Summary of Benefits and Coverage
What is it?
Under the health care reform law, the
Patient Protection and Affordable Care Act of 2010 (PPACA), all issuers of health insurance are required to provide consumers with clear, consistent and comparable information about their health plan benefits and coverage — a Summary of Benefits and Coverage (SBC).
What does an SBC look like?
The SBC is like a nutritional label for a health insurance plan. The eight-page form displays information about a health plan in a simple question-and-answer format. It answers questions like:
- What is the overall deductible?
- Is there an out-of-pocket limit on my expenses?
- Does this plan use a network of providers?
- Are there services this plan does not cover?
Here is a
sample SBC, generated by the Department of Health and Human Services.
If you need clarification on what certain terms mean, there is a
uniform glossary of terms commonly used in health insurance coverage.
How can I get an SBC?
To generate an SBC select your state from the drop-down box below. Then select the appropriate plan, deductible and coinsurance levels.
NOTE: At this time, SBC’s are only available for our
currently marketed plans. If your health insurance plan (plan name, coinsurance level, deductible) doesn’t appear in the drop-down menu below, your plan’s SBC is not available yet. Members in health insurance plans that aren’t currently marketed will receive an SBC before September 23, 2013.
Shoppers or policyholders with effective dates of 12/9/12 or AFTER (greater than), click the link on the left. Policyholders with effective dates PRIOR TO (less than) 12/9/12 click the link on the right.
Shopper or Effective > 12/9/12
Effective < 12/9/12
 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or certificate. You will also find details at www.[insert] or by calling 1-800-[insert].
| What is the overall deductible? |
$ person / $ family
Doesn’t apply to preventive care
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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. |
| Are there other deductibles for specific services? |
Yes. $ for prescription drug coverage. There are no other specific deductibles. |
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. |
| Is there an out-of-pocket limit on my expenses? |
Yes. For participating providers $ person / $ family
For non-participating providers $ person / $ family
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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. |
| What is not included in the out-of-pocket limit? |
Premiums, balance-billed 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. |
| Is there an overall annual limit on what the plan pays? |
No. |
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. |
| Does this plan use a network of providers? |
Yes. See www.[insert].com or call 1-800-[insert] for a list of participating providers. |
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. |
| Do I need a referral to see a specialist? |
No. You don’t need a referral to see a specialist. |
You can see the specialist you choose without permission from this plan. |
| Are there services this plan Doesn’t cover? |
Yes. |
Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services. |
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- Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
- Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
- The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
- This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts.
| If you visit a health care provider’s office or clinic |
Primary care visit to treat an injury or illness |
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| Specialist visit |
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| Other practitioner office visit |
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| Preventive care/screening/immunization |
No charge |
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-none- |
| If you have a test |
Diagnostic test (x-ray, blood work) |
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| Imaging (CT/PET scans, MRIs) |
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-none- |
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| If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.[insert].com.
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| If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.[insert].com.
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| If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
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| Physician/surgeon fees |
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| If you need immediate medical attention |
Emergency room services |
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| Emergency medical transportation |
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| Urgent care |
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-none- |
| If you have a hospital stay |
Facility fee (e.g., hospital room) |
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-none- |
| Physician/surgeon fee |
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Assistant surgeon’s fee is limited to 20% of primary surgeon’s fee. |
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| If you have mental health, behavioral health, or substance abuse needs |
Mental/Behavioral health outpatient services |
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| Mental/Behavioral health inpatient services |
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| Substance use disorder outpatient services |
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| Substance use disorder inpatient services |
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| If you are pregnant |
Prenatal and postnatal care |
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| Delivery and all inpatient services |
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| If you need help recovering or have other special health needs |
Home health care |
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| Rehabilitation services |
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| Habilitation services |
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| Skilled nursing care |
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| Durable medical equipment |
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| Hospice service |
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| If your child needs dental or eye care |
Eye exam |
Not Covered |
Not Covered |
-none- |
| Glasses |
Not Covered |
Not Covered |
-none- |
| Dental check-up |
Not Covered |
Not Covered |
-none- |
Excluded Services & Other Covered Services:
| Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) |
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| Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) |
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Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:
- You commit fraud
- The insurer stops offering services in the State
- You move outside the coverage area
For more information on your rights to continue coverage, contact the insurer at [contact number]. You may also contact your state insurance department at [insert applicable State Department of Insurance contact information].
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact:
- [insert applicable State Department of Insurance contact information].
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 page.———————————
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About these Coverage Examples:
These examples show how this plan might cover
medical care in given situations. Use these examples to see, in general,
how much financial protection a sample patient might get if they are
covered under different plans.
This is
not a cost estimator.
Don’t use these examples to estimate your actual
costs under this plan. The actual care you receive will be different
from these examples, and the cost of that care will also be different.
See the next page for important information about these examples.
◼ Amount owed to providers: $7,540
◼ Plan pays
◼ Patient pays
Sample care costs:
| Hospital charges (mother) |
$2,700 |
| Routine obstetric care |
$2,100 |
| Hospital charges (baby) |
$900 |
| Anesthesia |
$900 |
| Laboratory tests |
$500 |
| Prescriptions |
$200 |
| Radiology |
$200 |
| Vaccines, other preventive |
$40 |
| Total |
$7,540 |
Patient pays:
| Deductibles |
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| Copays |
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| Coinsurance |
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| Limits or exclusions |
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| Total |
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◼ Amount owed to providers: $5,400
◼ Plan pays
◼ Patient pays
Sample care costs:
| Prescriptions |
$2,900 |
| Medical equipment and supplies |
$1,300 |
| Office visits and procedures |
$700 |
| Education |
$300 |
| Laboratory tests |
$100 |
| Vaccines, other preventive |
$100 |
| Total |
$5,400 |
Patient pays:
| Deductibles |
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| Copays |
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| Coinsurance |
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| Limits or exclusions |
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| Total |
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Questions and answers about the Coverage Examples:
What are some of the assumptions behind the Coverage Examples?
- Costs don’t include premiums.
- Sample care costs are based on national averages
supplied by the U.S. Department of Health and Human Services, and aren’t
specific to a particular geographic area or health plan.
- The patient’s condition was not an excluded or preexisting condition.
- All services and treatments started and ended in the same coverage period.
- There are no other medical expenses for any member covered under this plan.
- Out-of-pocket expenses are based only on treating the condition in the example.
- The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.
What does a Coverage Example show?
For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.
Does the Coverage Example predict my own care needs?
✗ No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.
Does the Coverage Example predict my future expenses?
✗ No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.
Can I use Coverage Examples to compare plans?
✓ Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.
Are there other costs I should consider when comparing plans?
✓ Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.
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Licensed Product Advisors 