Summary of Benefits and Coverage

What This Plan Covers and What it Costs

Instruction Guide for Individual Health Insurance Coverage
Edition Date: February 2012
Purpose of the form: PHS Act section 2715 generally requires all health insurance
issuers offering individual health insurance coverage to provide applicants, enrollees,
and policyholders or certificate holders with an accurate summary of benefits and
coverage.
General Instructions: Read all instructions carefully before completing the form.
 Form language and formatting must be precisely reproduced, unless instructions
allow or instruct otherwise. Unless otherwise instructed, the issuer must use 12point (as required by Federal law) font, and replicate all symbols, formatting,
bolding, and shading.
 Special Rule: To the extent a plan’s terms that are required to be described in
the SBC template cannot reasonably be described in a manner consistent with
the template and instructions, the plan or issuer must accurately describe the
relevant plan terms while using its best efforts to do so in a manner that is still as
consistent with the instructions and template format as reasonably possible.
Such situations may occur, for example, if a plan provides a different structure for
provider network tiers or drug tiers than is represented in the SBC template and
these instructions, if a plan provides different benefits based on facility type (such
as hospital inpatient versus non-hospital inpatient), or if a plan provides different
cost sharing based on participation in a wellness program.
 Issuers must customize all identifiable company information throughout the
document, including websites and telephone numbers.
 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 must
always begin on page 2, and the rows shown in 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 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 issuer must
insert the appropriate telephone number and website information.

Individual - February 2012

 For all form sections to be filled out by the issuer (particularly in the Answers
column on page 1, and the Your Cost and Limitations & Exceptions columns in
the chart that starts on page 2), the issuer should use plain language and present
the information in a culturally and linguistically appropriate manner and utilize
terminology understandable by the average individual. For more information, see
paragraph (a)(5) of the Departments’ final regulations.
 For questions about completing the SBC, contact SBC@cms.hhs.gov.

Filling out the form:
Top of page 1
Top Left Header (page 1):
On the top left hand corner of the first page, the issuer 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”.
 Issuers have the option to use their logo instead of typing in the company name if
the logo includes the name of the entity issuing the coverage.
 The issuer must use the commonly known company name.
Top Right Header (page 1):
On the top right hand corner of the first page, the issuer must show the following
information:
First line: After Coverage Period, the issuer must show the beginning and end dates for
the applicable coverage period (such as policy year) in the following format:
“MM/DD/YYYY – MM/DD/YYYY”. For example: “Coverage Period: 01/01/2013 12/31/2013”.
 If the coverage period end date is not known when the SBC is prepared, the
issuer is permitted to insert only the beginning date of the coverage period. For
example: “Coverage Period: Beginning on or after 01/01/2013”.
 If the SBC is being provided to satisfy the notice of material modification
requirements, the issuer must show the beginning and end dates for the period
for which the modification is effective. For example, for a change effective March
15, 2013, and a plan year beginning on January 1, 2013 and ending on
December 31, 2013: “Coverage Period: 03/15/2013 - 12/31/2013”.
Second line:

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

After Coverage for, indicate who the coverage is for (such as Individual,
Individual + Spouse, Family). The issuer should use the terms used in the policy
documents.



After Plan Type, indicate the type of coverage, such as HMO, PPO, POS,

Indemnity, or High-deductible.

Disclaimer (page 1):
The disclaimer at the top of page 1 should be replicated and the issuer may not vary the
font size, graphic, or formatting. The issuer should insert a website and telephone
number for accessing or requesting copies of the policy documents. The issuer should
also include a website and telephone number for accessing or requesting copies of the
Uniform Glossary. (Note: the Uniform Glossary can be accessed at:
www.cciio.cms.gov. This Internet address may be used as the website designated for
obtaining the Uniform Glossary.)

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. Issuers must complete the Answers column for each question on
this chart, using the instructions below.
 Issuers must show the appropriate language in the Why This Matters box as
instructed in the instructions below. Issuers must replicate the language given for
the Why This Matters box exactly, and may not alter the language.
 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 issuer. 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 Answers column
should show “$2,000 preferred provider, $5,000 non-preferred provider”.
1. What Is The Overall Deductible?:
Answers column:
 If there is no overall deductible, answer “$0”.
 If there is an overall deductible, answer with the dollar amount and, if the
deductible is not annual, indicate the period of time that the deductible applies.
 If there is an overall deductible, underneath the dollar amount, issuers 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”.

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 If there is an overall deductible, underneath the dollar amount issuers must
include language listing major exceptions, such as out-of-network co-insurance,
deductibles for specific services and copayments, which do not count toward the
deductible. For example, “Out-of-network co-insurance and copayments don’t
count toward the deductible.”
 If portraying family coverage for which there is a separate deductible amount for
each individual and the family, show both the individual deductible and the family
deductible (for example, “$2,000 person / $3,000 family”).
Why This Matters column:
 If there is no overall deductible, show the following language: “See the chart
starting on page 2 for your costs for services this plan covers.”
 If there is an overall deductible, show the following language: “You must pay all
the costs up to the deductible amount before this plan begins to pay for covered
services you use. Check your policy or plan document 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.”
2. Are There Other Deductibles for Specific Services?:
Answers column:
 If the overall deductible is the only deductible, answer with the phrase “No.”
 If there are other deductibles, answer “Yes”, then list the names and deductible
amounts of the three most significant deductibles other than the overall
deductible. Significance of deductibles is determined by the issuer based on two
factors: probability of use and financial impact on an individual. Examples of
other deductibles include deductibles for Prescription Drugs and Hospital. For
example: “Yes, $2,000 for prescription drug expenses and $2,000 for
occupational therapy services”.
 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 specific deductibles.”
 If the plan has less than three other deductibles, the following statement must
appear at the end of the list: “There are no other specific deductibles.”
 If portraying family coverage 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:
 If there are no other deductibles, the issuer must show the following language:
“You don’t have to meet deductibles for specific services, but see the chart
starting on page 2 for other costs for services this plan covers.”

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 If there are other deductibles, the issuer must show the following language: “You
must pay all of the costs for these services up to the specific deductible amount
before this plan begins to pay for these services.”
3. Is There An Out-of-Pocket Limit On My Expenses?:
Answers column:
 If there are no out-of-pocket limits, respond “No.”
 If there is an out-of-pocket limit, respond “Yes”, along with a specific dollar
amount that applies in each coverage period. For example: “Yes. $5,000”.
 If portraying family coverage, and there is a single out-of-pocket limit for each
individual and a separate out-of-pocket limit for the family, show both the
individual out-of-pocket limit and the family out-of-pocket limit (for example,
“Individual $1,000 / Family $3,000”).
 If there are separate out-of-pocket limits for in-network providers and out-ofnetwork providers, show both the in-network out-of-pocket limit and the out-ofnetwork out-of-pocket limit. Plans and issuers should use the terminology in the
policy or plan document (e.g., in-network, participating, or preferred). For
example: “For participating providers $2,500 person/$5,000 family; For nonparticipating providers $4,000 person/$8,000 family”
Why This Matters column:
 If there is an out-of-pocket limit, the issuer must show the following language:
“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 helps
you plan for health care expenses.”
 If there is no out-of-pocket limit, the issuer must show the following language:
“There’s no limit on how much you could pay during a coverage period for your
share of the cost of covered services.”
4. What Is Not Included In The Out-of-Pocket Limit?:
Answers column:
 If there is no out-of-pocket limit, indicate “This plan has no out-of-pocket limit.”
 If there is an out-of-pocket limit, the issuer must list any major exceptions. This
list must always include the following three terms: premiums, balance-billed
charges (unless balanced billing is prohibited), and health care this plan doesn’t
cover. Depending on the policy, the list could also include: copayments, out-ofnetwork co-insurance, deductibles, and penalties for failure to obtain preauthorization for services. The issuer must state that these items do not count
toward the limit. For example: “Copayments, premiums, balance-billed charges,
and health care this plan doesn’t cover.”
Why This Matters column:
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 If there is an out-of-pocket limit, the issuer must show the following language:
“Even though you pay these expenses, they don’t count toward the out–of–
pocket limit.”
 If there is no out-of-pocket limit, the issuer must show “Not applicable because
there’s no out-of-pocket limit on your expenses.”
5. Is There An Overall Annual Limit On What The Plan Pays?:
Answers column:
 The issuer should respond “Yes” or “No” based on whether the policy has an
overall annual limit.
 If the answer is “Yes”, the issuer should include a brief description and dollar
amount of the overall annual limit. For example: “Yes, $2 million.”
 If the policy does not have an overall annual limit, the issuer should state, “No.”
Why This Matters column:
 If there is an overall annual limit, the issuer must show the following language:
“This plan will pay for covered services only up to this limit during each coverage
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.”
 If there is no overall annual limit, the issuer must show the following language:
“The chart starting on page 2 describes any limits on what the plan will pay for
specific covered services, such as office visits.”
6. Does This Plan Use A Network of Providers?:
Answers column:
 If this plan does not use a network, the issuer must respond, “No.”
 If the plan does use a network, the issuer must respond, “Yes,” and include
information on where to find a list of preferred providers or in-network providers,
etc. For example: “Yes. For a list of preferred providers, see www.[insert].com
or call 1-800-[insert].” Issuers should use the terminology in the policy or plan
document (e.g., in-network, participating, or preferred).
Why This Matters column:
 If this plan uses a network, the issuer 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. Be aware, your in-network doctor or hospital
may use an out-of-network provider for some services. Plans use the term innetwork, preferred, or participating for providers in their network. See the chart
starting on page 2 for how this plan pays different kinds of providers.”
 If this plan does not use a network, the issuer must show the following language:
“This plan treats providers the same in determining payment for the same
services.”
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7. Do I Need A Referral To See A Specialist?:
Answers column:
 Issuers should use plan specific language with respect to specialists. For
example, distinguishing between preferred and non-preferred specialists or innetwork and out-of-network specialists.
 Issuers should specify whether written or oral approval is required to see a

specialist.

 Issuers should specify whether specialist approval is different for different plan
benefits.
Why This Matters column:
 If there is a referral required, the issuer must show the following language: “This
plan will pay some or all of the costs to see a specialist for covered services but
only if you have the plan’s permission before you see the specialist.”
 If there is no referral required, the issuer must show the following language:
“You can see the specialist you choose without permission from this plan”.
8. Are there services this plan doesn’t cover?:
Answers column:
 If there are any items or services the plan doesn’t cover the issuer should answer
“Yes”. (A “No” answer should be inserted only if the plan covers all items and
services without any exclusions or limitations, including any limitations based on
medical necessity.)
Why This Matters column:
 If there are no excluded services shown in the Services Your Plan Does Not
Cover box on page 3 or 4, then the issuer must show the language: “See your
policy or plan document for information about excluded services.”
 If there are excluded services shown in the Services Your Plan Does Not Cover
box on page 3 or 4, then the issuer must show the language: “Some of the
services this plan doesn’t cover are listed on page [3 or 4]. See your policy or
plan document for additional information about excluded services.” The issuer
should insert the correct page (3 or 4) depending on where the Services Your
Plan Does Not Cover box appears on the form.

Common Medical Event, Services, Cost Sharing, Limitations &

Exceptions

Cost Sharing Information Box:
 The first three bullets in 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.

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 The fourth bullet will change depending on the plan:
o For plans that use a network, the issuer should fill in the blank on the
fourth bullet of the template, using the terminology that the issuer uses for
“in-network” or “preferred provider”. This should be the same term as
used in the heading of the first sub-column under the Your Cost column.
o For non-networked plans, the issuer should delete the fourth bullet and
replace it with: “Your cost sharing does not depend on whether a provider
is in a network.”
Chart Starting on page 2:
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 the top of all pages
used.
Your Cost columns:
 Issuers may vary the number of 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 innetwork provider may use three columns. Non-networked plans may use one
column.
 Issuers should insert the terminology used in the policy to title the 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. (Issuers 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 generous cost sharing to
least generous cost sharing. For example, if a 3-column format is used, the
columns might be labeled (from left to right) “In-Network Preferred Provider,” “InNetwork Provider,” and then “Out-of-Network Provider.”
 For HMOs providing no out-of-network benefits, the issuer 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).
 Issuers must complete the responses under these sub-headings based on how
the issuer covers the specific services listed in the chart. Fill in the Your Cost
column(s) with the co-insurance percentage, the co-payment amount, “No
charge” if the consumer pays nothing, or “Not covered” if the service is not
covered by the plan. When referring to co-insurance, include a percentage
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valuation. For example: 20% co-insurance. When referring to co-payments,
include a per occurrence cost. For example: $20/visit or $15/prescription.


Refer to the specific additional instructions below for details on completing the
Your Costs columns in the chart for the following common medical events:
o If you visit a health care provider’s office or clinic;
o If you need drugs to treat your illness or condition; and
o If you have mental health, behavioral health, or substance abuse needs.

Limitations & Exceptions column:
In this column, list the significant limitations and exceptions for each row. Significance
of limitations and exceptions is determined by the issuer based on two factors:
probability of use and financial impact on the consumer. Examples include, but are not
limited to, limits on the number of visits, limits on specific dollar amount paid by the
issuer, prior authorization requirements, unusual exceptions to cost sharing, lack of
applicability of a deductible, or a separate deductible.
 Each limitation or 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.”
 If the issuer requires the consumer to pay 100% of a service in-network, then that
should be considered an “excluded service” and should appear in the Limitations
& Exceptions column and also appear in the Services Your Plan Does Not Cover
box on page 3 or 4. For example, coverage that excludes services in-network
such as pregnancy, habilitation services, prescription drugs, or mental health
services, must show these exclusions in both the Limitations & Exceptions
column and the Services Your Plan Does Not Cover box.
 If there are pre-authorization requirements, the issuer must show the requirement
including specific information about the penalty for noncompliance.
 If there are no items that need to appear in the Limitations & Exceptions box for a
row, then the issuer should show “---none---”.


For each Common Medical Event in the chart, the issuer has the discretion to
merge the boxes in the Limitations & Exceptions column and display one
response across multiple rows if such a merger would lessen the need to
replicate comments and would save space.

 Refer to the specific additional instructions below for details on completing the
Limitations & Exceptions column in the chart for the following common medical
events:
o If you have outpatient surgery; and
o If you have a hospital stay.
Specific Additional Instructions for Some of the Common Medical Events:
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If you visit a health care provider’s office or clinic:
 If the issuer covers other practitioners care (which includes chiropractic care
and/or acupuncture), in the “Other practitioner office visit” row, the issuer will
provide the cost sharing for the other practitioners care in the Your Cost columns.
For example, under the in-network column, the issuer may respond “20% coinsurance for chiropractor and 10% co-insurance for acupuncture”.
 If the issuer does not cover other practitioners care, the issuer will show “Not
Covered” in the Your Cost columns for Other Practitioner Office visit.
If you need drugs to treat your illness or condition:


Under the Common Medical Events column, provide a link to the website location
where the consumer can find more information about prescription drug coverage
for this plan. If there is no website, provide a contact phone number where the
consumer can receive more information about prescription drug coverage for this
policy.



Under the Services You May Need column, the issuer should list and complete
the categories of prescription drug coverage under the policy (for example, the
issuer might fill out 4 rows with the terms, “Generic drugs”, “Preferred brand
drugs”, “Non-preferred brand drugs”, and “Specialty drugs”). It is recommended
that issuers avoid the term “tiers” and instead use “categories” as it is more easily
understood by consumers.



Under the Your Cost column, issuers should include the cost sharing for both
retail and mail order, as applicable.

If you have outpatient surgery:
 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 & Exceptions column.
Significance of such expenses is determined by the issuer based on two factors:
probability of use and financial impact on the consumer. For example, an issuer
might show that the cost sharing for the physician/surgeon fee row is “20% coinsurance”, but the Limitations & Exceptions might show “Radiology 50% coinsurance”.
If you have a hospital stay:
 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 under the Limitations & Exceptions column.
Significance of such expenses is determined by the issuer based on two factors:
probability of use and financial impact on the consumer. For example, an issuer
might show that the cost sharing for the facility fee row is “20% co-insurance”, but
the Limitations & Exceptions might show “Anesthesia 50% co-insurance”.
If you have mental health, behavioral health, or substance abuse needs:

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 If the cost sharing differs for outpatient services for mental/behavioral health
needs or substance abuse needs depending on whether the services are office
visits or are other outpatient services, show the cost sharing for each. For
example, an issuer might show that the cost sharing for Mental/Behavioral health
outpatient services is “$35 co-pay/visit for office visits and 20% co-insurance
other outpatient services”.

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:
 Each issuer 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:
o
o
o
o
o
o
o
o

Acupuncture,
Bariatric surgery,
Chiropractic care,
Cosmetic surgery,
Dental care (Adult),
Hearing aids,
Infertility treatment,
Long-term care,

o Non-emergency care
when traveling outside the
U.S.,
o Private-duty nursing,
o Routine eye care (Adult),
o Routine foot care, and
o Weight loss programs.

 The issuer may not add any other benefits to the Other Covered Services box
other than the ones listed above. However, other benefits may be added to the
Services Your Plan Does Not Cover box, as follows:
o If services appear in the Limitations & Exceptions column in the chart
starting on page 2 because the issuer requires the consumer to pay 100%
of the service in-network, those services should also appear in the
Services Your Plan Does Not Cover box.
o 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 & Exceptions
column (in the chart starting on page 2) and in the Services Your Plan
Does Not Cover box.
 List placement must be in alphabetical order for each box. The lists must use
bullets next to each item.
 In lieu of summarizing coverage for items and services provided outside the
United States, the plan or issuer may provide an internet address (or similar
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contact information) for obtaining information about benefits and coverage
provided outside the United States. This statement should appear in the Other
Covered Services box. For example: “Coverage provided outside the United
States. See www.[insert].com/expatriate”
 If the issuer provides limited coverage for any of the services listed above, the
limitation must be stated in the Services Your Plan Does Not Cover box or the
Other Benefits Covered box but not both. For example if an issuer provides
acupuncture in limited circumstances, the issuer could choose to include the
prescribed statement in the Services Your Plan Does Not Cover box, as follows:
“Acupuncture unless it is prescribed by a physician for rehabilitation purposes.”
Alternatively, the prescribed statement could be in the Other Covered Services
box as follows: “Acupuncture if it is prescribed by a physician for rehabilitation
purposes.”
 For example, if an issuer excludes all of the services on the list above except
Chiropractic services, and also showed exclusion of Habilitation Services on
page 2, the Other Covered Services box would show “Chiropractic Care” and the
Services Your Plan Does Not Cover box would show “Acupuncture, Bariatric
Surgery, Cosmetic surgery, Dental care (Adult), Habilitation Services, Hearing
Aids, Infertility treatment, Long-term care, Non-emergency care when travelling
outside the U.S., Private-duty nursing, Routine eye care (Adult), Routine foot
care, Weight loss programs."
Your Rights to Continue Coverage:
This section must appear without alteration, as follows:
“Federal and State laws may provide protections that allow you to keep this health
insurance coverage as long as you pay your premium. There are exceptions, however,
such as if:




You commit fraud

The insurer stops offering services in the State

You move outside the coverage area

For more information on your rights to continue coverage, contact the insurer at [contact
number]. You may also contact your state insurance department at [insert applicable
State Department of Insurance contact information].
Your Grievance and Appeals Rights:
This section must appear.
Contact information should be inserted as follows:
 Insert applicable State Department of Insurance contact information.

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 If applicable in your state insert: “Additionally, a consumer assistance program
can help you file your appeal. Contact [insert contact information].” Note: A list
of states with Consumer Assistance Programs is available at
http://cciio.cms.gov/programs/consumer/capgrants/index.html.

Coverage Examples
 The U.S. Department of Health and Human Services (HHS) will provide all
issuers with standardized data to be inserted in the Sample care costs section for
the coverage examples. HHS will also provide underlying detail that will allow
issuers to calculate Patient pays amounts, including: Date of Service, medical
coding information, Provider Type, Category, descriptive Notes identifying the
specific service provided, and Allowed Amounts.


The Amount owed to providers, also known as the Allowed Amount, will always
equal the Total of the Sample care costs. Each issuer must calculate cost
sharing, using the detailed data provided by HHS, and populate the Patient pays
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 $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 co-insurance amount is estimated at
$57, the issuer would list $60 in the appropriate Patient pays section of the
Coverage Examples.

 Services on the template provided by HHS are listed individually for classification
and pricing purposes to facilitate the population of the Patient pays 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 issuer should apply their cost
sharing and benefit features for each policy in order to complete the Patient pays
section, but must leave the Sample care costs section as is. Examples of
categories that might differ between the Patient pays and Sample care costs
sections could include, but are not limited to:
o Payment of services based on the location where they are provided
(inpatient, outpatient, office, etc.)
o Payment of items as prescription drugs vs. medical equipment
 Each issuer must calculate and populate the Patient pays 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).
o 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.
o Co-pays – those co-pays that don’t apply to the deductible.

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o Co-insurance – anything the 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 or exclusions.
o Limits or exclusions – anything the member pays for non-covered
services or services that exceed plan limits.
 Each issuer must calculate and populate the Plan pays amount by subtracting
the Patient pays total from the Amount owed to providers total.
 If the issuer has a wellness program that varies the deductibles, co-payments,
co-insurance, or coverage for any of the services listed in a treatment scenario,
the plan must complete the calculations for that treatment scenario assuming that
the patient is participating in the wellness program. Additionally, the issuer must
also include a box below the coverage example with the following language (and
appropriate contact information):
o For Pregnancy:
Note: These numbers assume the patient has given notice of her
pregnancy to the plan. If you are pregnant and have not given notice of
your pregnancy, your costs may be higher. For more information, please
contact: [insert].
o For Diabetes:
Note: These numbers assume the patient is participating in our diabetes
wellness program. If you have diabetes and do not participate in the
wellness program, your costs may be higher. For more information about
the diabetes wellness program, please contact [insert].
 If all of the costs associated with the Coverage Examples are excluded under the
plan, then the phrase “(This condition is not covered, so patient pays 100%)” is
added after the Patient pays amount. Otherwise no narrative should appear after
the Patient pays amount.
 Issuers must include the Questions and answers about the Coverage Examples
section as it appears and not alter the text, font, graphic, shading, etc. This
section should be placed immediately following the Coverage Examples.

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