_______________________: _________________ Coverage Period: [See Instructions]
Summary
of Benefits and Coverage: What
this Plan Covers & What it Costs Coverage
for: _____________
|
Plan
Type: _____
Important Questions |
Answers |
Why This Matters: |
What is the overall deductible? |
$ |
|
Are there other deductibles for specific services? |
$ |
|
Is there an out-of-pocket limit on my expenses? |
$ |
|
What is not included in the out-of-pocket limit? |
|
|
Does this plan use a network of providers? |
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|
Do I need a referral to see a specialist? |
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|
Common
|
Services You May Need |
Your Cost If You Use an In-network Provider |
Your Cost If You Use an Out-of-network Provider |
Limitations & Exceptions |
|
If you visit a health care provider’s office or clinic |
Primary care visit to treat an injury or illness |
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|
Specialist visit |
|
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||
Other practitioner office visit |
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||
Preventive care/screening/immunization |
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||
If you have a test |
Diagnostic test (x-ray, blood work) |
|
|
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|
Imaging (CT/PET scans, MRIs) |
|
|
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||
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.[insert]. |
Generic drugs |
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|
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|
Preferred brand drugs |
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||
Non-preferred brand drugs |
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Specialty drugs |
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||
If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
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Physician/surgeon fees |
|
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If you need immediate medical attention |
Emergency room services |
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Emergency medical transportation |
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Urgent care |
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|
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||
If you have a hospital stay |
Facility fee (e.g., hospital room) |
|
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|
Physician/surgeon fees |
|
|
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||
If you have mental health, behavioral health, or substance abuse needs |
Mental/Behavioral health outpatient services |
|
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|
Mental/Behavioral health inpatient services |
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Substance use disorder outpatient services |
|
|
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Substance use disorder inpatient services |
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||
If you are pregnant |
Prenatal and postnatal care |
|
|
|
|
Delivery and all inpatient services |
|
|
|
Common
|
Services You May Need |
Your Cost If You Use an In-network Provider |
Your Cost If You Use an Out-of-network Provider |
Limitations & Exceptions |
If you need help recovering or have other special health needs |
Home health care |
|
|
|
Rehabilitation services |
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Habilitation services |
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Skilled nursing care |
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Durable medical equipment |
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Hospice services |
|
|
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|
If your child needs dental or eye care |
Eye exam |
|
|
|
Glasses |
|
|
|
|
Dental check-up |
|
|
|
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.) |
||
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|
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.) |
||
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|
Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to continue health coverage after it would otherwise end. For more information, contact us at [insert contact information] or contact: [insert State, HHS, and/or DOL contact information, as applicable]. Other options to continue coverage are available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
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 more information about your rights, this notice, or assistance, contact: [insert applicable contact information from instructions].
Individual Responsibility: [insert applicable language from instructions].
[Insert heading and applicable tagline(s):
Language Access Services:
[Spanish (Español): Para obtener asistencia en Español, llame al [insert telephone number]. ]
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [insert telephone number]. ]
[Chinese (中文): 如果需要中文的帮助,请拨打这个号码 [insert telephone number]. ]
[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [insert telephone number].]]
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––
This
is not a cost estimator.
Don’t use these examples to estimate your actual costs under
this
plan.
Treatments
shown are just examples and your actual costs will be different
depending on the
actual care you receive, the prices your providers
charge,
and many other factors. Also, costs don’t include premiums
you pay to buy coverage under a plan.
About
these Coverage Examples:
These
examples show how this plan
might cover medical care in a few situations and show how
deductibles,
copayments,
and coinsurance
can add up. Use these examples to see, in general, how much
financial protection a sample patient might get from coverage under
this plan compared to other plans
by comparing
the “Patient
Pays” section for the same example
under each plan’s Summary of Benefits and Coverage.
Having
a baby
(normal
delivery)
Cost of care $14,150
Plan pays $
Patient
pays
$
Sample care costs:
Hospital charges (mother) |
$6,700 |
Routine obstetric care |
$2,500 |
Hospital charges (baby) |
$2,100 |
Anesthesia |
$1,200 |
Laboratory tests |
$1,000 |
Prescriptions |
$200 |
Radiology |
$200 |
Education |
$200 |
Vaccines, other preventive |
$50 |
Total |
$14,150 |
Patient pays:
Deductibles |
$ |
Copayments |
$ |
Coinsurance |
$ |
Limits or exclusions |
$ |
Total |
$ |
Managing
type 2 diabetes
a
well-controlled condition)
(routine
maintenance of
Cost of care $6,100
Plan pays $
Patient
pays
$
Sample care costs:
Prescriptions |
$3,300 |
Medical Equipment and Supplies |
$1,300 |
Office Visits and Procedures |
$800 |
Education |
$300 |
Laboratory tests |
$200 |
Vaccines, other preventive |
$200 |
Total |
$6,100 |
Patient pays:
Deductibles |
$ |
Copayments |
$ |
Coinsurance |
$ |
Limits or exclusions |
$ |
Total |
$ |
Simple
fracture
(with
emergency room visit)
Cost of care $2,400
Plan pays $
Patient
pays
$
Sample care costs:
Emergency Services |
$1,400 |
Medical Equipment and Supplies |
$400 |
Office Visits and Procedures |
$300 |
Physical Therapy |
$200 |
Laboratory tests |
$90 |
Prescriptions |
$10 |
Total |
$2,400 |
Patient pays:
Deductibles |
$ |
Copayments |
$ |
Coinsurance |
$ |
Limits or exclusions |
$ |
Total |
$ |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | DOL Comments |
File Modified | 0000-00-00 |
File Created | 2021-01-26 |