Summary of Benefits and Coverage

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

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 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?
Will you pay less if you
use a network provider?
Do you need a referral to
see a specialist?

Answers

Why This Matters

$0

See the Common Medical Events chart below for your costs for services this plan covers.

Yes.

This plan covers items and services even if you haven’t yet met the deductible amount.

No.

You don’t have to meet deductibles for specific services.

Not Applicable.

This plan does not have an out-of-pocket limit on your expenses.

Not Applicable.

This plan does not have an out-of-pocket limit on your expenses.

Not Applicable.

This plan does not use a provider network. You can receive covered services from any provider.

No.

You can see the specialist you choose without a referral.

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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
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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.
(DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022)
(HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022)

Page 1 of 6

Common Medical Event

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

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

If you have outpatient
surgery

Services You May Need

What You Will Pay
Indian Health Care
Non-IHCP Provider
Provider (ICHP)
(You will pay the most)
(You will pay the least)

Primary care visit to treat an
injury or illness

No charge

No charge

Specialist visit

No charge

No charge

Preventive care/screening/
immunization

No charge

No charge

No charge

No charge

No charge
No charge
No charge
No charge

No charge
No charge
No charge
No charge

No charge

No charge

Diagnostic test (x-ray, blood
work)
Imaging (CT/PET scans, MRIs)
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
Specialty drugs

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

No charge

No charge

Physician/surgeon fees

No charge

No charge

Limitations, Exceptions, & Other
Important Information
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. 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.
If an out-of-network provider charges more
than the allowed amount, you may have to
pay the difference (balance billing).
Covers up to a 30-day supply (retail
subscription); 31-90 day supply (mail order
prescription). 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. 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. If an outof-network provider charges more than the
allowed amount, you may have to pay the
difference (balance billing).
Page 2 of 6

Common Medical Event

If you need immediate
medical attention

Services You May Need
Emergency room care
Emergency medical
transportation
Urgent care

What You Will Pay
Indian Health Care
Non-IHCP Provider
Provider (ICHP)
(You will pay the most)
(You will pay the least)
No charge
No charge
No charge

No charge

No charge

No charge

Facility fee (e.g., hospital room) No charge

No charge

Physician/surgeon fees

No charge

No charge

Outpatient services

No charge

No charge

Inpatient services

No charge

No charge

Office visits
Childbirth/delivery professional
services

No charge

No charge

No charge

No charge

Childbirth/delivery facility
services

No charge

No charge

Home health care

No charge

No charge

No charge

No charge

No charge

No charge

If you have a hospital
stay

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

If you are pregnant

If you need help
recovering or have other Rehabilitation services
special needs
Habilitation services

Limitations, Exceptions, & Other
Important Information
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. 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. If an outof- network provider charges more than the
allowed amount, you may have to pay the
difference (balance billing).
If an out-of-network provider charges more
than the allowed amount, you may have to
pay the difference (balance billing).
Maternity care may include tests and
services described elsewhere in the SBC
(i.e. ultrasound). If an out-of-network
provider charges more than the allowed
amount, you may have to pay the difference
(balance billing).
60 visits/year. 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.
If an out-of-network provider charges more
than the allowed amount, you may have to
pay the difference (balance billing).
Page 3 of 6

Common Medical Event

Services You May Need

Skilled nursing care

No charge

No charge

No charge

No charge

Hospice services

No charge

No charge

Children’s eye exam

No charge

No charge

Children’s glasses

No charge

No charge

Children’s dental checkups

No charge

No charge

If you need help
Durable medical equipment
recovering or have other
special needs

If your child needs
dental or eye care

What You Will Pay
Indian Health Care
Non-IHCP Provider
Provider (ICHP)
(You will pay the most)
(You will pay the least)

Limitations, Exceptions, & Other
Important Information
60 visits/calendar year. 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. 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. 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. 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. If an out-of-network provider
charges more than the allowed amount, you
may have to pay the difference (balance
billing).
If an out-of-network provider charges more
than the allowed amount, you may have to
pay the difference (balance billing).

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
Page 4 of 6

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
purposes)
• Weight Loss Programs
• 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.

Page 5 of 6

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

$0
$0
0%
0%

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

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

$0
$0
0%
0%

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

$0
$0
0%
0%

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

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

$2,800

$0
$0
$0
$0
$0

Page 6 of 6