Attachment F – Checklist and Directions for Gathering Requested Documents

Attachment F – Checklist and Directions for Gathering Requested Documents

Health Insurance Coverage and Benefits Checklist

What do I have to do?

1. Collect your Summary of Benefits and Coverage (SBC). This document is described below. You may be able to call your employer or insurance company to request this document be sent to you by mail or to find out about accessing it electronically, or you may already have a copy of this document at home. If possible, please try more than one approach to access your SBC (e.g., electronic and mail).

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

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. \
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.
Insurance Card	Insurance card identifying your plan.

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 employer or insurance company and request the documents be mailed to you.

Please print documents that you find online and bring the hardcopies to the interview. If you are unable to print the documents, please save them to a flash drive, email them to [email protected], or bring the web address and login information you used to access the information with you to the interview.

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. These documents may be printed or electronic.

Document	How 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

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