Individual-plan-benefits-template

Draft Individual Benefits Template, RBIS, version 1

Issuer ID

10029

10029
10029

Product Smart ID
(Issuer ID + State + Product ID)
10029MD001

10029MD001
10029MD001

Temp Plan ID
(ProdSmartID + 4 digit #)

Plan Name

Spectrum
1000

PPO

No

This is a
preferred
provider
network.

50 Individual /
100 Deductible

100/201

Spectrum
2200

200/301

10029MD001

Spectrum
2500

10029

10029MD002

Advantage 500 HMO

10029

10029MD002

Advantage 700

10029

10029MD003

Prestige 1200 PPO

Product Level Data
Populated from First
Plan

No

Annual
Deductible

Spectrum
1500

10029

Key:

Provider
Network

Plan Type

Primary
Specialist
Care
Referrals
Physician
Required
Required

No

No

No

300/501
1000/2000

No

No

No

2001/4000
None

HSA
Eligible
No

Out-ofOut-ofAnnual Out-ofAdmin Fees(In
Network Country
Pocket Limit
Network)
Coverage Coverage
(In Network)
Yes

OOP
Exceptions
and Limits

Out of Pocket
Deductible(Ot
Limit (Out
her Services)
Network)

In-Network Coinsurance(O
Coinsurance ut Network)

Annual
Maximum
Limit

NA

50

No Limit

$X
Individual/$X
Family

$X
Individual/$X
Family

X % After
deductible

X % After
deductible

No Limit

No

No

Yes

NA

50

200/2929

12500/25000

10000/20000

20

50

200/2932

No

Yes

NA

100

No Limit

No Limit

None

40

60

200/2934

50/101
100/201
200/301

Primary care visit to treat an injury or illness:

In Network
$X Individual/$X
Family

Out of Network
$X Individual/$X
Family

50/101

50/101

Limitations and
Exception

Specialist Visit:

Other practitio

Limitations and
Exception

In
Network
--

In Network
--

Out of Network
X% Coinsurance
after deductible

Out of Network
X% Coinsurance
after deductible

50/101

50

50

--

50/101

100

150

$50 Copay/ $70
$50
Copay with $300
Copay/
annual maximum
$70 Copay
with $300

X% Coinsurance
after deductible

ner office visit:

Limitations and Exception

Preventive care/screening/immunization:

In Network
--

$50 Copay/ $70 Copay with
$300 annual maximum

Diagnostic tests and Lab Wo
Out-of-Net

In Network

Out of
Limitations and
Network
Exception
X%
Coinsuranc
e after
deductible

Standalon
Doctor’s Standalone
Doctor’s offices e centers Hospitals offices
centers
-$X Copay $X Copay $X Copay Not Covered

No Charge
after
deductible

$50 Copay/ $70
Copay with $300
annual maximum

50

50

70

Not Covered

Not
Covered

$50 Copay/ $70
Copay with $300
annual maximum

30

50

80

$70 Copay
10 Visits per
insured per
contract

rk
work

Imaging (CT/PET scans, MRIs)
Out-of-Network

In Network

I

Doctor’s
Standalone
offices
centers
X%
$X Copay
Coinsuran
ce before
deductible

Standalon
Hospitals Doctor’s offices e centers Hospitals
X%
$X Copay
X%
$X Copay
Coinsuran
Coinsuran
ce after
ce after
deductible
deductible

10

40

50

X% Coinsurance
after deductible

X%
$X Copay
Coinsuran
ce before
deductible

Hospitals
X% Coinsurance
after deductible

Exceptions

75

70

X%
$X Copay
Coinsuran
ce after
deductible

70

10

X%
$X Copay
Coinsuran
ce after
deductible

Exceptions

Doctor’s offices
$X Copay

50

$X Copay

Advanced Imaging
Out-of-Network

n Network

Standalone
centers
--

Hospitals
Doctor’s offices
$X
$X Copay
Individual
/$X Family

500/500

--

20

$X
$X Copay
Individual
/$X Family

Standalone
centers
$X Copay

X-Rays
In Network

Hospitals
X% Coinsurance
before deductible

Exceptions

Doctor’s offices
$X Copay

Standalon
Doctor’s
e centers
Hospitals
offices
X%
X% Coinsurance $X
Coinsuran before deductible Individual
ce after
/$X Family
deductible

80

150

500

20

80

150/150

$X Copay

X% Coinsurance
before deductible

$X Copay

X%
X% Coinsurance $X
Coinsuran before deductible Individual
ce after
/$X Family
deductible

Out-of-Network

Standalon
e centers
Hospitals
90
X% Coinsurance
after deductible

90

Generic Drugs

Exceptions

Fixed Cost
$X Copay

Co-Insurance
$X Copay

50

50

X% Coinsurance
after deductible

$X Copay

Preferred brand drugs

Exceptions and
Limitations

Fixed Cost
X% Coinsurance
after deductible

Co-Insurance
X% Coinsurance
after deductible

50

50

50

$X Copay

X% Coinsurance
after deductible

X% Coinsurance
after deductible

Exceptions and
Limitations

Non-Preferred brand drugs

Fixed Cost
Co-Insurance
X%
X% Coinsurance
Coinsuran after deductible
ce after
deductible

50

50

X%
X% Coinsurance
Coinsuran after deductible
ce after
deductible

Exceptions and
Limitations

Specialty drugs (e.g., chemotherapy)

Fixed Cost
Co-Insurance
X% Coinsurance after X% Coinsurance
deductible
after deductible

50

50

X% Coinsurance after X% Coinsurance
deductible
after deductible

Outpatient Surgery Facility fee (e.g.,

Exceptions and
Limitations In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

50

50

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

Limitations
and Exception

Outpatient Surgery Physician/surgeon fees

Emergency room services

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Emergency medical transportation

In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

50

50

50

50

50

50

50

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

Urgent care

Out of
Network
X%
Coinsurance
after
deductible

Hospital Stay Facility fee (e.g., hospital room)

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Hospital Stay Physician/surgeon fee

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Mental/Behavioral health outp

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

50

50

50

50

50

50

50

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

patient services

Substance use disorder outpatient services

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Prenatal and postnatal care

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Delivery and all inpatient services for

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

50

50

50

50

50

50

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

Limitations
and Exception

Home health care

Rehabilitation services

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Habilitation services

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Sk

In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

50

50

50

50

50

50

50

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

killed nursing care

Out of
Network
X%
Coinsurance
after
deductible

Durable medical equipment

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Hospice service

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Eye exam for childr

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

50

50

50

50

50

50

50

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

ren

Glasses for children

Dental check-up for children

Plan Brochure
Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

Limitations
and Exception In Network
X%
Coinsurance
after
deductible

Out of
Network
X%
Coinsurance
after
deductible

50

50

50

50

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

X%
Coinsurance
after
deductible

Limitations
and Exception

Excluded Services

Acupuncture, Bariatric Surgery, Nonemergency care when travelling outside the
U.S., Chiropractic Care, Cosmetic Surgery,
Dental care (adult), Hearing aids, Infertility
treatment, Long-term care, Private-duty
i R ti
( d lt) R ti f t