SBC Disclosure

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Insurance Company 1: AI/AN Limited Cost Sharing

OMB control number: 0938-1146/Expiration Date: XX/20XX

Coverage Period: 01/01/2022-12/31/2022 Coverage for:
Individual + Spouse | Plan Type: PPO

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 definitions of common
terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can general view the
Glossary at www.[insert].com or call 1-800-[insert] to request a copy.
Important Questions
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?

Answers
$0 at Indian Health Care Provider
(IHCP) or with IHCP referral at
non-IHCP; or $500
individual/$1,000 family.
Yes. Preventive care and primary
care services are covered before
you meet your deductible.
$0 at IHCP or with IHCP referral
at non-IHCP; or Yes, $300 for
prescription drug coverage and
$300 for occupational therapy
services.
For network provider $2,500
individual / $5,000 family; for outof-network provider $4,000
individual / $8,000 family.
Copayments for certain services,
premiums, balance-billing
charges, and health care this plan
doesn’t cover.

Will you pay less if you
use a network provider?

Yes. See www.[insert].com or call
1-800-[insert] for a list of network
providers.

Do you need a referral to
see a specialist?

Yes.

Why This Matters
Generally, you must pay all of the costs from providers up to the deductible amount before this
plan begins to pay. If you have other family members on the plan, each family member must
meet their own individual deductible until the total amount of deductible expenses paid by all
familyomembers meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount.
But a copayment or coinsurance may apply. For example, this plan covers certain preventive
services without cost-sharing and before you meet your deductible. See a list of covered
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
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.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other
family members in this plan, they have to meet their own out-of-pocket limits until the overall
family out-of-pocket limit has been met.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network.
You will pay the most if you use an out-of-network provider, and you might receive a bill from a
provider for the difference between the provider’s charge and what your plan pays (balance
billing). Be aware, your network provider might use an out-of-network provider for some services
(such as lab work). Check with your provider before you get services.
This plan will pay some or all of the costs to see a specialist for covered services but only if you
have a referral before you see the specialist.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

Page 1 of 8

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

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

If you have a test

Services You May Need

Indian Health Care
Provider (ICHP)
(You will pay the
least)

What You Will Pay
Non-IHCP Provider
In-Network Provider
(You will pay more)

Non-IHCP Out-ofNetwork Provider
(You will pay the
most)

Primary care visit to treat
an injury or illness

No charge

$35 copay/office visit
and 20% coinsurance
for other outpatient
services; deductible
does not apply

Specialist visit

No charge

$50 copay/visit

40% coinsurance

Preventive
care/screening/
immunization

No charge

No charge

40% coinsurance

Diagnostic test (x-ray,
blood work)

No charge

$10 copay/test

40% coinsurance

Imaging (CT/PET scans,
MRIs)

No charge

$50 copay/test

40% coinsurance

40% coinsurance

* For more information about limitations and exceptions, see the plan or policy document at [www.insert.com].

Limitations, Exceptions, & Other
Important Information

Cost sharing waived at non- IHCP
with IHCP referral. If an out-ofnetwork provider charges more
than the allowed amount, you may
have to pay the difference (balance
billing).
Preauthorization is required. If you
don't get preauthorization, benefits
could be reduced by 50% of the
total cost of the service. Cost
sharing waived at non-IHCP with
IHCP referral. If an out-of-network
provider charges more than the
allowed amount, you may have to
pay the difference (balance billing).
You may have to pay for services
that aren’t preventive. Ask your
provider if the services you need
are preventive. Then check what
your plan will pay for.
Cost sharing waived at non- IHCP
with IHCP referral. If an out-ofnetwork provider charges more
than the allowed amount, you may
have to pay the difference (balance
billing).

Page 2 of 8

Common Medical
Event
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.[insert].com

Services You May Need

Indian Health Care
Provider (ICHP)
(You will pay the
least)

What You Will Pay
Non-IHCP Provider
In-Network Provider
(You will pay more)
$10 copay/prescription
(retail & mail order)
$30 copay/prescription
(retail & mail order)

Non-IHCP Out-ofNetwork Provider
(You will pay the
most)

Generic drugs

No charge

40% coinsurance

Preferred brand drugs

No charge

Non-preferred brand
drugs

No charge

40% coinsurance

60% coinsurance

Specialty drugs

No charge

50% coinsurance

70% coinsurance

40% coinsurance

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

No charge

$100/day copay

40% coinsurance

Physician/surgeon fees

No charge

20% coinsurance

40% coinsurance

Emergency room care
Emergency medical
transportation

No charge

20% coinsurance

20% coinsurance

No charge

20% coinsurance

20% coinsurance

Urgent care

No charge

$30 copay/visit

40% coinsurance

If you have outpatient
surgery

If you need
immediate medical
attention

* For more information about limitations and exceptions, see the plan or policy document at [www.insert.com].

Limitations, Exceptions, & Other
Important Information

*See Section [X]. Cost sharing
waived at non-IHCP with IHCP
referral. If an out-of-network
provider charges more than the
allowed amount, you may have to
pay the difference (balance billing).
Preauthorization is required. If you
don't get preauthorization, benefits
could be reduced by 50% of the
total cost of the service. Cost
sharing waived at non-IHCP with
IHCP referral. If an out-of-network
provider charges more than the
allowed amount, you may have to
pay the difference (balance billing).
50% coinsurance for anesthesia.
Cost sharing waived at non-IHCP
with IHCP referral. If an out-ofnetwork provider charges more
than the allowed amount, you may
have to pay the difference (balance
billing).
Cost sharing waived at non- IHCP
with IHCP referral. If an out-ofnetwork provider charges more
than the allowed amount, you may
have to pay the difference (balance
billing).

Page 3 of 8

Common Medical
Event

Services You May Need

Indian Health Care
Provider (ICHP)
(You will pay the
least)

What You Will Pay
Non-IHCP Provider
In-Network Provider
(You will pay more)

Non-IHCP Out-ofNetwork Provider
(You will pay the
most)

Facility fee (e.g., hospital
room)

No charge

20% coinsurance

40% coinsurance

Physician/surgeon fees

No charge

20% coinsurance

40% coinsurance

Outpatient services

No charge

$35 copay/office visit
and 20% coinsurance
for other outpatient
services

40% coinsurance

Inpatient services

No charge

20% coinsurance

40% coinsurance

Office visits
Childbirth/delivery
professional services

No charge

20% coinsurance

40% coinsurance

No charge

20% coinsurance

40% coinsurance

No charge

20% coinsurance

40% coinsurance

If you have a hospital
stay

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

If you are pregnant

Childbirth/delivery facility
services

* For more information about limitations and exceptions, see the plan or policy document at [www.insert.com].

Limitations, Exceptions, & Other
Important Information

Preauthorization is required. If you
don't get preauthorization, benefits
could be reduced by 50% of the
total cost of the service. Cost
sharing waived at non-IHCP with
IHCP referral. If an out-of-network
provider charges more than the
allowed amount, you may have to
pay the difference (balance billing).
50% coinsurance for anesthesia.
Cost sharing waived at non-IHCP
with IHCP referral. If an out-ofnetwork provider charges more
than the allowed amount, you may
have to pay the difference (balance
billing).
Cost sharing waived at non- IHCP
with IHCP referral. If an out-ofnetwork provider charges more
than the allowed amount, you may
have to pay the difference (balance
billing).
Cost sharing does not apply to
certain preventive services.
Depending on the type of services,
coinsurance may apply. Maternity
care may include tests and
services described elsewhere in
the SBC (i.e. ultrasound).Cost
sharing waived at non-IHCP with
IHCP referral. If an out-of-network
provider charges more than the
allowed amount, you may have to
pay the difference (balance billing).
Page 4 of 8

Common Medical
Event

Services You May Need

Indian Health Care
Provider (ICHP)
(You will pay the
least)

What You Will Pay
Non-IHCP Provider
In-Network Provider
(You will pay more)

Non-IHCP Out-ofNetwork Provider
(You will pay the
most)

Home health care

No charge

20% coinsurance

40% coinsurance

Rehabilitation services

No charge

20% coinsurance

40% coinsurance

Habilitation services

No charge

20% coinsurance

40% coinsurance

Skilled nursing center

No charge

20% coinsurance

40% coinsurance

Durable medical
equipment

No charge

20% coinsurance

40% coinsurance

If you need help
recovering or have
other special health
needs

Limitations, Exceptions, & Other
Important Information

60 visits/year. Cost sharing waived
at non-IHCP with IHCP referral. If
an out-of-network provider charges
more than the allowed amount, you
may have to pay the difference
(balance billing).
60 visits/year. Includes physical
therapy, speech therapy, and
occupational therapy. Cost sharing
waived at non-IHCP with IHCP
referral. If an out-of-network
provider charges more than the
allowed amount, you may have to
pay the difference (balance billing).
60 visits/calendar year. Cost
sharing waived at non-IHCP with
IHCP referral. If an out-of-network
provider charges more than the
allowed amount, you may have to
pay the difference (balance billing).
Excludes vehicle modifications,
home modifications, exercise, and
bathroom equipment. Cost sharing
waived at non-IHCP with IHCP
referral. If an out-of-network
provider charges more than the
allowed amount, you may have to
pay the difference (balance billing).

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-XXXX (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to average XXX hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

* For more information about limitations and exceptions, see the plan or policy document at [www.insert.com].

Page 5 of 8

Common Medical
Event

If you need help
recovering or have
other special health
needs

If your child needs
dental or eye care

Services You May Need

Indian Health Care
Provider (ICHP)
(You will pay the
least)

What You Will Pay
Non-IHCP Provider
In-Network Provider
(You will pay more)

Non-IHCP Out-ofNetwork Provider
(You will pay the
most)

Hospice services

No charge

20% coinsurance

40% coinsurance

Children’s eye exam

No charge

$35 copay/visit

Not covered

Children’s glasses

No charge

20% coinsurance

Not covered

Children’s dental
checkups

No charge

No charge

Not covered

* For more information about limitations and exceptions, see the plan or policy document at [www.insert.com].

Limitations, Exceptions, & Other
Important Information

Preauthorization is required. If you
don't get preauthorization, benefits
could be reduced by 50% of the
total cost of the service. Cost
sharing waived at non-IHCP with
IHCP referral. If an out-of-network
provider charges more than the
allowed amount, you may have to
pay the difference (balance billing).
Coverage limited to one
exam/year. Cost sharing waived at
non-IHCP with IHCP referral. If an
out-of-network provider charges
more than the allowed amount, you
may have to pay the difference
(balance billing).
Coverage limited to one pair of
glasses/year. Cost sharing waived
at non-IHCP with IHCP referral. If
an out-of-network provider charges
more than the allowed amount, you
may have to pay the difference
(balance billing).
Cost sharing waived at non- IHCP
with IHCP referral. If an out-ofnetwork provider charges more
than the allowed amount, you may
have to pay the difference (balance
billing).

Page 6 of 8

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.)
• Long Term Care
• Cosmetic Surgery
• Non-emergency care when traveling outside
• Routine Eye Care (Adult)
• Dental Care
the U.S.
• Routine Foot Care
• Infertility Treatment
• Private Duty Nursing
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture (if prescribed for rehabilitation
• Chiropractic Care
• Weight Loss Programs
purposes)
• Hearing Aids
• Bariatric Surgery
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 on how 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]
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? [Yes/No/Not Applicable]
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.

* For more information about limitations and exceptions, see the plan or policy document at [www.insert.com].

Page 7 of 8

About these Coverage Examples
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on
the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and
coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note
these coverage examples are based on self-only coverage.

Peg is Having a Baby

Managing Joe’s Type 2 Diabetes

(9 months of in-network pre-natal care and a
hospital delivery)





The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other coinsurance

$500
$50
20%
20%

(a year of routine in-network care of a wellcontrolled condition)





The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other coinsurance

$500
$50
20%
20%

Mia’s Simple Fracture

(in-network emergency room visit and follow up
care)





The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other coinsurance

$500
$50
20%
20%

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)

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)

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

Total Example Cost

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

$12,700

$0
$0
$0
$0
$0

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

$5,600

$0
$0
$0
$0
$0

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

$2,800

$0
$0
$0
$0
$0

Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to
reduce your costs. For more information about the wellness program, please contact: [insert].
Note: These numbers assume the patient received care from an IHCP provider or with IHCP referral at a non-IHCP. If you receive care from a non-IHCP provider
without a referral from an IHCP your costs may be higher.
[The plan would be responsible for the other costs of these EXAMPLE covered services.
Page 8 of 8