Sample Completed SBC

Sample completed sbc 12-19-14 FINAL.doc

Affordable Care Act Section 2715 Summary Disclosures

Sample Completed SBC

OMB: 1210-0147

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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?

$500/person or
$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 1). The Common Medical Events chart below shows 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 or $5,000/family

For non-participating providers $4,000/person or $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, health care this plan doesn’t cover, [and out-of-network services].

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

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 health care provider, this plan will pay some or all of the costs of covered services. Lesser coverage, or no coverage, may be available for out-of-network providers. Be aware, your in-network doctor or hospital may use another out-of-network provider for some services (such as lab work).

Do I need a referral to see a specialist?

No. To see a specialist, you don’t need a referral from this plan.

You can see the specialist you choose without getting permission from this plan.



Common Medical Event

Services You May Need

Your Cost If You Use a

Participating Provider

Your Cost If You Use a

Non-Participating Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$35 copay/visit

40% coinsurance


–––––––––––none–––––––––––


Specialist visit

$50 copay/visit

40% coinsurance

Other practitioner office visit

20% coinsurance for chiropractor and acupuncture

40% coinsurance for chiropractor and acupuncture

Preventive care/screening/immunization

No charge

40% coinsurance

If you have a test

Diagnostic test (x-ray, blood work)

$10 copay/test

40% coinsurance

–––––––––––none–––––––––––

Imaging (CT/PET scans, MRIs)

$50 copay/test

40% coinsurance

If you need drugs to treat your illness or condition


More information about prescription drug coverage is available at www. [insert].

Generic drugs

$10 copay/

prescription (retail and mail order)

40% coinsurance

Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription)

Preferred brand drugs

20% coinsurance (retail and mail order)

40% coinsurance


–––––––––––none–––––––––––


Non-preferred brand drugs

40% coinsurance (retail and mail order)

60% coinsurance

Specialty drugs

50% coinsurance

70% coinsurance

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

20% coinsurance

40% coinsurance

–––––––––––none–––––––––––

Physician/surgeon fees

20% coinsurance

40% coinsurance

If you need immediate medical attention

Emergency room services

20% coinsurance

20% coinsurance

–––––––––––none–––––––––––

Emergency medical transportation

20% coinsurance

20% coinsurance

Urgent care

20% coinsurance

40% coinsurance

If you have a hospital stay

Facility fee (e.g., hospital room)

20% coinsurance

40% coinsurance

–––––––––––none–––––––––––

Physician/surgeon fees

20% coinsurance

40% coinsurance

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

$35 copay/office visit; 20% coinsurance/other outpatient services

40% coinsurance

–––––––––––none–––––––––––

Mental/Behavioral health inpatient services

20% coinsurance

40% coinsurance

Substance use disorder outpatient services

$35 copay/office visit; 20% coinsurance/other outpatient services

40% coinsurance

Substance use disorder inpatient services

20% coinsurance

40% coinsurance

If you are pregnant

Prenatal, postnatal care, delivery, and all inpatient services

20% coinsurance

40% coinsurance

–––––––––––none–––––––––––

If you need help recovering or have other special health needs

Home health care

20% coinsurance

40% coinsurance

–––––––––––none–––––––––––

Rehabilitation services

20% coinsurance

40% coinsurance

Habilitation services

20% coinsurance

40% coinsurance

Skilled nursing care

20% coinsurance

40% coinsurance

Durable medical equipment

20% coinsurance

40% coinsurance

Hospice services

20% coinsurance

40% coinsurance

If your child needs dental or eye care

Eye exam

$35 copay/visit

Not Covered

Plan coverage limited to one exam/year

Glasses

20% coinsurance

Not Covered

Plan coverage limited to one pair of glasses/year

Dental check-up

No Charge

Not Covered

Plan covers up to $50/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: 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 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].


Does this Coverage Satisfy the Individual Responsibility Requirement and Meet the Minimum Value Standard?

Yes. This coverage constitutes minimum essential coverage under the Affordable Care Act, so enrolling in this coverage satisfies your obligations under the individual responsibility requirement. In addition, this coverage provides a level of benefits specified in the Affordable Care Act as “minimum value.”

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

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.









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.


















Having a baby
(normal delivery)






Cost of care $14,150

Plan pays $11,650

Patient pays $2,550

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

$700

Copayments

$140

Coinsurance

$1660

Limits or exclusions

$0

Total

$2, 500







Managing type 2 diabetes
(routine maintenance of

a well-controlled condition)







Cost of care $6,100

Plan pays $4,130

Patient pays $1,970

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

$800

Copayments

$590

Coinsurance

$500

Limits or exclusions

$80

Total

$1,970

Note: The numbers in “Managing type 2 diabetes” assume the patient is participating in the plan’s 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].













Simple fracture
(with emergency room visit)






Cost of care $2,400

Plan pays $ 1,430

Patient pays $ 970

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

$560

Copayments

$100

Coinsurance

$300

Limits or exclusions

$10

Total

$970



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AuthorBeth Baum
Last Modified ByAmy Turner
File Modified2014-12-19
File Created2014-12-19

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