CMS-10407 Completed SBC Second Year

Summary of Benefits and Coverage and Uniform Glossary

CMS-10407 - sample_completed_sbc_second_year

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⚠️ Notice: This form may be outdated.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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Insurance Company 1: Plan Option 1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 – 12/31/2014
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?

You must pay all the costs up to the deductible amount before this plan begins to pay for
$500 person /
covered services you use. Check your policy or plan document to see when the deductible
$1,000 family
starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
Doesn’t apply to preventive care 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.

Is there an out–of–
pocket limit on my
expenses?

Yes. For participating providers
$2,500 person / $5,000
The out-of-pocket limit is the most you could pay during a coverage period (usually one
family
year) for your share of the cost of covered services. This limit helps you plan for health
For non-participating providers care expenses.
$4,000 person / $8,000 family

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

Are there services this
plan doesn’t cover?

Yes.

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.

Some 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.

Questions: Call 1-800-[insert] or visit us at www.[insert].
If you aren’t clear about any of the underlined 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.

OMB Control Numbers 1545-2229,
1210-0147, and 0938-1146
Released on April 23, 2013 (corrected)

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Insurance Company 1: Plan Option 1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 – 12/31/2014
Coverage for: Individual + Spouse | Plan Type: PPO

 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
 Coinsurance 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 coinsurance 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, copayments and coinsurance amounts.

Common
Medical Event

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

If you have a test

Services You May Need

Primary care visit to treat an injury or illness
Specialist visit
Other practitioner office visit
Preventive care/screening/immunization
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)

Your Cost If
You Use a
Participating
Provider
$35 copay/visit
$50 copay/visit
20% coinsurance
for chiropractor
and acupuncture
No charge
$10 copay/test
$50 copay/test

Your Cost If
You Use a
NonParticipating
Provider
40% coinsurance
40% coinsurance
40% coinsurance
for chiropractor
and acupuncture
40% coinsurance
40% coinsurance
40% coinsurance

Limitations & Exceptions

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Insurance Company 1: Plan Option 1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Common
Medical Event

If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at www.
[insert].
If you have
outpatient surgery
If you need
immediate medical
attention
If you have a
hospital stay

Services You May Need

Generic drugs
Preferred brand drugs
Non-preferred brand drugs

Your Cost If
You Use a
Participating
Provider
$10 copay/
prescription (retail
and mail order)
20% coinsurance
(retail and mail
order)
40% coinsurance
(retail and mail
order)

Coverage Period: 01/01/2014 – 12/31/2014
Coverage for: Individual + Spouse | Plan Type: PPO
Your Cost If
You Use a
NonParticipating
Provider

Limitations & Exceptions

40% coinsurance

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

40% coinsurance

–––––––––––none–––––––––––

60% coinsurance

–––––––––––none–––––––––––

Specialty drugs

50% coinsurance

70% coinsurance

–––––––––––none–––––––––––

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

20% coinsurance

40% coinsurance

–––––––––––none–––––––––––

Physician/surgeon fees
Emergency room services
Emergency medical transportation
Urgent care
Facility fee (e.g., hospital room)
Physician/surgeon fee

20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

40% coinsurance
20% coinsurance
20% coinsurance
40% coinsurance
40% coinsurance
40% coinsurance

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Insurance Company 1: Plan Option 1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Common
Medical Event

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

If you are pregnant
If you need help
recovering or have
other special health
needs

If your child needs
dental or eye care

Services You May Need

Your Cost If
You Use a
Participating
Provider

$35 copay/office
visit and 20%
Mental/Behavioral health outpatient services
coinsurance other
outpatient services
Mental/Behavioral health inpatient services
20% coinsurance
$35 copay/office
visit and 20%
Substance use disorder outpatient services
coinsurance other
outpatient services
Substance use disorder inpatient services
20% coinsurance
Prenatal and postnatal care
20% coinsurance
Delivery and all inpatient services
20% coinsurance
Home health care
20% coinsurance
Rehabilitation services
20% coinsurance
Habilitation services
20% coinsurance
Skilled nursing care
20% coinsurance
Durable medical equipment
20% coinsurance
Hospice service
20% coinsurance
Eye exam
$35 copay/ visit
Glasses
20% coinsurance
Dental check-up
No Charge

Coverage Period: 01/01/2014 – 12/31/2014
Coverage for: Individual + Spouse | Plan Type: PPO
Your Cost If
You Use a
NonParticipating
Provider

Limitations & Exceptions

40% coinsurance

–––––––––––none–––––––––––

40% coinsurance

–––––––––––none–––––––––––

40% coinsurance

–––––––––––none–––––––––––

40% coinsurance
40% coinsurance
40% coinsurance
40% coinsurance
40% coinsurance
40% coinsurance
40% coinsurance
40% coinsurance
40% coinsurance
Not Covered
Not Covered
Not Covered

–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
–––––––––––none–––––––––––
Limited to one exam per year
Limited to one pair of glasses per year
Covers up to $50 per year

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Insurance Company 1: Plan Option 1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 – 12/31/2014
Coverage for: Individual + Spouse | Plan Type: PPO

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



Long-term care



Routine eye care (Adult)



Dental care (Adult)



Routine foot care



Infertility treatment

Non-emergency care when traveling outside
the U.S.



Private-duty nursing

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

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Insurance Company 1: Plan Option 1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 – 12/31/2014
Coverage for: Individual + Spouse | Plan Type: PPO

Your Rights to Continue Coverage:
** Individual health insurance sample –

** Group health coverage 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:

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.



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].

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].

Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy [does/
does not] provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage [does/does not] meet the minimum value standard for the benefits it provides.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-800-[insert] or visit us at www.[insert].
If you aren’t clear about any of the underlined 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.

6 of 8

Insurance Company 1: Plan Option 1

Coverage Period: 1/1/2014 – 12/31/2014
Coverage for: Individual + Spouse | Plan Type: PPO

Coverage Examples

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.

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.

Having a baby

Managing type 2 diabetes

(normal delivery)

(routine maintenance of
a well-controlled condition)

 Amount owed to providers: $7,540
 Plan pays $5,490
 Patient pays $2,050

 Amount owed to providers: $5,400
 Plan pays $3,520
 Patient pays $1,880

Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total

$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540

Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total

$2,900
$1,300
$700
$300
$100
$100
$5,400

Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total

$700
$30
$1320
$0
$2,050

Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total

$800
$500
$500
$80
$1,880

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].

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Insurance Company 1: Plan Option 1
Coverage Examples

Coverage Period: 1/1/2014 – 12/31/2014
Coverage for: Individual + Spouse | Plan Type: PPO

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 innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.

What does a Coverage Example
show?

Can I use Coverage Examples
to compare plans?

For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance 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.

Yes. When you look at the Summary of

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.

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-ofpocket costs, such as copayments,
deductibles, and coinsurance. 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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File Type	application/pdf
Author	Beth Baum
File Modified	2013-04-25
File Created	2013-04-25