Summary of Benefits and Coverage

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered
Services:

Coverage Period: [See Instructions]
Coverage for:
|Plan Type:

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a
summary. For more information about your coverage, or to get a copy of the complete terms of coverage, [insert contact information]. For definitions of common
terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the
Glossary at www.[insert].com or call 1-800-[insert] to request a copy.
Important Questions
What is the overall
deductible?
Are there services
covered before you meet
your deductible?
Are there other
deductibles for specific
services?
What is the out-of-pocket
limit for this plan?
What is not included in
the out-of-pocket limit?
Will you pay less if you
use a network provider?
Do you need a referral to
see a specialist?

Answers

Why This Matters

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PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

(DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date:
5/31/2022)(HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022)

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event
If you visit a health care
provider’s office or
clinic
If you have a test
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available at
www.[insert].com
If you have outpatient
surgery
If you need immediate
medical attention
If you have a hospital
stay
If you need mental
health, behavioral
health, or substance
abuse services
If you are pregnant

Services You May Need
Primary care visit to treat an
injury or illness
Specialist visit
Preventive care/screening/
immunization
Diagnostic test (x-ray, blood
work)
Imaging (CT/PET scans, MRIs)
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
Specialty drugs

What You Will Pay
Network Provider
Out-of-Network Provider
(You will pay the least)
(You will pay the most)

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Facility fee (e.g., ambulatory
surgery center)
Physician/surgeon fees
Emergency room care
Emergency medical
transportation
Urgent care
Facility fee (e.g., hospital room)
Physician/surgeon fees
Outpatient services

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Inpatient services

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Office visits
Childbirth/delivery professional
services

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Limitations, Exceptions, & Other
Important Information

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[* For more information about limitations and exceptions, see the plan or policy document at [www.insert.com].]

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Common Medical Event

What You Will Pay
Network Provider
Out-of-Network Provider
(You will pay the least) (You will pay the most)

Services You May Need

Childbirth/delivery facility
services
Home health care
Rehabilitation services
If you need help
Habilitation services
recovering or have other
Skilled nursing care
special needs
Durable medical equipment
Hospice services
Children’s eye exam
If your child needs
Children’s glasses
dental or eye care
Children’s dental checkups
If you are pregnant

Limitations, Exceptions, & Other
Important Information
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Excluded Services & Other Covered Services
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
•

•

•

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
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Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: [insert State, HHS, DOL, and/or other applicable agency contact information]. Other coverage options may be 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: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or
assistance, contact: [insert applicable contact information from instructions].
Does this plan provide Minimum Essential Coverage? [Yes/No]
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? [Yes/No/Not Applicable]
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

[* For more information about limitations and exceptions, see the plan or policy document at [www.insert.com].]

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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.

[* For more information about limitations and exceptions, see the plan or policy document at [www.insert.com].]

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About these Coverage Examples
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on
the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and
coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note
these coverage examples are based on self-only coverage.

Peg is Having a Baby

Managing Joe’s Type 2 Diabetes

(9 months of in-network pre-natal care and a
hospital delivery)





The plan's overall deductible
Specialist [cost sharing]
Hospital (facility) [cost sharing]
Other [cost sharing]

$
$
%
%

(a year of routine in-network care of a wellcontrolled condition)





The plan's overall deductible
Specialist [cost sharing]
Hospital (facility) [cost sharing]
Other [cost sharing]

$
$
%
%

Mia’s Simple Fracture

(in-network emergency room visit and follow up
care)





The plan's overall deductible
Specialist [cost sharing]
Hospital (facility) [cost sharing]
Other [cost sharing]

$
$
%
%

This EXAMPLE event includes services
like: Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services Diagnostic
tests (ultrasounds and blood work)
Specialist visit (anesthesia)

This EXAMPLE event includes services
like: Primary care physician office visits
(including disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)

This EXAMPLE event includes services
like: Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

Total Example Cost

Total Example Cost

Total Example Cost

In this example, Peg would pay:
Cost Sharing
Deductibles
Copayments
Coinsurance
What isn’t covered
Limits or exclusions
The total Peg would pay is

$12, 700

$
$
$
$
$

In this example, Joe would pay:
Cost Sharing
Deductibles
Copayments
Coinsurance
What isn’t covered
Limits or exclusions
The total Joe would pay is

$5,600

$
$
$
$
$

In this example, Mia would pay:
Cost Sharing
Deductibles
Copayments
Coinsurance
What isn’t covered
Limits or exclusions
The total Mia would pay is

$2,800

$
$
$
$
$

[The plan would be responsible for the other costs of these EXAMPLE covered services.]
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