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Summary of Benefits
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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?

Step 1:
Step 2:
Step 3:



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 above, your plan’s SBC is not available at this time.

How can I get a copy of my policy or certificate?

Contact Customer Service at (800) 657-8205 for a copy of your policy or certificate, or to obtain a sample policy.

Golden Rule Insurance Company: Plan Option 1
Coverage Period: 01/01/201312/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual + Spouse | Plan Type: PPO
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].
Important Questions Answers Why this Matters:
What is the overall deductible? $ person / $ family

Doesn’t apply to preventive care

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

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.
Golden Rule Insurance Company: Plan Option 1
Coverage Period: 01/01/201312/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual + Spouse | Plan Type: PPO
  • 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.
Common
Medical Event
Services You May Need Your cost if you use a Limitations & Exceptions
Network Provider Non-Network Provider
If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness      
Specialist visit      
Other practitioner office visit      
Preventive care/screening/immunization No charge -none-
If you have a test Diagnostic test (x-ray, blood work)      
Imaging (CT/PET scans, MRIs)     -none-
Golden Rule Insurance Company: Plan Option 1
Coverage Period: 01/01/201312/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual + Spouse | Plan Type: PPO
Common
Medical Event
Services You May Need Your cost if you use a Limitations & Exceptions
Network Provider Non-Network Provider
If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.[insert].com.

       
       
     
     
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 Facility fee (e.g., ambulatory surgery center)      
Physician/surgeon fees      
If you need immediate medical attention Emergency room services      
Emergency medical transportation    
Urgent care     -none-
If you have a hospital stay Facility fee (e.g., hospital room)     -none-
Physician/surgeon fee     Assistant surgeon’s fee is limited to 20% of primary surgeon’s fee.
Golden Rule Insurance Company: Plan Option 1
Coverage Period: 01/01/201312/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual + Spouse | Plan Type: PPO
Common
Medical Event
Services You May Need Your cost if you use a Limitations & Exceptions
Network Provider Non-Network Provider
If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services      
Mental/Behavioral health inpatient services      
Substance use disorder outpatient services      
Substance use disorder inpatient services      
If you are pregnant Prenatal and postnatal care    
Delivery and all inpatient services    
If you need help recovering or have other special health needs Home health care      
Rehabilitation services      
Habilitation services      
Skilled nursing care      
Durable medical equipment      
Hospice service      
Golden Rule Insurance Company: Plan Option 1
Coverage Period: 01/01/201312/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual + Spouse | Plan Type: PPO
Common
Medical Event
Services You May Need Your cost if you use a Limitations & Exceptions
Network Provider Non-Network Provider
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.)
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.)
    Golden Rule Insurance Company: Plan Option 1
    Coverage Period: 01/01/201312/31/2013
    Summary of Benefits and Coverage: What this Plan Covers & What it Costs
    Coverage for: Individual + Spouse | Plan Type: PPO

    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.———————————

    Golden Rule Insurance Company: Plan Option 1
    Coverage Period: 01/01/201312/31/2013
    Summary of Benefits and Coverage: What this Plan Covers & What it Costs
    Coverage for: Individual + Spouse | Plan Type: PPO
    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.

    Having a baby
    (normal delivery)

    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  
    Copays  
    Coinsurance  
    Limits or exclusions  
    Total  
    Managing type 2 diabetes
    (routine maintenance of a
    well-controlled condition)

    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  
    Copays  
    Coinsurance  
    Limits or exclusions  
    Total  
    Golden Rule Insurance Company: Plan Option 1
    Coverage Period: 01/01/201312/31/2013
    Summary of Benefits and Coverage: What this Plan Covers & What it Costs
    Coverage for: Individual + Spouse | Plan Type: PPO
    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.

    Colorado Supplement to the Summary of Benefits and Coverage Form

    Golden Rule Insurance Company

    Name of Carrier

    {PLAN_NAME}

    Name of Plan

    Individual

    Policy Type

    TYPE OF COVERAGE

    1. Type of plan.

    Preferred provider organization (PPO)

    2. Out-of-network care covered?1

    Yes, but patient pays more for out-of-network care.

    3. Areas of Colorado where plan is available.

    Plan is available throughout Colorado



    SUPPLEMENTAL INFORMATION REGARDING BENEFITS

    Important Note: The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditions of coverage. It provides additional information meant to supplement the Summary of Benefits and Coverage you have received for this plan. This plan may exclude coverage for certain treatments, diagnoses, or services not specifically noted. Consult the actual policy to determine the exact terms and conditions of coverage.

     

    Description

    What this means.

    4. Deductible Period

    Calendar year

    Calendar year deductibles restart each January 1.

    5. Annual Deductible Type

    Individual/Family

    “Individual” means the deductible amount you and each individual covered by the plan will have to pay for allowable covered expenses before the carrier will cover those expenses.  “Family” is the maximum deductible amount that is required to be met for all family members covered by the plan. It may be an aggregated amount (e.g., “$3,000 per family”) or specified as the number of individual deductibles that must be met (e.g., “3 deductibles per family”).

    6. What cancer screenings are covered?

    Breast (mammograms), cervical, colorectal, human papillomavirus, ovarian (for those at risk), pap smear, prostate.

    LIMITATIONS AND EXCLUSIONS

    7. Period during which pre-existing conditions are not covered for covered persons age 19 and older.2

    12 months for all pre-existing conditions.

    8. How does the policydefine a “pre-existing condition”?

    A pre-existing condition is an injury, sickness, or pregnancy for which a person, 19 or older, incurred charges, received medical treatment, consulted a health care professional, or took prescription drugs within 12 months immediately preceding the effective date of coverage.

    9. Exclusionary Riders. Can an individual’s specific, pre-existing condition be entirely excluded from the policy?

    Yes

    USING THE PLAN

     

    IN-NETWORK

    OUT-OF-NETWORK

    10. If the provider charges more for a covered service than the plan normally pays, does the enrollee have to pay the difference?

    No

    Yes

    11. Does the plan have a binding arbitration clause?

    No

    No

    Questions: Call 1-800-657-8205 or visit us at www.goldenrule.com.

    If you are not satisfied with the resolution of your complaint or grievance, contact: Colorado Division of Insurance Consumer Affairs Section 1560 Broadway, Suite 850, Denver, CO 80202 Call: 303-894-7490 (in-state, toll-free: 800-930-3745) Email: insurance@dora.state.co.us

    Endnotes

    1. “Network” refers to a specified group of physicians, hospitals, medical clinics and other health care providers that this plan may require you to use in order for you to get any coverage at all under the plan, or that the plan may encourage you to use because it may pay more of your bill if you use their network providers (i.e., go in-network) than if you don’t (i.e., go out-of-network).
    2. Waiver of pre-existing condition exclusions. State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage you recently may have had. Ask your carrier or plan sponsor (e.g., employer) for details.

    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].

     

    GRLCSUMBENCR04