CMS-10407 CMS-10407_Summary_of_Coverage_(Blank)-F

Blank Summary of Coverage

_______________________: _________________
Summary of Coverage: What this Plan Covers & What it Costs

Policy Period: ________ – ________
Coverage for: _____________ | Plan Type: _____

This is not a policy. You can get the policy at www.insurancecompany.com/PLAN1500 or by calling 1-800-XXX-XXXX.

A policy has more detail about how to use the plan and what you and your insurer must do. It also has more detail about your coverage and costs.

Important Questions

Answers

Why this Matters:

What is the premium?

$

The premium is the amount paid for health insurance. This is only an estimate based on
information you’ve provided. After the insurer reviews your application, your actual
premium may be higher or your application may be denied.

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?
Is there an overall
annual limit on what
the insurer pays?
Does this plan use a
network of providers?
Do I need a referral to
see a specialist?
Are there services this
plan doesn’t cover?

Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.

If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov. 

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_______________________: _________________
Summary of Coverage: What this Plan Covers & What it Costs

Policy Period: ________ – ________
Coverage for: _____________ | Plan Type: _____

 Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
 Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. You pay this plus
any deductible amounts you owe under this health insurance plan. For example, if the health plan’s allowed amount for an overnight hospital
stay is $1,000 and you’ve met your deductible, your co-insurance payment of 20% would be $200. If you haven’t met any of the deductible
and it’s at least $1,000, you would pay the full cost of the hospital stay.
 The plan’s payment for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
 This plan may encourage you to use ______________ providers by charging you lower deductibles, co-payments and co-insurance amounts.
Your cost if you use a
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 drug coverage is
at
www.insurancecompa
ny.com/prescriptions.
If you have
outpatient surgery
If you need

Services You May Need

Participating
Provider

NonParticipating
Provider

Limitations & Exceptions

Primary care visit to treat an injury or illness
Specialist visit
Other practitioner office 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 (e.g., chemotherapy)

Facility fee (e.g., ambulatory surgery center)
Physician/surgeon fees
Emergency room services

Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.

If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov. 

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_______________________: _________________
Summary of Coverage: What this Plan Covers & What it Costs

Policy Period: ________ – ________
Coverage for: _____________ | Plan Type: _____

Your cost if you use a
Common
Medical Event
immediate medical
attention
If you have a
hospital stay
If you have mental
health, behavioral
health, or substance
abuse needs
If you become
pregnant

If you have a
recovery or other
special health need

If your child needs
dental or eye care

Services You May Need

Participating
Provider

NonParticipating
Provider

Limitations & Exceptions

Emergency medical transportation
Urgent care
Facility fee (e.g., hospital room)
Physician/surgeon fee
Mental/Behavioral health outpatient services
Mental/Behavioral health inpatient services
Substance use disorder outpatient services
Substance use disorder inpatient services
Prenatal and postnatal care
Delivery and all inpatient services
Home health care
Rehabilitation services
Habilitation services
Skilled nursing care
Durable medical equipment
Hospital service
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 for others.)






Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.

If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov. 

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_______________________: _________________
Summary of Coverage: What this Plan Covers & What it Costs

Policy Period: ________ – ________
Coverage for: _____________ | Plan Type: _____

Other Covered Services (This isn’t a complete list. Check your policy for other covered services and your costs for these services.)


Your Rights to Continue Coverage:
You can keep this insurance as long as you pay your premium unless one or more of the following happens:




you commit fraud

the insurer stops offering services in the state

you move outside the coverage area

Your Grievance and Appeals Rights:
 A grievance is a complaint you have about your health insurer or plan. You have the right to file a written complaint to express your
dissatisfaction or denial of coverage for claims under this health insurance. Call 1-800-XXX-XXXX or visit www. Xxxxxxxxxxxxxx.com.
 An appeal is a request for your health insurer or plan to review a decision or a grievance again. For more information on the appeals process, call
your state office of health insurance customer assistance at: 1-800-XXX-XXXX or visit www. Xxxxxxxxxxxxxx.gov.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.

If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov. 

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_______________________: _________________
Coverage Examples

About these
Coverage
Examples:
These examples show how this
plan might cover medical care in
three situations. Use these
examples to see, in general, how
much insurance protection you
might get from different plans.

This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care also will be
different.
See the next page for
important information about
these examples. 

Policy Period: ________ – ________
Coverage for: _____________ | Plan Type: _____

Treating breast cancer

Having a baby

(lumpectomy, chemotherapy,
radiation)

(normal delivery)

Managing diabetes
(routine maintenance of existing
condition)

 Amount owed to providers:
$10,000
 Plan pays $
 You pay $

 Amount owed to providers:
$98,000
 Plan pays $
 You pay $

 Amount owed to providers:
$7,800
 Plan pays $
 You pay $

Sample care costs:
First office visit
Radiology
Laboratory tests
Routine obstetric care
Hospital charges
(mother)
Hospital charges
(baby)
Anesthesia
Circumcision
Vaccines, other
preventive
Total

Sample care costs:
Office visits &
procedures
Radiology
Laboratory tests
Hospital charges
Inpatient medical care
Outpatient surgery
Chemotherapy
Radiation therapy
Prostheses (wig)
Pharmacy
Mental health
Total

Sample care costs:
Office visits &
procedures
Laboratory tests
Medical equipment &
supplies
Pharmacy
Total

You pay:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total

$100
$300
$200
$2,000
$4,100
$1,900
$1,000
$200
$200
$10,000
$
$
$
$
$

$4,000
$4,000
$2,400
$3,300
$200
$3,400
$64,000
$13,000
$500
$2,000
$1,200
$98,000

You pay:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total

You pay:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total

$960
$300
$40
$6,500
$7,800
$
$
$
$
$

$
$
$
$
$

Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.

If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov. 

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_______________________: _________________
Coverage Examples

Policy Period: ________ – ________
Coverage for: _____________ | Plan Type: _____

Questions and answers about Coverage Examples:

What are some of the
assumptions behind the
Coverage Examples?



Costs don’t include premiums.

Sample care costs are based on national

averages supplied to the U.S. Department
of Health and Human Services (HHS),
and aren’t specific to a particular
geographic area or health plan.
 Patient’s condition was not an excluded or
preexisting condition.
 All services and treatments started and
ended in the same policy period.
 There are no other medical expenses for

any member covered under this plan.

Out-of-pocket expenses are based only

on treating the condition in the example.
 The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.

What does a Coverage Example
show?

Can I use Coverage Examples
to compare plans?

For each treatment situation, the Coverage
Example helps you see how deductibles, copayments, and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.

Yes. When you look at the Summaries of

Does the Coverage Example
predict my own care needs?

 No. Treatments shown are just examples.
The care you would receive for these
conditions could be different, based on
your doctor’s advice, your age, how serious
your condition is, and many other factors.

Does the Coverage Example
predict my future expenses?

No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.

Coverage for other plans, you’ll find the
same coverage examples. When you
compare plans, check the “You Pay” box
for each example. The smaller that
number, the more coverage the plan
provides.

Are there other costs I should
consider when comparing
plans?

Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket costs, such as co-payments,
deductibles, and co-insurance. You also
should consider contributions to accounts
such as health savings accounts (HSAs),
flexible spending arrangements (FSAs) or
health reimbursement accounts (HRAs)
that help you pay out-of-pocket expenses.

Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.

If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov. 

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