Sample-Completed-SBC-Accessible-Format 051222

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Insurance Company 1: Plan Option 1

Coverage Period: 01/01/2022-12/31/2022
Coverage for: Family | 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 general 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?

Answers

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
$500 / individual or $1,000 / family
meet their own individual deductible until the total amount of deductible expenses paid by all
family members meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount.
Yes. Preventive care and primary
But a copayment or coinsurance may apply. For example, this plan covers certain preventive
care services are covered before
services without cost sharing and before you meet your deductible. See a list of covered
you meet your deductible.
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Yes. $300 for prescription drug
coverage and $300 for
You must pay all of the costs for these services up to the specific deductible amount before this
occupational therapy services.
plan begins to pay for these services.
There are no other specific
deductibles.
For network providers $2,500
The out-of-pocket limit is the most you could pay in a year for covered services. If you have
individual / $5,000 family; for outother family members in this plan, they have to meet their own out-of-pocket limits until the
of-network providers $4,000
overall family out-of-pocket limit has been met.
individual / $8,000 family
Copayments for certain services,
premiums, balance-billing charges,
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
and health care this plan doesn’t
cover.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network.
Yes. See www.[insert].com or call You will pay the most if you use an out-of-network provider, and you might receive a bill from a
1-800-[insert] for a list of network 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
providers.
services (such as lab work). Check with your provider before you get services.
OMB control number: 0938-1146/Expiration date: XX/XX/20XX

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Important Questions

Answers

Why This Matters:

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.

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
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

What You Will Pay
Services You May Need
Network Provider
Out-of-Network Provider
(You will pay the least) (You will pay the most)
$35 copay/office visit
and 20% coinsurance
Primary care visit to treat an
for other outpatient
40% coinsurance
injury or illness
services; deductible
does not apply
Specialist visit

$50 copay/visit

40% coinsurance

Preventive care/screening/
immunization

No charge

40% coinsurance

$10 copay/test

40% coinsurance

$50 copay/test

40% coinsurance

Diagnostic test (x-ray, blood
work)
Imaging (CT/PET scans,
MRIs)
Generic drugs (Tier 1)
Preferred brand drugs (Tier
2)
Non-preferred brand drugs
(Tier 3)
Specialty drugs (Tier 4)

$10 copay/prescription
(retail & mail order)
$30 copay/prescription
(retail & mail order)

Limitations, Exceptions, & Other Important
Information

None
Preauthorization is required. If you don't get
preauthorization, benefits could be reduced by
50% of the total cost of the service.
You may have to pay for services that aren’t
preventive. Ask your provider if the services
needed are preventive. Then check what your
plan will pay for.
None

40% coinsurance
40% coinsurance

40% coinsurance

60% coinsurance

50% coinsurance

70% coinsurance

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

$100/day copay

40% coinsurance

Physician/surgeon fees

20% coinsurance

40% coinsurance

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

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

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

If you need immediate
medical attention

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 special health
needs

If your child needs
dental or eye care

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

What You Will Pay
Network Provider
Out-of-Network Provider
(You will pay the least) (You will pay the most)
20% coinsurance
20% coinsurance
20% coinsurance

20% coinsurance

$30 copay/visit

40% coinsurance

Limitations, Exceptions, & Other Important
Information

None

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.

Physician/surgeon fees

20% coinsurance

40% coinsurance

50% coinsurance for anesthesia.

Outpatient services

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

40% coinsurance

Inpatient services

20% coinsurance

40% coinsurance

Office visits
Childbirth/delivery
professional services
Childbirth/delivery facility
services
Home health care
Rehabilitation services
Habilitation services
Skilled nursing care

20% coinsurance

40% coinsurance

20% coinsurance

40% coinsurance

20% coinsurance

40% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
40% coinsurance

Durable medical equipment

20% coinsurance

40% coinsurance

Hospice services

20% coinsurance

40% coinsurance

Children’s eye exam
Children’s glasses
Children’s dental check-up

$35 copay/visit
20% coinsurance
No charge

Not covered
Not covered
Not covered

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

None

Cost sharing does not apply for preventive
services. Depending on the type of services, a
coinsurance may apply. Maternity care may
include tests and services described
elsewhere in the SBC (i.e., ultrasound).
60 visits/year
60 visits/year. Includes physical therapy,
speech therapy, and occupational therapy.
60 visits/calendar year
Excludes vehicle modifications, home
modifications, exercise, and bathroom
equipment.
Preauthorization is required. If you don't get
preauthorization, benefits could be reduced by
50% of the total cost of the service.
Coverage limited to one exam/year.
Coverage limited to one pair of glasses/year.
None
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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
• Long-term care
• Routine eye care (Adult)
• Dental care (Adult)
• Non-emergency care when traveling
• Routine foot care
outside the U.S.
• 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
• Chiropractic care
• Weight loss programs
rehabilitation 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 1-800-3182596.
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.
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.
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 0.02 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].]

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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.

Managing Joe’s Type 2 Diabetes

Peg is Having a Baby

(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

$12,700

$500

In this example, Joe would pay:
Cost Sharing
Deductibles*

Copayments

$200

Coinsurance

$1,800

In this example, Peg would pay:
Cost Sharing
Deductibles

What isn’t covered
Limits or exclusions
The total Peg would pay is

$60
$2,560

$5,600

$2,800

$800

In this example, Mia would pay:
Cost Sharing
Deductibles*

$500

Copayments

$900

Copayments

$200

Coinsurance

$100

Coinsurance

$400

What isn’t covered
Limits or exclusions
The total Joe would pay is

$20
$1,820

What isn’t covered
Limits or exclusions
The total Mia would pay is

$0
$1,100

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.

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