Attachment F – Checklist and Directions for Gathering Requested Documents

Attachment F – Checklist and Directions for Gathering Requested Documents

What do I have to do?

1. Collect the documents described below, as well as any other documents you can obtain that provide information about the services your health plan covers and the costs associated with those services.

1. Complete the checklist on the back.

2. Put the documents in the provided folder and bring it with you to the interview.

Document	Description
Summary of Benefits and Coverage (SBC)	This is usually a table that includes information about what the plan covers and what you would pay for covered services. It will list services, like a visit to a specialist, and what you will pay for that service. It may compare various offered plans to help you decide the best plan for you.
Health Policy Booklet	This is a bound booklet that your insurance company provides specific to your health plan. The cover will indicate the specific plan. The contents include a summary of benefits and information about your insurance policy.
Insurance Plan Summary	A summary of benefits for your plan, including eligibility and coverage.

Documents will include words like deductible, out-of-pocket, copayment, and coinsurance.

Where can I find the documents?

There are various places you may find information about your health insurance plan:

• Hardcopy documents that you have at home.

• Online from your employer website.

• Online from your health insurance company member portal.

• Contact your insurance company and request the documents be mailed to you.

Please print documents that you find online and bring the hardcopies to the focus group/interview. If you are unable to print, please download the documents and bring them with you on a flash drive.

Your interview is scheduled on:

____________________		_____	/	_____	/	_____
day of the week		mm		dd		yy

at	a	_____	:	__________
		appointment time

For each item on the checklist, record where you found the document and the time you spent locating the document.

Document	Where Did You Find It?	How Much Time Did You Spend Locating It?
☐ Summary of Benefits and Coverage (SBC)
☐ Health Policy Booklets
☐ Insurance Plan Summary Documents
☐ Other Insurance Coverage Documents
☐ Your Insurance Card

Please remember to bring your insurance card to the interview!

If you have any questions, please contact Jill Simmerman at (240) 333-3363 or [email protected].