to the deductible”.
Chart Starting on Page 2 :
1.

Location of Chart: This chart must always begin on Page 2, and the rows shown on Pages
2 and 3 must always appear in the same order. However, the rows shown on Page 2 may
extend to Page 3 if space requires, and the rows shown on Page 3 may extend to the
beginning of Page 4 if space requires. The heading of the chart must appear on all pages
used.

2.

Your Cost columns:
a.
Insurers may vary the number of sub-columns depending upon the type of policy
and the number of preferred provider networks. Most policies that use a network
should use two columns, although some policies with more than one level of in-

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b.

c.

d.

e.

3.

network provider may use three columns. HMOs should use two columns. Nonnetworked plans may use one column.
Insurers should insert the terminology used in the policy to title the sub-columns.
For example, the columns may be called “In-Network” and “Out-of-Network”, or
“Preferred Provider” and “Non-Preferred Provider” based on the terms used in the
policy. Insurers should be aware that consumer testing has demonstrated that
consumers more readily understand the terms “In-Network” and “Out-ofNetwork”. The sub-headings should be deleted for non-networked plans with
only one column.
The columns should appear from left to right, from most in-network to most outof-network. For example, if a 3-column format is used, the sub-columns might be
labeled (from left to right) “In-Network Preferred Provider,” “In-Network
Provider,” and then “Out-of-Network Provider.”
For HMOs providing no out-of-network benefits, the insurer should insert “Not
covered” in all applicable boxes under the far-right sub-heading under the Your
Cost column (which, for policies providing out-of-network benefits, would
usually be out-of-network provider or non-preferred provider column.
Insurers must complete the responses under these sub-columns based on how the
health insurance coverage covers the specific services listed in the chart.
1)
Fill in the costs column(s) with the co-insurance percentage, the copayment amount, “No charge” if the employee pays nothing, or “Not
covered” if the service is not covered by the plan. When referring to
coinsurance, include a percentage valuation. For example: 20%
coinsurance. When referring to co-payments, include a per occurrence
cost. For example: $20/visit or $15/prescription.
2)
When responding with a list of items, use words such as “and”, “or”, or
“plus” rather than using a semi-colon. For example: “Yes, $5,000
deductible for prescription drugs and $2,000 for occupational therapy”
rather than “Yes, $5,000 for prescription drugs; $2,000 for occupational
therapy”.

Limitations and Exceptions column:
a.
In this column, list the significant limitations and exceptions for each row.
Significance of limitations and exceptions is determined by the insurer based on
two factors: probability of use and financial impact on the employee. Examples
include, but are not limited to, limits on the number of visits, limits on specific
dollar amount paid by the insurer, prior authorization requirements, unusual
exceptions to cost sharing, lack of applicability of a deductible, or a separate
deductible.
b.
The limitation and exception should specify dollar amounts, service limitations,
and annual maximums if applicable. Language should be formatted as follows
“Coverage is limited to $XX/visit and $XXX annual max.” or “No coverage for
XXXX.”
c.
If the policy requires the employee to pay 100% of a service in-network, then that
should be considered an “excluded service” and should appear in the Limitations
and Exceptions column and also appear in the Services Your Plan Does Not Cover
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d.
e.
f.

4.

box on Page 3 or 4. For example, policies that exclude services in-network such
as pregnancy, habilitation services, prescription drugs, or mental health services,
must show these exclusions in both the Limitations and Exceptions column and
the Services Your Policy Does Not Cover box.
If there are pre-authorization requirements, the insurer must show the requirement
including specific information about the penalty for non-compliance.
If there are no items that need to appear in the limitations and exceptions box for a
row, then the insurer should show “----none---”.
For each section of the chart (for each Common Medical Event ), the insurer has
the discretion to merge the boxes in the Limitations and Exceptions column and
display one response across multiple rows if such a merger would lessen the need
to replicate comments and would save space.

Specific Instructions for Common Medical Events:
a.

If you visit a health care provider’s office or clinic:
1)
If the policy covers other practitioners care (which includes chiropractic
care and/or acupuncture), in the “Other practitioner office visit” row, the
insurer will provide the cost-sharing for the other practitioners care in the
Your Cost columns. For example, under in-network sub-column, the
insurer may respond “20% coinsurance for chiropractor and 10%
coinsurance for acupuncture”.
2)
If the policy does not cover other practitioners care, the insurer will show
“Not Covered” in the Your Cost columns for Other Practitioner Office
visit.

b.

If you need drugs to treat your illness or condition:
1)
Under the Common Medical Events column, provide a link to the website
location where the employee can find more information about prescription
drug coverage for this policy.
2)
Under the Services You May Need column, the insurer should list and
complete the categories of prescription drug coverage in the policy (for
example, the insurer might fill out 4 rows with the terms, “Generic drugs”,
“Preferred brand drugs”, “Non-preferred brand drugs”, and “Specialty
drugs”. It is recommended that insurers avoid the term “tiers” and instead
use “categories” as it is more easily understood by consumers.
3)
Under the Your Cost column, insurers should include the cost-sharing for
both retail and mail-order.

c.

If you have outpatient surgery:
1)
If there are significant expenses associated with a typical outpatient
surgery that have higher cost-sharing than the facility fee or
physician/surgeon fee, or are not covered, then they must be shown under
the Limitations and Exceptions column. Significance of such expenses are
determined by the insurer based on two factors: probability of use and
financial impact on the employee. For example, an insurer might show
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that the cost-sharing for the physician/surgeon fee row is “20%
coinsurance”, but the Limitations and Exceptions might show “Radiology
50% coinsurance”.
d.

If you have a hospital stay:
1)
If there are significant expenses associated with a typical hospital stay that
has higher cost-sharing than the facility fee or physician/surgeon fee, or
are not covered, then that must be shown in under the Limitations and
Exceptions column. Significance of such expenses are determined by the
insurer based on two factors: probability of use and financial impact on
the employee. For example, an insurer might show that the cost-sharing
for the facility fee row is “20% coinsurance”, but the Limitations and
Exceptions might show “anesthesia 50% coinsurance”.

Disclosures:
The Excluded Services and Other Covered Services, Your Rights to Continue Coverage, Your
Grievance and Appeals Rights and Coverage Examples sections must always appear in the order
shown. The Excluded Services and Other Covered Benefits section may appear on Page 3 or
Page 4 depending on the length of the chart starting on page 2, but it will always follow
immediately after the chart starting on page 2.
Excluded Services and Other Covered Services:
1.

Each insurer must place all services listed below in either the “Services Your Plan Does
Not Cover” box or the “Other Covered Services” box according to the policy provisions.
The required list of services includes: Acupuncture, Bariatric Surgery, Non-emergency
care when travelling outside the U.S., Chiropractic Care, Cosmetic Surgery, Dental care
(adult), Hearing aids, Infertility treatment, Long-term care, Private-duty nursing, Routine
eye care (adult), Routine foot care, and Weight loss programs.

2.

The insurer may not add any other benefits to the Other Covered Services box other than
the ones listed in (1) above.

3.

Services that appear in the Limitations and Exceptions column in the chart starting on
page 2 because the policy requires the employee to pay 100% of the service in-network,
should also appear in the Services Your Plan Does Not Cover box. For example, policies
that exclude services in-network such as pregnancy, habilitation services, prescription
drugs, or mental health services, must show these exclusions in both the Limitations and
Exceptions column (in the chart starting on page 2 chart) and in this Services Your Plan
Does Not Cover box.

4.

List placement must be in alphabetical order for each box. The lists must use bullets next
to each item.

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5.

For example, if an insurer excludes all of the services on the list above (#1) except
Chiropractic services, and also showed exclusion of Habilitation Services on Page 2 and
exclusion of Dental care (child) on page 3, the Other Benefits Covered box would show
“Chiropractic Care” and the Services Your Plan Does Not Cover box would show
“Acupuncture, Non-emergency care when travelling outside the U.S., Cosmetic surgery,
Dental care (child), Habilitation Services, Infertility treatment, Long-term care, Privateduty nursing, Routine eye care (adult), Routine foot care, Routine hearing tests, Weight
loss programs."

6.

If the insurer provides limited coverage for one of the services listed in (1) above, the
limitation must be stated in the Services Your Plan Does Not Cover box or the Other
Benefits Covered box. For example if an insurer provides acupuncture in limited
circumstances, the statement in the Services Your Plan Does Not Cover box would show:
Acupuncture unless it is prescribed by a physician for rehabilitation purposes, Nonemergency care when travelling outside the U.S., Cosmetic surgery, Dental care (adult),
Infertility treatment, Long-term care, Private-duty nursing, Routine eye care (adult),
Routine foot care, Routine hearing tests, Weight loss programs."

Your Rights to Continue Coverage:
This section must appear. Insurers must include the following items for all policies:
 “you or your employer commit fraud or intentional misrepresentations of material fact”,
 “the insurer stops offering this policy or services in the state”
 “you move outside the coverage area”
Insurers must also include the following for group plans:
 “your employer/sponsor changes insurance carrier”
 “your employer cancels or non-renews your coverage”
 “your employment/sponsorship terminates and you are not eligible to continue coverage
under COBRA or state law”
Your Grievance and Appeals Rights:
This section must appear. Depending on where plans are sold, identify the proper state health
insurance customer assistance program and include their website and phone number.
Coverage Examples:
a. HHS will provide all insurers with standardized data to be inserted in the “Sample care
costs” section for each coverage example. HHS will also provide underlying detail that
will allow carriers to calculate “You Pay” amounts, payments including: Date of Service,
CPT code, Provider Type, Category, descriptive Notes identifying the specific service
provided, and Allowed Amount.
b. The “Amount owed to providers,” also known as the Allowed Amount, will always equal
the Total of the “Sample care costs.” Each insurer must calculate cost sharing, using the
detailed data provided by HHS, and populate the “You Pay” fields. Dollar values are to
be rounded off to the nearest hundred dollars (for Sample care costs that are equal to or
greater than $100) or to the nearest ten dollars (for Sample care costs that are less than
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$100), in order to reinforce to consumers that numbers in the examples are estimates and
do not reflect their actual medical costs. For example, if the coinsurance amount is
estimated at $57, the insurer would list $60 in the appropriate “You Pay” section of the
Coverage Example.
c. Services on the template provided by HHS are listed individually for classification and
pricing purposes to facilitate the population of the “You Pay” section. HHS specifies the
Category used to roll up detail costs into the “Sample care costs” categories section.
Some plans may classify that service under another category and should reflect that
difference accordingly. The insurer should apply their cost sharing and benefit features
for each policy in order to complete the “You pay” section, but must leave the “Sample
care costs” section as is. Examples of categories that might differ between the You Pay
and Sample Care Costs sections could include, but are not limited to:
• Payment of services based on the location where they are provided (inpatient,
outpatient, office, etc.)
• Payment of items as prescription drugs vs. medical equipment
d. Each insurer must calculate and populate the “You pay” total and sub-totals based upon
the cost sharing and benefit features of the plan for which the document is being created.
These calculations should be made using the order in which the services were provided
(Date of Service).
1. Deductible – includes everything the member pays up to the deductible amount.
Any co-pays that accumulate toward the deductible are accounted for in this cost
sharing category, rather than under co-pays
2. Co-pays – those co-pays that don’t apply to the deductible
3. Limits or exclusions – anything member pays for non-covered services or
services that exceed plan limits.
4. Co-insurance – anything member pays above the deductible that’s not a co-pay
or non-covered service. This should be the same figure as the Total less the
Deductible, Co-Pays and Limits.
e. Each insurer must calculate and populate the “Plan pays” amount by subtracting the “You
pay” total from the “Amount owed to providers” total.
f. If all of the costs associated with the “having a baby” example are excluded under the
plan, then the phrase “(maternity is not covered, so you pay 100%)” is added after the
“You pay” amount. Otherwise no narrative should appear after the “You pay” amount.
g. Insurers must use the “Questions and answers about Coverage Examples” as they appear
and not alter the text, font, graphic, shading or colors [Should insurers be allowed to print
in black and white?]. This should be placed immediately following the Coverage
Examples.
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h. If the insurer provides coverage only for medical services (e.g., pharmacy or mental
health benefits are carved out and administered by another insurer), the insurer should
complete the Coverage Example for only those benefits that it covers, consistent with the
features outlined on pages 1 to 4 of the Summary of Coverage. These non-covered costs
for excluded services would show up under the “limits and exclusions” section of the
“You Pay” table. [NOTE: Should we require inclusion of a disclaimer on the Coverage
Example (and on the Summary of Coverage) that notes that certain benefits may be
administered by a separate insurer? Should we also amend the instructions for the
Summary of Coverage to address this issue in terms of how the benefits are described?]
Need Assistance?
Insurers should contact _________________ at ________________ to obtain assistance in
completing these documents.

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