CMS-10407 Appendix A

Summary of Benefits and Coverage and Uniform Glossary

Appendix_A_ SBC PlanFinder New Benefit Template

SBC Disclosure

OMB: 0938-1146

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1146 can be found here:

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IFP Benefits Template v5.0

Issuer ID

Enter the
Issuer ID.

Product
Smart ID

Enter the
Product
Smart ID.

Plan ID

Plan Name

Enter the Plan ID. Enter the Plan Name.

Plan Effective Date

Enter the Plan
Effective Date.

Collection Control Number(s): 0938-1086; 1545-2229; 1210-0147; and 0938-1146).

Plan Expiration Date

Enter the Plan
Expiration Date.

Product Type

HSA-Eligible

Enter one of the
following Plan
Types:
INDEMNITY,
PPO, POS, EPO,
HMO, or
Other/Describe.

Enter Yes or
No. Enter Yes
if this plan
qualifies as
an HSAEligible
HDHP.

Same-Sex
Partners

Does this plan
allow
enrollment of
same-sex
partners?

Domestic
Partners

Annual Deductible (IN)

Does this plan Enter the Annual Inallow
Network Deductible for
enrollment of this plan.
domestic
partners?

Annual Deductible (OON)

Enter the Annual Out-ofNetwork Deductible for this
plan.

No Deductible

Deductible Exceptions

List the services not subject Lists the services that do
to the deductible separated not count towards the
by commas.
deductible separated by
commas

Other Deductible 1

Enter a service for which
there is a seperate
deductible

Other Deductible 1 (IN)

Enter the In-Network
Deductible for this service

Other Deductible 1 (OON)

Enter the Out-Of-Network
Deductible for this service

Other Deductible 2

Enter a service for which
there is a seperate
deductible

Other Deductible 2 (IN)

Enter the In-Network
Deductible for this service

Other Deductible 2 (OON)

Enter the Out-Of-Network
Deductible for this service

Collection Control Number(s): 0938-1086; 1545-2229; 1210-0147; and 0938-1146).

Other Deductible 3

Enter a service for which
there is a seperate
deductible

Other Deductible 3 (IN)

Enter the In-Network
Deductible for this service

Other Deductible 3 (OON)

Enter the Out-Of-Network
Deductible for this service

More Deductibles

PCP Copay
(IN)

PCP Copay
(OON)

If there are additional
services that require a
separate Deductible select
"Yes" otherwise select "No"

Enter the InNetwork PCP
Copay for this
plan.

Enter the Outof-Network
PCP Copay
for this plan.

Coinsurance
(IN)

Enter the InNetwork
Coinsurance
amount for
this plan.

Coinsurance
(OON)

Enter the Outof-Network
Coinsurance
amount for
this plan.

Annual Out-ofPocket Limit (IN)

Enter the InNetwork Out-ofPocket Maximum
amount for this
plan.

Annual Out-ofPocket Limit (OON)

Enter the Out-ofNetwork Out-ofPocket Maximum
amount for this
plan.

Annual Out-ofPocket Limit
Elements

Enter what
elements are
calculated the
for the Annual
Out-of-Pocket
Limit.

Excluded Annual Out- Excluded Annual Outof-Pocket Limit (IN) of-Pocket Limit (OON)

Annual Max
Benefit (IN)

Is a Referral Required to
see a Specialist?

Describe exclusions Describe exclusions to Enter the Annual Select "Yes" if a Referral is
to the Annual Out-of- the Annual Out-ofIn-Network
required to see a specialist
Pocket Limit (IN)
Pocket Limit (OON)
Maximum Benefit otherwise select "No"
amount for this
plan.

Collection Control Number(s): 0938-1086; 1545-2229; 1210-0147; and 0938-1146).

Type of Specialists Requiring a
Referral

Primary Care Visit to
Treat Injury or Illness
(IN)

Enter the specialists by service Enter the applicable Inand indicate if its In or Out of
Network amount.
Network (e.g Specialist (IN),
Diagnostic X-Ray (OON))
separated by commas

Primary Care
Visit to Treat Primary Care Visit to Treat
Injury or
Injury or Illness Exceptions
Illness (OON)
Enter the
applicable
Out-ofNetwork
amount.

Each limitation or exception
should specify dollar
amounts, service limitations,
and annual maximums if
applicable. Language should
be formatted as follows
“Coverage is limited to
$XX/visit and $XXX annual
max.” or “No coverage for
XXXX.”

Specialist
Visit (IN)

Enter the
applicable InNetwork
amount.

Specialist
Visit (OON)

Enter the
applicable
Out-ofNetwork
amount.

Other
Other Practitioner
Practitioner
Office Visit
Specialist Visit Exceptions
Office Visit
(Nurse,Physician
(Nurse,Physician
Assistant) (IN)
Assistant) (OON)

Other Practitioner Office
Visit (Nurse,Physician
Assistant) Exceptions

Preventive
Preventive
Care/Screening/I
Care/Screening/I
mmunization
mmunization (IN)
(OON)

Each limitation or exception Enter the
Enter the
Each limitation or exception Enter the
Enter the
should specify dollar
applicable Inapplicable Out-of- should specify dollar
applicable Inapplicable Out-ofamounts, service limitations, Network amount. Network amount. amounts, service limitations, Network amount. Network amount.
and annual maximums if
and annual maximums if
applicable. Language should
applicable. Language should
be formatted as follows
be formatted as follows
“Coverage is limited to
“Coverage is limited to
$XX/visit and $XXX annual
$XX/visit and $XXX annual
max.” or “No coverage for
max.” or “No coverage for
XXXX.”
XXXX.”

Preventive
Care/Screening/Immunizatio
n Exceptions

Diagnostic
Test (X-Ray
and Lab
Work) (IN)
Enter the
applicable InNetwork
amount.

Diagnostic
Test (X-Ray
and Lab
Work) (OON)
Enter the
applicable
Out-ofNetwork
amount.

Imaging
Imaging
Diagnostic Test (X-Ray and
(CT/PET
(CT/PET
Lab Work) Exceptions
Scans, MRIs) - Scans, MRIs) (IN)
(OON)
Each limitation or exception
should specify dollar
amounts, service limitations,
and annual maximums if
applicable. Language should
be formatted as follows
“Coverage is limited to
$XX/visit and $XXX annual
max.” or “No coverage for
XXXX.”

Enter the
applicable InNetwork
amount.

Collection Control Number(s): 0938-1086; 1545-2229; 1210-0147; and 0938-1146).

Enter the
applicable
Out-ofNetwork
amount.

Imaging (CT/PET Scans,
MRIs) Exceptions

Generic
Generic
Drugs -Retail Drugs -Retail
(IN)
(OON)

Enter the
applicable
Fixed Cost or
Co-Insurance
amount.

Generic
Drugs -Mail
Order (IN)

Generic
Drugs -Mail
Order (OON)

Enter the
applicable
Fixed Cost or
Co-Insurance
amount.

Generic Drugs Exceptions

Preferred
Preferred
Preferred
Preferred
Brand Drugs - Brand Drugs Brand Drugs - Brand Drugs Mail Order
Mail Order
Retail (IN)
Retail (OON)
(IN)
(OON)
Enter the
applicable
Fixed Cost or
Co-Insurance
amount.

Enter the
applicable
Fixed Cost or
Co-Insurance
amount.

Preferred Brand Drugs
Exceptions

Non-Preferred Non-Preferred
Brand Drugs - Brand Drugs Retail (IN)
Retail (OON)

Enter the
applicable
Fixed Cost or
Co-Insurance
amount.

Non-Preferred Non-Preferred
Specialty
Specialty
Brand Drugs - Brand Drugs - Non-Preferred Brand Drugs
Drugs - Retail Drugs - Retail
Mail Order
Mail Order
Exceptions
(IN)
(OON)
(IN)
(OON)
Enter the
applicable
Fixed Cost or
Co-Insurance
amount.

Enter the
applicable
Fixed Cost or
Co-Insurance
amount.

Specialty
Drugs - Mail
Order (IN)

Enter the
applicable
Fixed Cost or
Co-Insurance
amount.

Collection Control Number(s): 0938-1086; 1545-2229; 1210-0147; and 0938-1146).

Specialty
Drugs - Mail Specialty Drugs Exceptions
Order (OON)

Enter the
applicable
Fixed Cost or
Co-Insurance
amount.

Outpatient
Facility Fee
(e.g.,
Ambulatory
Surgery
Center) (IN)
Enter the
applicable InNetwork
amount.

Outpatient
Facility Fee
Outpatient Facility Fee (e.g., Outpatient Surgery Outpatient Surgery
Outpatient Surgery
Emergency
(e.g.,
Ambulatory Surgery Center) - Physician/Surgical Physician/Surgical Physician/Surgical Services Room
Ambulatory
Exceptions
Services (IN)
Services (OON)
Exceptions
Services (IN)
Surgery
Center) (OON)
Enter the
applicable
Out-ofNetwork
amount.

Each limitation or exception Enter the
should specify dollar
applicable Inamounts, service limitations, Network amount.
and annual maximums if
applicable. Language should
be formatted as follows
“Coverage is limited to
$XX/visit and $XXX annual
max.” or “No coverage for
XXXX.”

Enter the
applicable Out-ofNetwork amount.

Enter the
applicable InNetwork
amount.

Emergency
Room
Services
(OON)
Enter the
applicable
Out-ofNetwork
amount.

Emergency
Emergency Room Services
Transportation/A
Exceptions
mbulance (IN)

Emergency
Transportation/
Ambulance
(OON)
Enter the
applicable Outof-Network
amount.

Emergency
Transportation/Ambulance
Exceptions

Urgent Care
(IN)

Enter the
applicable InNetwork
amount.

Urgent Care
(OON)

Enter the
applicable
Out-ofNetwork
amount.

Urgent Care Exceptions

Collection Control Number(s): 0938-1086; 1545-2229; 1210-0147; and 0938-1146).

Inpatient
Inpatient
Inpatient
Inpatient
Hospital
Hospital
Inpatient Hospital Services
Physician and
Physician and
Services (e.g., Services (e.g.,
(e.g., Hospital Stay)
Surgical
Surgical
Hospital Stay) Hospital Stay)
Exceptions
Services
Services (IN)
(IN)
(OON)
(OON)
Enter the
applicable InNetwork
amount.

Enter the
applicable
Out-ofNetwork
amount.

Enter the
applicable InNetwork
amount.

Enter the
applicable
Out-ofNetwork
amount.

Inpatient Physician and
Surgical Services
Exceptions

Mental/Behavioral
Health Outpatient
Services (IN)

Mental/Behavioral
Health Outpatient
Services (OON)

Each limitation or exception Enter the applicable Enter the
should specify dollar
In-Network amount. applicable Out-ofamounts, service limitations,
Network amount.
and annual maximums if
applicable. Language should
be formatted as follows
“Coverage is limited to
$XX/visit and $XXX annual
max.” or “No coverage for
XXXX.”

Mental/Behavioral Health
Outpatient Services
Exceptions

Mental/Behavioral
Health Inpatient
Services (IN)

Each limitation or exception Enter the applicable
should specify dollar
In-Network amount.
amounts, service limitations,
and annual maximums if
applicable. Language should
be formatted as follows
“Coverage is limited to
$XX/visit and $XXX annual
max.” or “No coverage for
XXXX.”

Mental/Behavioral
Health Inpatient
Services (OON)

Enter the applicable
Out-of-Network
amount.

Mental/Behavioral Health
Inpatient Services
Exceptions

Substance Abuse
Disorder
Outpatient
Services (IN)

Substance
Abuse
Disorder
Outpatient
Services
(OON)
Enter the
applicable
Out-ofNetwork
amount.

Substance Abuse Disorder
Outpatient Services
Exceptions

Substance Abuse
Disorder Inpatient
Services (IN)

Substance Abuse
Disorder Inpatient
Services (OON)

Each limitation or exception Enter the applicable Enter the applicable
should specify dollar
In-Network amount. Out-of-Network
amounts, service limitations,
amount.
and annual maximums if
applicable. Language should
be formatted as follows
“Coverage is limited to
$XX/visit and $XXX annual
max.” or “No coverage for
XXXX.”

Collection Control Number(s): 0938-1086; 1545-2229; 1210-0147; and 0938-1146).

Substance Abuse Disorder
Inpatient Services
Exceptions

Prenatal and
Postnatal
Care (IN)

Enter the
applicable InNetwork
amount.

Prenatal and
Postnatal
Care (OON)

Enter the
applicable
Out-ofNetwork
amount.

Prenatal and Postnatal Care
Exceptions

Delivery and
All Inpatient
Services for
Maternity
Care (IN)
Enter the
applicable InNetwork
amount.

Delivery and
All Inpatient
Services for
Maternity
Care (OON)
Enter the
applicable
Out-ofNetwork
amount.

Delivery and All Inpatient
Home Health Home Health
Home Health Care Services
Services for Maternity Care Care Services Care Services
Exceptions
Exceptions
(IN)
(OON)

Enter the
applicable InNetwork
amount.

Enter the
applicable
Out-ofNetwork
amount.

Inpatient
Rehabilitation
Services (IN)

Enter the
applicable InNetwork
amount.

Inpatient
Rehabilitation
Services (OON)

Enter the
applicable Outof-Network
amount.

Inpatient Rehabilitation
Services Exceptions

Outpatient
Outpatient
Rehabilitation Rehabilitation
Services (IN) Services (OON)

Enter the
applicable InNetwork
amount.

Enter the
applicable Outof-Network
amount.

Outpatient Rehabilitation
Services Exceptions

Habilitation
Services (IN)

Enter the
applicable InNetwork
amount.

Collection Control Number(s): 0938-1086; 1545-2229; 1210-0147; and 0938-1146).

Habilitation
Services
(OON)

Enter the
applicable
Out-ofNetwork
amount.

Habilitation Services
Exceptions

Skilled
Nursing
Facility (IN)

Enter the
applicable InNetwork
amount.

Skilled
Nursing
Facility (OON)

Enter the
applicable
Out-ofNetwork
amount.

Skilled Nursing Facility
Exceptions

Durable
Medical
Equipment
(IN)
Enter the
applicable InNetwork
amount.

Durable
Medical
Equipment
(OON)
Enter the
applicable
Out-ofNetwork
amount.

Durable Medical Equipment
Hospice
Exceptions
Services (IN)

Enter the
applicable InNetwork
amount.

Hospice
Services
(OON)

Enter the
applicable
Out-ofNetwork
amount.

Hospice Services
Exceptions

Routine Eye
Exam for
Children (IN)

Enter the
applicable InNetwork
amount.

Routine Eye
Exam for
Children
(OON)
Enter the
applicable
Out-ofNetwork
amount.

Routine Eye Exam for
Children Exceptions

Eye Glasses
for Children
(IN)

Enter the
applicable InNetwork
amount.

Eye Glasses
for Children
(OON)

Enter the
applicable
Out-ofNetwork
amount.

Eye Glasses for Children
Exceptions

Collection Control Number(s): 0938-1086; 1545-2229; 1210-0147; and 0938-1146).

Dental CheckDental CheckUp for
Up for
Children
Children (IN)
(OON)
Enter the
applicable InNetwork
amount.

Enter the
applicable
Out-ofNetwork
amount.

Dental Check-Up for
Children Exceptions

Acupuncture

Each limitation or exception Select the
should specify dollar
applicable
amounts, service limitations, coverage.
and annual maximums if
applicable. Language should
be formatted as follows
“Coverage is limited to
$XX/visit and $XXX annual
max.” or “No coverage for
XXXX.”

Bariatric
Surgery

Select the
applicable
coverage.

NonEmergency
Care when
Travelling
Outside the
U.S.
Select the
applicable
coverage.

Chiropractic
Care

Select the
applicable
coverage.

Cosmetic
Surgery

Select the
applicable
coverage.

Routine
Dental
Services
(Adult)
Select the
applicable
coverage.

Hearing Aids

Select the
applicable
coverage.

Infertility
Treatment

Select the
applicable
coverage.

LongTerm/Custodial
Nursing Home
Care
Select the
applicable
coverage.

Private-Duty
Nursing

Select the
applicable
coverage.

Routine Eye
Exam (Adult)

Select the
applicable
coverage.

Routine Foot
Care

Select the
applicable
coverage.

Weight Loss
Programs

Select the
applicable
coverage.

Routine
Hearing Tests

Select the
applicable
coverage.

Plan Brochure

Enter the Plan Brochure URL.

Is notice required for
Pregnancy?

Select "Yes" if notice is
required for Pregnancy,
otherwise select "No"

Maternity Deductibles

Enter the Deductible
amount

Collection Control Number(s): 0938-1086; 1545-2229; 1210-0147; and 0938-1146).

Maternity Co-pays

Enter the Co-pays
amount

Maternity Co-insurance

Enter the Co-insurance
amount

Maternity Limits or
Exclusions

Enter the Limits or
Exclusion amount

Is Diabetes wellness
program offered?

Diabetes Deductibles

Select "Yes" if Diabetes Enter the Deductible
wellness program is
amount
offered, otherwise select
"No"

Diabetes Co-pays

Enter the Co-pays
amount

Diabetes Co-insurance

Enter the Co-insurance
amount

Diabetes Limits or
Exclusions

Enter the Limits or
Exclusion amount

File Type	application/pdf
File Title	RBIS IFP Benefits Template v5.0
Subject	IFP Benefits Template
Author	Payal Doshi
File Modified	2012-08-08
File Created	2012-08-08