Summary of Benefits and Coverage

What This Plan Covers and What it Costs

Instruction Guide for Group Coverage

Edition Date: February 2012
Purpose of the form: PHS Act section 2715 generally requires all group health plans
and health insurance issuers offering group health insurance coverage to provide
applicants, enrollees, and policyholders or certificate holders with an accurate summary
of benefits and coverage.
General Instructions: Read all instructions carefully before completing the form.
 Form language and formatting must be precisely reproduced, unless instructions
allow or instruct otherwise. Unless otherwise instructed, the plan or issuer must
use 12-point (as required by Federal law) font, and replicate all symbols,
formatting, bolding, and shading.
 Special Rule: To the extent a plan’s terms that are required to be described in
the SBC template cannot reasonably be described in a manner consistent with
the template and instructions, the plan or issuer must accurately describe the
relevant plan terms while using its best efforts to do so in a manner that is still as
consistent with the instructions and template format as reasonably possible.
Such situations may occur, for example, if a plan provides a different structure for
provider network tiers or drug tiers than is represented in the SBC template and
these instructions, if a plan provides different benefits based on facility type (such
as hospital inpatient versus non-hospital inpatient), in a case where a plan is
denoting the effects of a related health flexible spending arrangement or a health
reimbursement arrangement, or if a plan provides different cost sharing based on
participation in a wellness program.
 Plans and issuers must customize all identifiable company information

throughout the document, including websites and telephone numbers.

 The items shown on page 1 must always appear on page 1, and the rows of the
chart must always appear in the same order. The chart starting on page 2 must
always begin on page 2, and the rows shown in this chart must always appear in
the same order. However, the chart rows shown on page 2 may extend to page
3 if space requires, and the chart rows on page 3 may extend to the beginning of
page 4 if space requires. The Excluded Services and Other Covered Services
section may appear on page 3 or page 4, but must always immediately follow the
chart starting on page 2. The Excluded Services and Other Covered Services
section must be followed by the Your Rights to Continue Coverage section, the
Your Grievance and Appeals Rights section, and the Coverage Examples
section, in that order.
 Footer: The footer must appear at the bottom left of every page. The plan or
issuer must insert the appropriate telephone number and website information.

Group– February 2012

 For all form sections to be filled out by the plan or issuer (particularly in the
Answers column on page 1, and the Your Cost and Limitations & Exceptions
columns in the chart that starts on page 2), the plan or issuer should use plain
language and present the information in a culturally and linguistically appropriate
manner and utilize terminology understandable by the average individual. For
more information, see paragraph (a)(5) of the Departments’ final regulations.
 Plans and issuers with questions about completing the SBC may contact the
Department of Health and Human Services at [email protected] or the
Department of Labor at 866-444-EBSA(3272) or www.askebsa.dol.gov.

Filling out the form:
Top of page 1
Top Left Header (page 1):
On the top left hand corner of the first page, the plan or issuer must show the following
information:
First line: Show the plan name and name of plan sponsor and/or insurance company
as applicable in 16 point font and bold. Example: “Maximum Health Plan: Alpha
Insurance Group”.


Plans and issuers have the option to use their logo instead of typing in the
company name if the logo includes the name of the entity sponsoring the plan or
issuing the coverage.



The plan or issuer must use the commonly known company name.

Top Right Header (page 1):
On the top right hand corner of the first page, the plan or issuer must show the following
information:
First line: After Coverage Period, the plan or issuer must show the beginning and end
dates for the applicable coverage period (such as plan or policy year) in the following
format: “MM/DD/YYYY – MM/DD/YYYY”. For example: “Coverage Period:
01/01/2013 - 12/31/2013”.


If the coverage period end date is not known when the SBC is prepared, the plan
or issuer is permitted to insert only the beginning date of the coverage period.
For example: “Coverage Period: Beginning on or after 01/01/2013”.



If the SBC is being provided to satisfy the notice of material modification
requirements, the plan or issuer must show the beginning and end dates for the
period for which the modification is effective. For example, for a change effective
March 15, 2013, and a plan year beginning on January 1, 2013 and ending on
December 31, 2013: “Coverage Period: 03/15/2013 - 12/31/2013”.
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Second line:


After Coverage for, indicate who the coverage is for (such as Individual,
Individual + Spouse, Family). The plan or issuer should use the terms used in the
policy or plan documents.



After Plan Type, indicate the type of coverage, such as HMO, PPO, POS,

Indemnity, or High-deductible.

Disclaimer (page 1):
The disclaimer at the top of page 1 should be replicated and the plan or issuer may not
vary the font size, graphic, or formatting. The plan or issuer should insert a website and
telephone number for accessing or requesting copies of the policy or plan documents.
The plan or issuer should also include a website and telephone number for accessing or
requesting copies of the Uniform Glossary. (Note: the Uniform Glossary can be
accessed at: www.dol.gov/ebsa/healthreform and www.cciio.cms.gov. One or both of
these Internet addresses may be used as a website designated for obtaining the
Uniform Glossary.)

Important Questions/Answers/Why This Matters Chart
General Instructions for the Important Questions chart:


This chart must always appear on page 1, and the rows must always appear in
the same order. Plans and issuers must complete the Answers column for each
question on this chart, using the instructions below.



Plans and issuers must show the appropriate language in the Why This Matters
box as instructed in the instructions below. Plans and issuers must replicate the
language given for the Why This Matters box exactly, and may not alter the
language.



If there is a different amount for in-network and out-of-network expenses (such
as annual deductible, additional deductibles, or out-of-pocket limits), list both
amounts and indicate as such, using the terms to describe provider networks
used by the plan or issuer. For example, if the plan uses the terms “preferred
provider” and “non-preferred provider” and the annual deductible is $2,000 for a
preferred provider and $5,000 for a non-preferred provider, then the Answers
column should show “$2,000 preferred provider, $5,000 non-preferred provider”.

1. What Is The Overall Deductible?:
Answers column:
 If there is no overall deductible, answer “$0”.
 If there is an overall deductible, answer with the dollar amount and, if the
deductible is not annual, indicate the period of time that the deductible applies.

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 If there is an overall deductible, underneath the dollar amount, plans and issuers
must include language specifying major categories of covered services that are
NOT subject to this deductible. For example, “Does not apply to preventive care
and generic drugs”.
 If there is an overall deductible, underneath the dollar amount plans and issuers
must include language listing major exceptions, such as out-of-network coinsurance, deductibles for specific services and copayments, which do not count
toward the deductible. For example, “Out-of-network co-insurance and
copayments don’t count toward the deductible.”
 If portraying family coverage for which there is a separate deductible amount for
each individual and the family, show both the individual deductible and the family
deductible (for example, “$2,000 person / $3,000 family”).
Why This Matters column:
 If there is no overall deductible, show the following language: “See the chart
starting on page 2 for your costs for services this plan covers.”
 If there is an overall deductible, show the following language: “You must pay all
the costs up to the deductible amount before this plan begins to pay for covered
services you use. Check your policy or plan document to see when the
deductible starts over (usually, but not always, January 1st). See the chart
starting on page 2 for how much you pay for covered services after you meet the
deductible.”
2. Are There Other Deductibles for Specific Services?:
Answers column:
 If the overall deductible is the only deductible, answer with the phrase “No.”
 If there are other deductibles, answer “Yes”, then list the names and deductible
amounts of the three most significant deductibles other than the overall
deductible. Significance of deductibles is determined by the plan or issuer based
on two factors: probability of use and financial impact on an individual. Examples
of other deductibles include deductibles for Prescription Drugs and Hospital. For
example: “Yes, $2,000 for prescription drug expenses and $2,000 for
occupational therapy services”.
 If the plan has more than three other deductibles and not all deductibles are
shown, the following statement must appear at the end of the list: “There are
other specific deductibles.”
 If the plan has less than three other deductibles, the following statement must
appear at the end of the list: “There are no other specific deductibles.”
 If portraying family coverage for which there is a separate deductible amount for
each individual and the family, show both the individual and family deductible.
For example: “Prescription drugs -- Individual $200, Family $500”
Why This Matters column:
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 If there are no other deductibles, the plan or issuer must show the following
language: “You don’t have to meet deductibles for specific services, but see the
chart starting on page 2 for other costs for services this plan covers.”
 If there are other deductibles, the plan or issuer must show the following
language: “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.”
3. Is There An Out-of-Pocket Limit On My Expenses?:
Answers column:
 If there are no out-of-pocket limits, respond “No.”
 If there is an out-of-pocket limit, respond “Yes”, along with a specific dollar
amount that applies in each coverage period. For example: “Yes. $5,000”.
 If portraying family coverage, and there is a single out-of-pocket limit for each
individual and a separate out-of-pocket limit for the family, show both the
individual out-of-pocket limit and the family out-of-pocket limit (for example,
“Individual $1,000 / Family $3,000”).
 If there are separate out-of-pocket limits for in-network providers and out-ofnetwork providers, show both the in-network out-of-pocket limit and the out-ofnetwork out-of-pocket limit. Plans and issuers should use the terminology in the
policy or plan document (e.g., in-network, participating, or preferred). For
example: “For participating providers $2,500 person/$5,000 family; For nonparticipating providers $4,000 person/$8,000 family”
Why This Matters column:
 If there is an out-of-pocket limit, the plan or issuer must show the following
language: “The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered services. This
limit helps you plan for health care expenses.”
 If there is no out-of-pocket limit, the plan or issuer must show the following
language: “There’s no limit on how much you could pay during a coverage
period for your share of the cost of covered services.”
4. What Is Not Included In The Out-of-Pocket Limit?:
Answers column:
 If there is no out-of-pocket limit, indicate “This plan has no out-of-pocket limit.”
 If there is an out-of-pocket limit, the plan or issuer must list any major exceptions.
This list must always include the following three terms: premiums, balance-billed
charges (unless balanced billing is prohibited), and health care this plan doesn’t
cover. Depending on the plan, the list could also include: copayments, out-ofnetwork co-insurance, deductibles, and penalties for failure to obtain preauthorization for services. The plan or issuer must state that these items do not
count toward the limit. For example: “Copayments, premiums, balance-billed
charges, and health care this plan doesn’t cover.”
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Why This Matters column:
 If there is an out-of-pocket limit, the plan or issuer must show the following
language: “Even though you pay these expenses, they don’t count toward the
out–of–pocket limit.”
 If there is no out-of-pocket limit, the issuer must show “Not applicable because
there’s no out-of-pocket limit on your expenses.”
5. Is There An Overall Annual Limit On What The Plan Pays?:
Answers column:
 The plan or issuer should respond “Yes” or “No” based on whether the plan has
an overall annual limit.
 If the answer is “Yes”, the plan or issuer should include a brief description and
dollar amount of the overall annual limit. For example: “Yes, $2 million.”
 If the plan does not have an overall annual limit, the plan or issuer should state,
“No.”
Why This Matters column:
 If there is an overall annual limit, the plan or issuer must show the following
language: “This plan will pay for covered services only up to this limit during each
coverage period, even if your own need is greater. You’re responsible for all
expenses above this limit. The chart starting on page 2 describes specific
coverage limits, such as limits on the number of office visits.”
 If there is no overall annual limit, the plan or issuer must show the following
language: “The chart starting on page 2 describes any limits on what the plan
will pay for specific covered services, such as office visits.”
6. Does This Plan Use A Network of Providers?:
Answers column:
 If this plan does not use a network, the plan or issuer must respond, “No.”
 If the plan does use a network, the plan or issuer must respond, “Yes,” and
include information on where to find a list of preferred providers or in-network
providers, etc. For example: “Yes. For a list of preferred providers, see
www.[insert].com or call 1-800-[insert].” Plans and issuers should use the
terminology in the policy or plan document (e.g., in-network, participating, or
preferred).
Why This Matters column:
 If this plan uses a network, the plan or issuer must show the following language:
“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.”
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 If this plan does not use a network, the plan or issuer must show the following
language: “This plan treats providers the same in determining payment for the
same services.”
7. Do I Need A Referral To See A Specialist?:
Answers column:
 Plans and issuers should use plan specific language with respect to specialists.
For example, distinguishing between preferred and non-preferred specialists or
in-network and out-of-network specialists.
 Plans and issuers should specify whether written or oral approval is required to
see a specialist.
 Plans and issuers should specify whether specialist approval is different for
different plan benefits.
Why This Matters column:
 If there is a referral required, the plan or issuer must show the following
language: “This plan will pay some or all of the costs to see a specialist for
covered services but only if you have the plan’s permission before you see the
specialist.”
 If there is no referral required, the plan or issuer must show the following
language: “You can see the specialist you choose without permission from this
plan”.
8. Are there services this plan doesn’t cover?:
Answers column:
 If there are any items or services the plan doesn’t cover the plan or issuer should
answer “Yes”. (A “No” answer should be inserted only if the plan covers all items
and services without any exclusions or limitations, including any limitations based
on medical necessity.)
Why This Matters column:
 If there are no excluded services shown in the Services Your Plan Does Not
Cover box on page 3 or 4, then the plan or issuer must show the language: “See
your policy or plan document for information about excluded services.”
 If there are excluded services shown in the Services Your Plan Does Not Cover
box on page 3 or 4, then the plan or issuer must show the language: “Some of
the services this plan doesn’t cover are listed on page [3 or 4]. See your policy
or plan document for additional information about excluded services.” The plan
or issuer should insert the correct page (3 or 4) depending on where the Services
Your Plan Does Not Cover box appears on the form.

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Common Medical Event, Services, Cost Sharing, Limitations &

Exceptions

Cost Sharing Information Box:
 The first three bullets in the information box at the top of page 2 should be replicated
with the same text, formatting, graphic, bolded words, and bullet points. Only the
fourth bullet may change.
 The fourth bullet will change depending on the plan:
o For plans that use a network, the plan or issuer should fill in the blank on
the fourth bullet of the template, using the terminology that the plan or
issuer uses for “in-network” or “preferred provider”. This should be the
same term as used in the heading of the first sub-column under the Your
Cost column.
o For non-networked plans, the plan or issuer should delete the fourth bullet
and replace it with: “Your cost sharing does not depend on whether a
provider is in a network.”
Chart Starting on page 2:
Location of Chart:
This chart must always begin on page 2, and the rows shown on pages 2 and 3 must
always appear in the same order. However, the rows shown on page 2 may extend to
page 3 if space requires, and the rows shown on page 3 may extend to the beginning of
page 4 if space requires. The heading of the chart must appear on the top of all pages
used.
Your Cost columns:
 Plans and issuers may vary the number of columns depending upon the type of
coverage and the number of preferred provider networks. Most plans or issuers
that use a network should use two columns, although some plans or issuers with
more than one level of in-network provider may use three columns. Nonnetworked plans may use one column.
 Plans and issuers should insert the terminology used in the policy or plan
document to title the columns. For example, the columns may be called “Innetwork” and “Out-of-network”, or “Preferred Provider” and “Non-Preferred
Provider” based on the terms used in the policy. (Plans and issuers should be
aware that consumer testing has demonstrated that consumers more readily
understand the terms “In-network” and “Out-of-network”.) The sub-headings
should be deleted for non-networked plans with only one column.
 The columns should appear from left to right, from most generous cost sharing to
least generous cost sharing. For example, if a 3-column format is used, the
columns might be labeled (from left to right) “In-Network Preferred Provider,” “InNetwork Provider,” and then “Out-of-Network Provider.”

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 For HMOs providing no out-of-network benefits, the plan or issuer should insert
“Not covered” in all applicable boxes under the far-right sub-heading under the
Your Cost column (which, for coverage providing out-of-network benefits, would
usually be out-of-network provider or non-preferred provider column).
 Plans and issuers must complete the responses under these sub-headings
based on how the plan or issuer covers the specific services listed in the chart.
Fill in the Your Cost column(s) with the co-insurance percentage, the co-payment
amount, “No charge” if the employee pays nothing, or “Not covered” if the service
is not covered by the plan. When referring to co-insurance, include a percentage
valuation. For example: 20% co-insurance. When referring to co-payments,
include a per occurrence cost. For example: $20/visit or $15/prescription.
 Refer to the specific additional instructions below for details on completing the
Your Costs columns in the chart for the following common medical events:
o If you visit a health care provider’s office or clinic;
o If you need drugs to treat your illness or condition; and
o If you have mental health, behavioral health, or substance abuse needs.
Limitations & Exceptions column:
In this column, list the significant limitations and exceptions for each row. Significance
of limitations and exceptions is determined by the plan or issuer based on two factors:
probability of use and financial impact on an individual. Examples include, but are not
limited to, limits on the number of visits, limits on specific dollar amount paid by the plan,
prior authorization requirements, unusual exceptions to cost sharing, lack of applicability
of a deductible, or a separate deductible.
 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.”
 If the plan or issuer requires the participant or beneficiary to pay 100% of a
service in-network, then that should be considered an “excluded service” and
should appear in the Limitations & Exceptions column and also appear in the
Services Your Plan Does Not Cover box on page 3 or 4. For example, coverage
that excludes services in-network such as habilitation services, prescription
drugs, or mental health services, must show these exclusions in both the
Limitations & Exceptions column and the Services Your Plan Does Not Cover
box.
 If there are pre-authorization requirements, the plan or issuer must show the
requirement including specific information about the penalty for noncompliance.
 If there are no items that need to appear in the Limitations & Exceptions box for a
row, then the plan or issuer should show “---none---”.


For each Common Medical Event in the chart, the plan or issuer has the
discretion to merge the boxes in the Limitations & Exceptions column and display
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one response across multiple rows if such a merger would lessen the need to
replicate comments and would save space.
 Refer to the specific additional instructions below for details on completing the
Limitations & Exceptions column in the chart for the following common medical
events:
o If you have outpatient surgery; and
o If you have a hospital stay.
Specific Additional Instructions for Some of the Common Medical Events:
If you visit a health care provider’s office or clinic:
 If the plan or issuer covers other practitioners care (which includes chiropractic
care and/or acupuncture), in the “Other practitioner office visit” row, the issuer will
provide the cost sharing for the other practitioners care in the Your Cost columns.
For example, under the in-network column, the issuer may respond “20% coinsurance for chiropractor and 10% co-insurance for acupuncture”.
 If the plan or issuer does not cover other practitioners care, the issuer will show
“Not Covered” in the Your Cost columns for Other Practitioner Office visit.
If you need drugs to treat your illness or condition:


Under the Common Medical Events column, provide a link to the website location
where the participant or beneficiary can find more information about prescription
drug coverage for this plan. If there is no website, provide a contact phone
number where the participant or beneficiary can receive more information about
prescription drug coverage for this plan.



Under the Services You May Need column, the plan or issuer should list and
complete the categories of prescription drug coverage under the plan (for
example, the issuer might fill out 4 rows with the terms, “Generic drugs”,
“Preferred brand drugs”, “Non-preferred brand drugs”, and “Specialty drugs”). It
is recommended that plans and issuers avoid the term “tiers” and instead use
“categories” as it is more easily understood by consumers.



Under the Your Cost column, plans and issuers should include the cost sharing
for both retail and mail order, as applicable.

If you have outpatient surgery:
 If there are significant expenses associated with a typical outpatient surgery that
have higher cost sharing than the facility fee or physician/surgeon fee, or are not
covered, then they must be shown under the Limitations & Exceptions column.
Significance of such expenses is determined by the plan or issuer based on two
factors: probability of use and financial impact on the participant or beneficiary.
For example, a plan or issuer might show that the cost sharing for the
physician/surgeon fee row is “20% co-insurance”, but the Limitations &
Exceptions might show “Radiology 50% co-insurance”.
If you have a hospital stay:
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 If there are significant expenses associated with a typical hospital stay that has
higher cost sharing than the facility fee or physician/surgeon fee, or are not
covered, then that must be shown under the Limitations & Exceptions column.
Significance of such expenses is determined by the plan or issuer based on two
factors: probability of use and financial impact on the participant or beneficiary.
For example, a plan or issuer might show that the cost sharing for the facility fee
row is “20% co-insurance”, but the Limitations & Exceptions might show
“Anesthesia 50% co-insurance”.
If you have mental health, behavioral health, or substance abuse needs:
 If the cost sharing differs for outpatient services for mental/behavioral health
needs or substance abuse needs depending on whether the services are office
visits or are other outpatient services, show the cost sharing for each. For
example, a plan or issuer might show that the cost sharing for Mental/Behavioral
health outpatient services is “$35 co-pay/visit for office visits and 20% coinsurance other outpatient services”.

Disclosures
The Excluded Services and Other Covered Services, Your Rights to Continue
Coverage, Your Grievance and Appeals Rights, and Coverage Examples sections must
always appear in the order shown. The Excluded Services and Other Covered Benefits
section may appear on page 3 or page 4 depending on the length of the chart starting
on page 2, but it will always follow immediately after the chart starting on page 2.
Excluded Services and Other Covered Services:
 Each plan or issuer must place all services listed below in either the Services
Your Plan Does Not Cover box or the Other Covered Services box according to
the plan provisions. The required list of services includes:
o
o
o
o
o
o
o
o

Acupuncture,
Bariatric surgery,
Chiropractic care,
Cosmetic surgery,
Dental care (Adult),
Hearing aids,
Infertility treatment,
Long-term care,

o Non-emergency care
when traveling outside the
U.S.,
o Private-duty nursing,
o Routine eye care (Adult),
o Routine foot care, and
o Weight loss programs.

 The plan or issuer may not add any other benefits to the Other Covered Services
box other than the ones listed above. However, other benefits may be added to
the Services Your Plan Does Not Cover box, as follows:
o If services appear in the Limitations & Exceptions column in the chart
starting on page 2 because the plan or issuer requires the participant or
beneficiary to pay 100% of the service in-network, those services should
also appear in the Services Your Plan Does Not Cover box.
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o For example, coverage that excludes services in-network, such as
habilitation services, prescription drugs, or mental health services, must
show these exclusions in both the Limitations & Exceptions column (in the
chart starting on page 2) and in the Services Your Plan Does Not Cover
box.
 List placement must be in alphabetical order for each box. The lists must use
bullets next to each item.
 In lieu of summarizing coverage for items and services provided outside the
United States, the plan or issuer may provide an internet address (or similar
contact information) for obtaining information about benefits and coverage
provided outside the United States. This statement should appear in the Other
Covered Services box. For example: “Coverage provided outside the United
States. See www.[insert].com/expatriate”
 If the plan or issuer provides limited coverage for any of the services listed
above, the limitation must be stated in the Services Your Plan Does Not Cover
box or the Other Benefits Covered box but not both. For example if a plan
provides acupuncture in limited circumstances, the plan or issuer could choose to
include the prescribed statement in the Services Your Plan Does Not Cover box,
as follows: “Acupuncture unless it is prescribed by a physician for rehabilitation
purposes.” Alternatively, the prescribed statement could be in the Other Covered
Services box, as follows: “Acupuncture if it is prescribed by a physician for
rehabilitation purposes.”
 For example, if a plan or issuer excludes all of the services on the list above
except Chiropractic services, and also showed exclusion of Habilitation Services
on page 2, the Other Covered Services box would show “Chiropractic Care” and
the Services Your Plan Does Not Cover box would show “Acupuncture, Bariatric
Surgery, Cosmetic surgery, Dental care (Adult), Habilitation Services, Hearing
Aids, Infertility treatment, Long-term care, Non-emergency care when travelling
outside the U.S., Private-duty nursing, Routine eye care (Adult), Routine foot
care, Weight loss programs."
Your Rights to Continue Coverage:
The following language must appear without alteration, as follows:
“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.
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 1-877267-2323 x61565 or www.cciio.cms.gov.”

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Your Grievance and Appeals Rights:
This section must appear.
Contact information should be inserted as follows (more than one of these instructions
may be applicable):
 For group health coverage subject to ERISA, insert applicable plan contact
information. Also insert contact information for the Department of Labor’s
Employee Benefits Security Administration at 1-866-444-EBSA (3272) or
www.dol.gov/ebsa/healthreform. If coverage is insured, also insert applicable
State Department of Insurance contact information.
 For non-federal governmental group health plans and church plans that are
group health plans, insert contact information for member assistance provided by
any TPA or issuer that is hired by or contracts with the plan, and, if available,
consumer assistance offered directly by the plan such as applicable member
services, employee services, Human Relations or Fiscal and Personnel
Department, or consumer support services. If coverage is insured, also insert
applicable State Department of Insurance contact information.
 If applicable in your state insert: “Additionally, a consumer assistance program
can help you file your appeal. Contact [insert contact information].” A list of
states with Consumer Assistance Programs is available at
www.dol.gov/ebsa/healthreform and
http://cciio.cms.gov/programs/consumer/capgrants/index.html.

Coverage Examples
 The U.S. Department of Health and Human Services (HHS) will provide all plans
and issuers with standardized data to be inserted in the Sample care costs
section for the coverage examples. HHS will also provide underlying detail that
will allow plans and issuers to calculate Patient pays amounts, including: Date of
Service, medical coding information, Provider Type, Category, descriptive Notes
identifying the specific service provided, and Allowed Amounts.


The Amount owed to providers, also known as the Allowed Amount, will always
equal the Total of the Sample care costs. Each plan or issuer must calculate
cost sharing, using the detailed data provided by HHS, and populate the Patient
pays fields. Dollar values are to be rounded off to the nearest hundred dollars
(for sample care costs that are equal to or greater than $100) or to the nearest
ten dollars (for sample care costs that are less than $100), in order to reinforce to
consumers that numbers in the examples are estimates and do not reflect their
actual medical costs. For example, if the co-insurance amount is estimated at
$57, the issuer would list $60 in the appropriate Patient pays section of the
Coverage Examples.

 Services on the template provided by HHS are listed individually for classification
and pricing purposes to facilitate the population of the Patient pays section. HHS
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specifies the Category used to roll up detail costs into the Sample care costs
categories section. Some plans may classify that service under another category
and should reflect that difference accordingly. The plan or issuer should apply
their cost sharing and benefit features for each plan in order to complete the
Patient pays section, but must leave the Sample care costs section as
is. Examples of categories that might differ between the Patient pays and
Sample care costs sections could include, but are not limited to:
o Payment of services based on the location where they are provided
(inpatient, outpatient, office, etc.)
o Payment of items as prescription drugs vs. medical equipment
 Each plan or issuer must calculate and populate the Patient pays total and subtotals based upon the cost sharing and benefit features of the plan for which the
document is being created. These calculations should be made using the order
in which the services were provided (Date of Service).
o Deductible – includes everything the participant or beneficiary pays up to
the deductible amount. Any co-pays that accumulate toward the
deductible are accounted for in this cost sharing category, rather than
under co-pays.
o Co-pays – those co-pays that don’t apply to the deductible.
o Co-insurance – anything the participant or beneficiary pays above the
deductible that’s not a co-pay or non-covered service. This should be the
same figure as the Total less the Deductible, Co-Pays and Limits or
exclusions.
o Limits or exclusions – anything the participant or beneficiary pays for
non-covered services or services that exceed plan limits.
 Each plan or issuer must calculate and populate the Plan pays amount by
subtracting the Patient pays total from the Amount owed to providers total.
 If the plan has a wellness program that varies the deductibles, co-payments, coinsurance, or coverage for any of the services listed in a treatment scenario, the
plan must complete the calculations for that treatment scenario assuming that the
patient is participating in the wellness program. Additionally, the plan must also
include a box below the coverage example with the following language (and
appropriate contact information):
o For Pregnancy:
Note: These numbers assume the patient has given notice of her
pregnancy to the plan. If you are pregnant and have not given notice of
your pregnancy, your costs may be higher. For more information, please
contact: [insert].
o For Diabetes:
Note: These numbers assume the patient is participating in our diabetes
wellness program. If you have diabetes and do not participate in the
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wellness program, your costs may be higher. For more information about
the diabetes wellness program, please contact [insert].
 If all of the costs associated with the Coverage Examples are excluded under the
plan, then the phrase “(This condition is not covered, so patient pays 100%)” is
added after the Patient pays amount. Otherwise no narrative should appear after
the Patient pays amount.
 Plans and issuers must include the Questions and answers about the Coverage
Examples section as it appears and not alter the text, font, graphic, shading, etc.
This section should be placed immediately following the Coverage Examples.

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