SBC Disclosure

Summary of Benefits and Coverage and Uniform Glossary (CMS-10407)

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SBC Disclosure

OMB: 0938-1146

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2022 12/31/2022

Insurance Company 1: Plan Option 1 Coverage for: Family | Plan Type: PPO

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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 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?


$500/Individual or $1,000/family

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 family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Preventive care and primary care services are covered before you meet your 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/.

Are there other deductibles for specific services?

Yes. $300 for prescription drug coverage and $300 for occupational therapy services.

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.


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

For network providers $2,500 individual / $5,000 family; for out- of-network providers $4,000 individual / $8,000 family

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.


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

Copayments for certain services, premiums, balance-billing charges, and health care this plan doesn’t cover.


Even though you pay these expenses, they don’t count toward the out–of–pocket limit.


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.

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.

Do you need a referral to see a specialist?

Yes.

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

[Expiration date: XX/20XX]


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


What You Will Pay:

Limitations, Exceptions, & Other

Common Medical Event Services You May Need Network Provider Out-of-Network Provider Important Information

(You will pay the least) (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

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


40% coinsurance


None


Specialist visit


$50 copay/visit


40% coinsurance

Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service.


Preventive care/screening/immunization


No charge


40% coinsurance

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.

If you have a test

Diagnostic test (x-ray, blood work)

$10 copay/test

40% coinsurance

None

Imaging (CT/PET scans, MRIs)

$50 copay/test

40% coinsurance

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

Generic drugs (Tier 1)

$10 copay/prescription (retail & mail order)

40% coinsurance


Covers up to a 30-day supply (retail subscription); 31-90 day supply (mail order prescription).

Preferred brand drugs (Tier 2)

$30 copay/prescription (retail & mail order)

40% coinsurance

Non-preferred brand drugs (Tier 3)

40% coinsurance

60% coinsurance

Specialty drugs (Tier 4)

50% coinsurance

70% coinsurance


If you have outpatient surgery


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


$100/day copay


40% coinsurance

Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service.

Physician/surgeon fees

20% coinsurance

40% coinsurance

50% coinsurance for anesthesia.

If you need immediate medical attention

Emergency room care

20% coinsurance

20% coinsurance


None

Emergency medical transportation

20% coinsurance

20% coinsurance

Urgent care

$30 copay/visit

40% coinsurance


If you have a hospital stay


Facility Fee (e.g., hospital room)


20% coinsurance


40% coinsurance

Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service.



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 have a hospital stay

Physician/surgeon fees

20% coinsurance

40% coinsurance

50% coinsurance for anesthesia

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


Outpatient services

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


40% coinsurance


None

Inpatient services

20% coinsurance

40% coinsurance



If you are pregnant


Office visits


20% coinsurance


40% coinsurance

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).

Childbirth/delivery professional services

20% coinsurance

40% coinsurance

Childbirth/delivery facility services

20% coinsurance

40% coinsurance





If you need help recovering or have other special needs

Home health care

20% coinsurance

40% coinsurance

60 visits/year

Rehabilitation services

20% coinsurance

40% coinsurance

60 visits/year. Includes physical therapy, speech therapy, and occupational therapy.

Habilitation services

20% coinsurance

40% coinsurance

Skilled nursing center

20% coinsurance

40% coinsurance

60 visits/calendar year


Durable medical equipment


20% coinsurance


40% coinsurance

Excludes vehicle modifications, home modifications, exercise, and bathroom equipment.


Hospice services


20% coinsurance


40% coinsurance

Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service.


If your child needs dental or eye care

Children’s eye exam

$35 copay/visit

Not covered

Coverage limited to one exam/year.

Children’s glasses

20% coinsurance

Not covered

Coverage limited to one pair of glasses/year.

Children’s dental checkups

No charge

Not covered

None


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.)

  • Cosmetic Surgery

  • Dental Care

  • Infertility Treatment

  • Long Term Care

  • Non-emergency care when traveling outside the U.S.

  • Private Duty Nursing

  • Routine eye care (Adult)

  • Routine Foot Care


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 purposes)

  • Bariatric Surgery

  • Chiropractic Care

  • Hearing Aids

  • Weight Loss Programs

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.





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 0938-1146.  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.


Peg is Having a Baby

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


Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)


Mia’s Simple Fracture

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


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About these Coverage Examples



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)


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In this example, Peg would pay:

In this example, Joe would pay:

In this example, Mia would pay:

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Deductibles $500

Copayments $300

Coinsurance $2,300

Deductibles $800

Copayments $1,200

Coinsurance $300

Deductibles $700

Copayments $50

Coinsurance $300


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Limits or exclusions $60

Limits or exclusions $60

Limits or exclusions $0

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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: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?” row above.




[The plan would be responsible for the other costs of these EXAMPLE covered services.]

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSummary of Benefits and Coverage Completed Example
SubjectExample of completed summary of benefits and coverage
AuthorCMS
File Modified0000-00-00
File Created2021-01-15

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