CMS-10407 Sample Completed SBC

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013

S ummary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.[insert] or by calling 1-800-[insert].

Important Questions	Answers	Why this Matters:
What is the overall deductible?	$500 person / $1,000 family Doesn’t apply to preventive care	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.
Are there other deductibles for specific services?	Yes. $300 for prescription drug coverage. There are no other specific deductibles.	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.
Is there an out–of–pocket limit on my expenses?	Yes. For participating providers $2,500 person / $5,000 family For non-participating providers $4,000 person / $8,000 family	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.
What is not included in the out–of–pocket limit?	Premiums, balance-billed charges, and health care this plan doesn’t cover.	Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall annual limit on what the plan pays?	No.	The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a network of providers?	Yes. See www.[insert].com or call 1-800-[insert] for a list of participating providers.	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 in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to see a specialist?	No. You don’t need a referral to see a specialist.	You can see the specialist you choose without permission from this plan.
Are there services this plan doesn’t cover?	Yes.	S OMB Control Numbers 1545-XXXX, 1210-0147, and 0938-1146 ome of the services this plan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.

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. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven’t met your deductible. The amount the plan pays 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 participating providers by charging you lower deductibles, co-payments and co-insurance amounts.

Common Medical Event	Services You May Need	Your cost if you use a		Limitations & Exceptions
		Participating Provider	Non-Participating Provider
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness	$35 co-pay/visit	40% co-insurance	–––––––––––none–––––––––––
	Specialist visit	$50 co-pay/visit	40% co-insurance	–––––––––––none–––––––––––
	Other practitioner office visit	20% co-insurance for chiropractor and acupuncture	40% co-insurance for chiropractor and acupuncture	–––––––––––none–––––––––––
	Preventive care/screening/immunization	No charge	40% co-insurance
If you have a test	Diagnostic test (x-ray, blood work)	$10 co-pay/test	40% co-insurance	–––––––––––none–––––––––––
	Imaging (CT/PET scans, MRIs)	$50 co-pay/test	40% co-insurance	–––––––––––none–––––––––––
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www. [insert].	Generic drugs	$10 co-pay/ prescription (retail and mail order)	40% co-insurance	Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription)
	Preferred brand drugs	20% co-insurance (retail and mail order)	40% co-insurance	–––––––––––none–––––––––––
	Non-preferred brand drugs	40% co-insurance (retail and mail order)	60% co-insurance	–––––––––––none–––––––––––
	Specialty drugs	50% co-insurance	70% co-insurance	–––––––––––none–––––––––––
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
	Physician/surgeon fees	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
If you need immediate medical attention	Emergency room services	20% co-insurance	20% co-insurance	–––––––––––none–––––––––––
	Emergency medical transportation	20% co-insurance	20% co-insurance	–––––––––––none–––––––––––
	Urgent care	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
If you have a hospital stay	Facility fee (e.g., hospital room)	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
	Physician/surgeon fee	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
If you have mental health, behavioral health, or substance abuse needs	Mental/Behavioral health outpatient services	$35 co-pay/office visit and 20% co-insurance other outpatient services	40% co-insurance	–––––––––––none–––––––––––
	Mental/Behavioral health inpatient services	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
	Substance use disorder outpatient services	$35 co-pay/office visit and 20% co-insurance other outpatient services	40% co-insurance	–––––––––––none–––––––––––
	Substance use disorder inpatient services	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
If you are pregnant	Prenatal and postnatal care	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
	Delivery and all inpatient services	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
If you need help recovering or have other special health needs	Home health care	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
	Rehabilitation services	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
	Habilitation services	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
	Skilled nursing care	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
	Durable medical equipment	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
	Hospice service	20% co-insurance	40% co-insurance	–––––––––––none–––––––––––
If your child needs dental or eye care	Eye exam	$35 co-pay/ visit	Not Covered	Limited to one exam per year
	Glasses	20% co-insurance	Not Covered	Limited to one pair of glasses per year
	Dental check-up	No Charge	Not Covered	Covers up to $50 per year

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.)
Cosmetic surgery Dental care (Adult) Infertility treatment	Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing	Routine eye care (Adult) Routine foot care

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.)
Acupuncture (if prescribed for rehabilitation purposes) Bariatric surgery	Chiropractic care Hearing aids	Most coverage provided outside the United States. See www.[insert] Weight loss programs

Your Rights to Continue Coverage:

** Individual health insurance sample – 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].

OR

** Group health coverage sample – If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.”

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 questions about your rights, this notice, or assistance, you can contact: [insert applicable contact information from instructions].

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

About these Coverage Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Having a baby
(normal delivery)

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 will also be different.

See the next page for important information about these examples.

 Amount owed to providers: $7,540

 Plan pays $5,490

 Patient pays $2,050

Sample care costs:

Hospital charges (mother)	$2,700
Routine obstetric care	$2,100
Hospital charges (baby)	$900
Anesthesia	$900
Laboratory tests	$500
Prescriptions	$200
Radiology	$200
Vaccines, other preventive	$40
Total	$7,540

Patient pays:

Deductibles	$700
Co-pays	$30
Co-insurance	$1320
Limits or exclusions	$0
Total	$2,050

Managing type 2 diabetes
(routine maintenance of

a well-controlled condition)

 Amount owed to providers: $4,100

 Plan pays $2,480

 Patient pays $ 1,620

Sample care costs:

Prescriptions	$1,500
Medical Equipment and Supplies	$1,300
Office Visits and Procedures	$730
Education	$290
Laboratory tests	$140
Vaccines, other preventive	$140
Total	$4,100

Patient pays:

Deductibles	$800
Co-pays	$500
Co-insurance	$240
Limits or exclusions	$80
Total	$1,620

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].

Questions and answers about the 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 by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

• The patient’s condition was not an excluded or preexisting condition.

• All services and treatments started and ended in the same coverage 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 in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, 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.

Does the Coverage Example predict my own care needs?

 No. Treatments shown are just examples. The care you would receive for this condition 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.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in 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-of-pocket costs, such as co-payments, deductibles, and co-insurance. You should also 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.

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uestions: Call 1-800-[insert] or visit us at www.[insert].com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary

at www.[insert] or call 1-800-[insert] to request a copy.