SBC template 4.4

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The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
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 underlined 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 services covered before you meet your deductible?


Are there other
deductibles for specific services?
$

What is the out-of-pocket limit for this plan?
$

What is not included in
the out-of-pocket limit?


Will you pay less if you use a network provider?


Do you need a referral to see a specialist?










All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common 
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important Information


Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most) 

If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness




Specialist 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].com
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 care




Emergency medical transportation




Urgent care



If you have a hospital stay
Facility fee (e.g., hospital room)




Physician/surgeon fees



If you need mental health, behavioral health, or substance abuse services
Outpatient services




Inpatient services



If you are pregnant
Office visits




Childbirth/delivery professional services




Childbirth/delivery facility services



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
Children’s eye exam




Children’s glasses




Children’s dental check-up




Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
    • 
    • 
    • 

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
    • 
    • 
    • 

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: [insert State, HHS, DOL, and/or other applicable agency contact information]. Other coverage options may be 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: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: [insert applicable contact information from instructions].

Does this plan provide Minimum Essential Coverage?  [Yes/No]
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards?  [Yes/No] 
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

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.––––––––––––––––––––––


















 The plan’s overall deductible 	$
 Specialist [cost sharing]	$
 Hospital (facility) [cost sharing]	%
 Other [cost sharing]	%

This EXAMPLE event includes services like: 
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia) 

Total Example Cost
$
 
In this example, Peg would pay:
Cost Sharing
Deductibles
$
Copayments
$
Coinsurance
$
What isn’t covered
Limits or exclusions
$
The total Peg would pay is
$









 The plan’s overall deductible 	$
 Specialist [cost sharing]	$
 Hospital (facility) [cost sharing]	%
 Other [cost sharing]	%

This EXAMPLE event includes services like: 
Primary care physician office visits (including disease education)
Diagnostic tests (blood work)
Prescription drugs 
Durable medical equipment (glucose meter) 

Total Example Cost
$
 
In this example, Joe would pay:
Cost Sharing
Deductibles
$
Copayments
$
Coinsurance
$
What isn’t covered
Limits or exclusions
$
The total Joe would pay is
$








 
 The plan’s overall deductible 	$
 Specialist [cost sharing]	$
 Hospital (facility) [cost sharing]	%
 Other [cost sharing]	%

This EXAMPLE event includes services like: 
Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

Total Example Cost
$
 
In this example, Mia would pay:
Cost Sharing
Deductibles
$
Copayments
$
Coinsurance
$
What isn’t covered
Limits or exclusions
$
The total Mia would pay is
$