Summary of Benefits and Coverage

_______________________: _________________ Coverage Period: [See Instructions]

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: _____________ | Plan Type: _____

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 general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other bolded terms see the Glossary. You can view the Glossary at www.[insert].com or call 1-800-[insert] to request a copy.

Important Questions	Answers	Why This Matters:
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?
Does this plan use a network of providers?
Do I need a referral to see a specialist?

Common Medical Event	Services You May Need	Your Cost If You Use an In-network Provider	Your Cost If You Use an Out-of-network Provider		Limitations & Exceptions
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness
	Specialist visit
	Other practitioner office visit
	Preventive care/screening/immunization
If you have a test	Diagnostic test (x-ray, blood work)
	Imaging (CT/PET scans, MRIs)
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.[insert].	Generic drugs
	Preferred brand drugs
	Non-preferred brand drugs
	Specialty drugs
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)
	Physician/surgeon fees
If you need immediate medical attention	Emergency room services
	Emergency medical transportation
	Urgent care
If you have a hospital stay	Facility fee (e.g., hospital room)
	Physician/surgeon fees
If you have mental health, behavioral health, or substance abuse needs	Mental/Behavioral health outpatient services
	Mental/Behavioral health inpatient services
	Substance use disorder outpatient services
	Substance use disorder inpatient services
If you are pregnant	Prenatal and postnatal care
	Delivery and all inpatient services

Common Medical Event	Services You May Need	Your Cost If You Use an In-network Provider	Your Cost If You Use an Out-of-network Provider	Limitations & Exceptions
If you need help recovering or have other special health needs	Home health care
	Rehabilitation services
	Habilitation services
	Skilled nursing care
	Durable medical equipment
	Hospice services
If your child needs dental or eye care	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 or plan document for other excluded services.)

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.)

Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to continue health coverage after it would otherwise end. For more information, contact us at [insert contact information] or contact: [insert State, HHS, and/or DOL contact information, as applicable]. Other options to continue coverage are 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: 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 more information about your rights, this notice, or assistance, contact: [insert applicable contact information from instructions].

Individual Responsibility: [insert applicable language from instructions].

[Insert heading and applicable tagline(s):

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.––––––––––––––––––––––

This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. Treatments shown are just examples and your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Also, costs don’t include premiums you pay to buy coverage under a plan.

About these Coverage Examples:

These examples show how this plan might cover medical care in a few situations and show how deductibles, copayments, and coinsurance can add up. Use these examples to see, in general, how much financial protection a sample patient might get from coverage under this plan compared to other plans by comparing the “Patient Pays” section for the same example under each plan’s Summary of Benefits and Coverage.

Having a baby
(normal delivery)

 Cost of care $14,150

 Plan pays $

 Patient pays $

Sample care costs:

Hospital charges (mother)	$6,700
Routine obstetric care	$2,500
Hospital charges (baby)	$2,100
Anesthesia	$1,200
Laboratory tests	$1,000
Prescriptions	$200
Radiology	$200
Education	$200
Vaccines, other preventive	$50
Total	$14,150

Patient pays:

Deductibles	$
Copayments	$
Coinsurance	$
Limits or exclusions	$
Total	$

Managing type 2 diabetes
(routine maintenance of

a well-controlled condition)

 Cost of care $6,100

 Plan pays $

 Patient pays $

Sample care costs:

Prescriptions	$3,300
Medical Equipment and Supplies	$1,300
Office Visits and Procedures	$800
Education	$300
Laboratory tests	$200
Vaccines, other preventive	$200
Total	$6,100

Patient pays:

Deductibles	$
Copayments	$
Coinsurance	$
Limits or exclusions	$
Total	$

Simple fracture
(with emergency room visit)

 Cost of care $2,400

 Plan pays $

 Patient pays $

Sample care costs:

Emergency Services	$1,400
Medical Equipment and Supplies	$400
Office Visits and Procedures	$300
Physical Therapy	$200
Laboratory tests	$90
Prescriptions	$10
Total	$2,400

Patient pays:

Deductibles	$
Copayments	$
Coinsurance	$
Limits or exclusions	$
Total	$