Summary of Benefits and CoverageInstruction Guide for Individual Healt - PDF document

1 Summary of Benefits and CoverageInstruct
Summary of Benefits and CoverageInstruction Guide for Individual Health InsuranceCoverage Background EditionDate: April201Applicabilityssuers that maintain an annual open enrollment periodwill be required to use theApril, 2017 edition of the SBC template and associated documents beginning on the first day of the first open enrollment period that begins on or after April 1, 2017 with respect to coverage for playears (or, in the individual market, policy years) beginning on or after that date. For issuers that do ��Individual – April 2017 - 1 - be presentedtheform of options,such deductible optionsandout-of-pocket maximum options.thesecircumstances,thecoverageexamples should notetheassumptionsusedcreatingthem. example how to noteassumptionsusedcreatingcoverageexamples provided theDepartments'samplecompletedSBC.Issuersmay combine information foraddons to major medicalcoveragethatcouldaffectcost sharing(such as a healthFSA,HRA,healthsavingsaccount(HSA), or wellnessprogram) and other information in the SBC,oneSBCtheinformationunderstandable. Thatis, theeffects of suchaddonscan be denoted the appropriate spaces on theSBCfor deductibles, copayments,coinsurance,andbenefits otherwise not covered the major medicalcoverage.suchcircumstances, the coverageexamples should note the assumptionsused in creatingthem.Terms that are defined in the Uniform Glossary should be underlined in the SBC. Plans and issuers providing an electronic SBC may hyperlink defined terms directly to the Uniform Glossary, ideally directly to the definition in the Uniform Glossary for that term. HHS will maintain a microsite for the Uniform Glossary at https://www.healthcare.gov/sbc-glossary/allowing plans to electronically link defined terms in the SBC directly to the term’s definition on the webpage. While providing SBCs with embedded links is not a requirement, the blank mplate includes embedded hyperlinks. In addition, a list of terms with corresponding anchor links is available http://www.cciio.cms.govPlansand issuers may also choose to utilize hover text applications in the electronic SBC that allow for a text bubble to appear with the definition when a reader places their cursor over the term. Issuersmustcustomizeallidentifiablecompany information roughout the document, including websitesand telephone numbers. Minor adjustmentsarepermitted to rowor columnsize order accommodatetheplan’sinformation, as long

2 informationunderstandable. However,del
informationunderstandable. However,deletionof columns or rowsnot permittedunless otherwise noted in these instructions. Additionally, rollingover information fromonepage to another permitted.Theitems shown on page 1 must beginpage 1, and the rowsof thechartmustappearthe same order.However, the chartstarting on page 2 maybegin on page 2 or the alternativemay be movedto thebottom ofpagespaceallows the firstbox to appearitsentirety.Therowsshownthischartmustappear the same order. Further, therowsshown on page 2 mayextend to page 3 spacerequires,and the rows on page 3 mayextendto the beginning of page 4 spacerequires. The ExcludedServicesandOther CoveredServicessectionmustimmediately follow the chartthatstartson page TheExcludedServicesandOtherCoveredServicessectionmustbe followedby the YourRightsto Continue Coverage section,theYourGrievanceand Appeals Rightssection, the Minimum Essential Coverage/Minimum Value Standardsection,theanguage AccessServices(ifapplicable),andtheCoverage Examples section,that order.Forallform sections to filledoutby theissuer(particularly the Answerscolumnpage 1, andtheWhat You Will PayandLimitationsExceptions, andOther Important Information columnsthechart thatstartson page 2) the issuershoulduseplainlanguage ��Individual – April 2017 - 2 - andpresentthe information culturallyandlinguistically appropriate manner andutilizeterminology understandable by the average individual. Formore information, seeparagraph(a)(5) of theDepartments’ regulations.TheSBCnotpermitted to substitute crossreference to the SPD or other documentsforanycontentelement of theSBC, except as permitted in the Limitations, Exceptions, andOther Important InformationcolumnHowever,SBCmay include a referencethe SPDthebox atthetopof thefirst page of the SBC.(Forexample,"Questions:Call 1-800[insert] or visit us at www.[insert].comfor moreinformation, including a copy of your plan's policy document.")In addition, whereverSBC provides informationthatfullysatisfiesa particularcontentelementof theSBC,mayadd to that information a referenceto specifiedpagesor sections of thein ordersupplementor elaborate on thatinformation. Barcodes,control numbers, or othersimilarlanguagemay be added to SBCsissuersfor quality control purposes.Page numbers may be relocated along the bottom of pages to accommodate barcodes, control numbers, or other similar language. issuermay choose to add premium informationtheSBC. the issu

3 er voluntarily adds the premiuminformati
er voluntarily adds the premiuminformation,it should be added theend of theSBCformimmediatelybeforethe YourRights to Continue Coveragesection.Issuers with questions about completing the SBC, contact the Department of Health and Human Services at SBC@cms.hhs.gov. ��Individual – April 2017 - 3 - Fillingouttheform GENERAL INFORMATIONTopandBottompage 1Header:Theheadermay be includedonly on the firstpage of SBC.TopLeftHeader(page1):On the topleft hand cornerof thefirst page, theissuermustshow the following information: SecondlineShowtheplannameand insurance company as applicablebold. Example: Maximum HealthPlan:AlphaInsuranceGroupIssuers have theoptionto use theirlogoinstead of typing thecompanyname the logoincludes the name of the entity issuing the coverage.Theheadermayrollontothirdlineallrequired information cannot fitinto twolines.Theissuermust use the commonly known company name.Plannamesmay be generic,suchstandard or highoption.Additionally, issuer nameandplannameareinterchangeable in order. TopRightHeader(page1):On the topright hand cornerof thefirstpage, the issuer must show the followinginformation:FirstlineAfterCoverage Period, the issuer mustshow the beginningandenddatesfortheapplicable coverageperiod(suchpolicyyear)in the following format:“MM/DD/YYYY – MM/DD/YYYY”.For example:“CoveragePeriod:01/01/2018 - 12/31/201 the coverageperiodenddatenot known when the SBCprepared,theissuerpermitted to insertonlythe beginning date of thecoverage period. Forexample:“CoveragePeriod:Beginning on or after 01/01/201 the SBC being provided to satisfy the notice of materialmodificationrequirements, the issuermust showthe beginning andenddatesforthe period forwhichthemodificationeffective.Forexample,for a changeeffectiveMarch 15, 2018, andplanyear beginning on January 1, 2018 and ending on December31, 2018: “CoveragePeriod: 03/15/2018 - 12/31/2018Thedateslistedforthecoverage period mayreflect thecoverageperiodfor the planpolicy whole, notthe period applicable to eachindividual.Therefore,plancalendaryearplanand individual enrolls on January 19, the coverage period permittedto be the calendaryear. Issuersarenotrequired individualize the coverageperiodforindividual'senrollment. ��Individual – April 2017 - 4 - If a policy haspolicy yearthatdiffers from the benefityear;for examplethe planyearbegins Oct.but thebenefits(e.g. deductibles and out-of-pocket

4 limits)reset onJan.1; theissuermay choo
limits)reset onJan.1; theissuermay choose, based on a determination of whatmostrelevanttheconsumer,to reflectthecoverageperiodeitherthepolicyyear or the benefit year.Secondline: AfterCoverage forindicatewho the coveragefor (such Individual, Individual Spouse,Family).Theissuershould use the terms used the policy documents. AfterPlanTypeindicate the type of coverage,suchHMO, PPO,POS, oIndemnity.Disclaimer(page1):Thedisclaimerat the top of page 1 should be replicatedexactly,without changes to the font size,graphic, or formatting.Theissuer should insertcontact information (such telephone number andwebsite)for obtainingmoredetaila copy of the completetermscoverage.Issuersmust also include websitewhere consumers canreviewandobtaincopies of the individual insurance policy. Finally, the issuermust include a websiteandtelephone number foraccessing or requesting copiestheUniformGlossary.(One or both of the followingInternetaddressesmay beusedwebsitedesignatedforobtaining the Uniform Glossary:http://www.dol.gov/ebsa/healthreform or http://www.cciio.cms.govor https://www.healthcare.gov/sbc-glossaryIMPORTANTQUESTIONS/ANSWERS/WHYTHISMATTERSCHARTGeneralInstructions forthe ImportantQuestionschart:Thischartmustalwaysbeginpage 1, and the rows mustalwaysappear the sameorder.Issuers mustcomplete the Answerscolumnfor question on thischart, usingtheinstructions below. Issuersmustshow the appropriate languagetheWhy ThisMattersbox asinstructedthe instructions below. Issuers mustreplicate the languagegivenfor the WhyThisMattersbox exactly,and may not alter the language.there a different amount for innetworkandout-of-networkexpenses(suchannualdeductible, additional deductibles, out-of-pocketlimits),listbothamountsandindicatesuch, using the termsto describe provider networks used the issuer. Forexample,if the policyusestheterms“preferred provider” and“nonpreferred provider” andthedeductible $2,000 forpreferred provider and $5,000 fornonpreferred provider, thenthe Answerscolumn should show “$2,000 preferred provider, $5,000 nonpreferredproviderSpecific Instructions for Important Questions: What is tverall deductible? ��Individual – April 2017 - 5 - Answerscolumn:there no overalldeductible,answer “$0.” thereoveralldeductible,answerwiththedollar amount and, the deductible is not annual, indicatethe period time that the deductible applies.If portraying familycoveragefor whichtherea separatededu

5 ctible amount foreachindividual andthe f
ctible amount foreachindividual andthe family,show both the individual deductible and the family deductible (forexample,500/individual or $1,000/family”).WhyThis Matterscolumn:there no overalldeductible, show the followinglanguage:“See the CommonMedicalEventschart belowfor your costsforservices thisplancovers.” there overall deductible, show the followinglanguage: “Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay.” If portraying family coverage for which there is an embedded deductible, plans and issuers must include the following language: “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.” If portraying family coverage for which there is a non-embedded deductible, plans and issuers must include the following language: “If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay.” e there services covered before you meet your deductible?Answers column:If there are no services covered before the deductible is met, answer "No.”If there are services covered before the deductible is met, plans and issuers must answer “Yes” and list major categories of covered services that are NOT subject to the deductible, for example, preventive care. Why This Matters column:If there are no services covered before the deductible, show the following language: “You will have to meet the deductible before the planpays for any services.” If there are services covered before the deductible is met, show the following language: “This plancovers some items and services even if you haven’t yet met the deductible amount. But a copaymentor coinsurance y apply. If the plan or coverage is non-grandfathered, insert: “For example, this plancovers certain preventive serviceswithout cost sharing and before you meet your deductible. See a list of covered preventive servicesat https://www.healthcare.gov/coverage/preventive-carebenefits/Are there othereductiblesforpecificervices?: ��Individual – April 2017 - 6 - Answerscolumn the overall deductible theonlydeductible,answerwith the phrase “No.”thereare other deductibles, answer“Yes”, thenlist the

6 namesand deductible amountsof the three
namesand deductible amountsof the three most significant deductibles other than the overalldeductible.Significance of deductibles determined the issuer basedtwofactors: probability of use andfinancialimpact on individual. Examples of other deductibles include deductibles forPrescriptionDrugsandHospital.Forexample:“Yes, $2,000 for prescription drug coverageand $2,000 for occupational therapyservices”. the planhasmorethanthreeotherdeductiblesandnotall deductibles areshown,thefollowing statementmustappear the end ofthelist: “Thereare other specificdeductibles.” the planhaslessthanthreeother deductibles, the following statementmustappearthe end of thelist:“Thereareno otherspecificdeductibles.” If portraying familycoveragefor whichtherea separate deductible amountforindividual andthe family,showboththeindividualandfamily deductible. Forexample:Prescription drugs $200/individual $500/family”WhyThis Matterscolumn:thereare no other deductibles, the issuermustshowthe following language:“Youdon’t have to meet deductiblesforspecificservices.”thereare other deductibles, the issuermust show the followinglanguage:“Youmustpay all of thecostsfor these services up thespecificdeductibleamountbeforethis planbegins to pay for these services.”What is the out-of-pocket limit for this planAnswerscolumn:If there are no out-of-pocket limits, answer“Not Applicable.” If there is an out-of-pocket limit, respond with a specific dollar amount that applies in each coverage period. For example: “$5,000.” If portraying family coverage, and there is a single out-of-pocket limit for each individual and a separate out-of-pocket limit for the family, show both the individual out-of-pocket limit and the family outpocket limit (for example, “$1,000 individual / $3,000 family”).If there are separate out-of-pocket limits for innetwork providers and outof network providers, show both the innetwork outpocket limit and the outof network out-of-cket limit. Plans and issuers should use the terminology in the policy or plan document (e.g., innetwork, participating, or preferred). For example: “For network providers $2,500 individual / $5,000 family; for out-of-network providers $4,000 individual / $8,000 family.” Why This Matterscolumn: If there is no out-of-pocket limit, the plan or issuer must show the following language: “This plan does not have an out-of-po

7 cket limiton your expenses.” �
cket limiton your expenses.” ��Individual – April 2017 - 7 - If there is an out-of-pocket limit, the plan or issuer must show the following language: “The out-of-pocket limit is the most you could pay in a year for covered services.” If portraying family coverage for which there is an embedded out-of-pocket limit, plans and issuers must include the following language: “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 limithas been met.” If portraying family coverage for which there is a nonembedded out-of-pocket limit, plans and issuers must include the following language: “If you have other family members in this plan, the overall family out-of-pocket limitmust be met.”What is nncluded-of-pocket limit?: Answerscolumn:there no out-of-pocketlimit,indicateNot Applicablethereout-of-pocketlimit, theissuermustlistanymajor exceptions.Thislistmustalways include the following threeterms:premiums,balancebillingcharges(unlessbalancedbillingis prohibited), andhealthcarethisplan doesn’t cover. Depending thepolicy, the listcouldalso include: copayments on certainservices, out-of-network coinsurance, deductibles, andpenaltiesforfailure to obtainpreauthorizationforservices.Theissuermuststatethat theseitems do not count towardthelimit.For example:“Copaymentscertainservices,premiumsbalancebilling charges,andhealthcarethis plandoesn’t cover.”WhyThis Matterscolumn:thereout-pocket limit, theissuermustshow the followinglanguage:“Eventhoughyou pay theseexpenses, they don’t count towardtheout–of– pocket limit.” thereout-of-pocketlimit, theissuermust show “This plandoes not have anout-of-pocketlimiton your expenses.” Will you pay less if you use a network providerAnswerscolumn: the plan does not use network, theplan or issuer should answer, “Not Applicable.”If the plan or issuer uses a network, the plan or issuer should say “Yes. See [insert direct linkor URL to planspecific provider directory] or call 1-800-[insert] for a list of network providers].”WhyThis Matterscolumn:If the plan does not use a network, the following language must be used: “This plan does not use a provider networkYou can receive covered services from any provider.” If there is a simple in-network/out-of-network coveragearrangement, this language

8 must be used: “This planuses a prov
must be used: “This planuses a provider networkYou 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 ��Individual – April 2017 - 8 - might receive a bill from a provider for the difference between the provider’scharge and what your planpays (balance billing).”If the plan uses a tiered network, this language must be used: “You pay the least if you use provider in [insert tier name]. You pay more if you use a provider in [insert tier name]. 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’scharge and what your planpays balance billing).”If the provider uses any form of provider network, this languagemust also appear: “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. you n a referral to sa specialist?: AnswerscolumnIf there is a referral required, the issuer should answer, “Yes.” If no referral is required, the issuer should answer, “No.”WhyThis Matterscolumn:there a referralrequired,theissuer must show the following language:“Thisplanwillpay some or all of the costsseespecialistforcovered servicesbutonlyyou have a referralbeforeyouseethespecialist” no referralrequired, the issuermust show the following language:“Youseethespecialistyou choose withoutreferral.” III.COMMONMEDICAL EVENT, SERVICES,WHAT YOU WILL PAY,LIMITATIONS, EXCEPTIONS, & OTHER IMPORTANT INFORMATIONGeneral Instructions: Location Chart:Thischartshouldbegin on page 2 (orat the bottomof page 1, spaceallows)and the rowsshown on pages 2 and 3 mustappear the sameorder. However, the rows shown on pagemay extend to pagespacerequires,and the rows shown on page 3 mayextend to thebeginning of page 4 spacerequires.The heading of thechartmustappear on thetop of allpages used. If a deductible applies, plans and issuers must include the disclaimer, as shown in the template, with language “All copayment and coinsurancecosts shown in this chart are after your deductible has been met, if a deductibleapplies.” at the top of the Common Medical Event chart.What You Will Pay columns:Issuersmayvarythe numberof columns depending upon the type of coverageandthe ��Individual

9 50; April 2017 - 9 - number of prefe
50; April 2017 - 9 - number of preferred provider networks. Mostpoliciesthatuse a network should usetwocolumns, althoughsome policies withmorethanonelevel of - network provider may use three columns.Non-networked plansmay use one column.Thecolumnsare intended to reflecttheconsumercostsafter the deductiblehasbeensatisfied.Issuersshould denote these columns exceptions,suchwhenspecificservicesubject to a separatedeductible or covered no cost.Issuers should insert the terminology usedthe policy or plan document titlethecolumns. For example, the columnsmay be called “Network Provider” and“Out-of-etwork Provider or “Preferred Provider” and“NonPreferredProvider”based on thetermsused in the policy.Thesub-headings should be deletedfornon-networked plans withonly one column.The columns shouldappearfrom leftright, from most generouscost sharingleastgenerous cost sharing. Forexample,columnformatused, the columnsmight be labeled(fromleft to right) “NetworkPreferred Provider,” “Network Provider,” andthen“Out-of-Network Provider.” ForHMOs providing no out-of-network benefits, theissuer should insert“Notcovered”allapplicableboxes under the farrightsubheading under the YourCostcolumn(which,forcoverage providing out-of-network benefits, would usually be out-of-network provider or nonpreferred provider column). Issuersmustcompletetheresponses under these sub-headingsbasedhow the issuercovers the specificserviceslistedin thechart after thedeductiblehasbeensatisfied.Fillthe What You Will Paycolumn(s) with the coinsurancepercentage, the copayment amount, “Nocharge”if theconsumerpays nothing, or “Not covered” if theservicenotcovered the plan. Whenreferring coinsurance, includea percentage valuation.Forexample:“20% coinsurance.” Whenreferring copayments, include a peroccurrencecost. Forexample:$20/visit” or “$15/prescriptionIf the plan has a deductible and the deductible does not apply to a particular benefit, the issuer should insert “Deductible does not apply”. Refer to the specificadditional instructions below fordetails on completing theWhat You Will Paycolumns the chart for the followingcommonmedicalevents:If youvisit healthcareprovider’soffice or clinic;If youneed drugs treat your illness or condition;andIf youneed mentalhealth, behavioral health, or substanceabuseservices. Limitations, Exceptions, & Othe

10 r Important Informationcolumn:Core limit
r Important Informationcolumn:Core limitations, exceptions, and other important information ��Individual – April 2017 - 10 - In this column, list the significant limitations, exceptions, and other important information for each service listed. This column must indicate:When a service category or a substantial portion of a service category is excluded from coverage (i.e.column should indicate “brand name drugs excluded” in health benefit plans that only cover generic drugs);When cost sharing for covered innetwork services does not count toward the out-of-pocket Limits on the number of visits or on specific dollar amounts payable under the health benefit plan; and When prior authorization is required for services. Special Rule for . Core limitations, exceptions, and other important information Plans and issuers must accurately describe as many core limitations and exceptions specified in 3.a. as reasonably possible,in a manner that is consistent with the instructions and template format. To the extent that the inclusion of all such limitations and exceptions would make compliance with the four doublesided page limit t reasonably possible, for each set of limitations or exceptions that cannot be fully described, the plan or issuer should cross reference the pages or identify the sections where the limitations andexceptions are described in the applicable document that fully describes the limitations andexception, such as the relevant pages of a policy document, in order to limit the length of theSBC to four doublesided pages. For example, if an issuerwould have to show “peechgenerating devices arelimited to $1,250/calendar year, no coverage forother communications equipment, devices, or aids”andinclusion of this information would cause the SBC to exceed the four doublesided page limit, in the “Limitations,Exceptions, and Other Important Information”column, the issuer should include “*See sectionX.” At the bottom of each applicable page, the plan should include the following language “*For more information about limitations and exceptions, see plan or policy document at [www.insert.com].” Other significant limitations, exceptions, and other important informationSignificance of other limitations, exceptionsand other important information is determined by the plan or issuer based on two factors: services with historically high utilization and financial

11 impact on an individual. A plan or issue
impact on an individual. A plan or issuer may include as important information coverage elements or features that provide more benefit to the consumers, such as the impact of wellness incentives or the option to elect an FSA. Plans and issuers should NOT use this box to identify services listed in “Excluded Services” or “Other Covered Services”Information provided should specify dollar amounts, service limitations, and annual maximums if applicable. Language should be formatted as follows: “”XX visit limit”, “No coverage for XXX”, “$XX/visit limit”, and/or “$XX annual max”. ��Individual – April 2017 - 11 - If the plan or issuer requires the participant or beneficiary to pay 100% of a service innetwork, then that should be considered an “excluded service” and should appear in the Services Your Plan Generally Does Not Coverbox following the chart. For example, coverage that excludes services innetwork such as habilitation services, prescription drugs, or mental health services, must show these exclusions in the Services Your Plan Generally Does Not Cover box. If the health benefit plan has a preauthorization requirement that includes a penalty when a participant or beneficiary fails to obtain preauthorization, such as a denial of payment or care that would otherwise be covered, or a reduced payment, the plan or issuer must include specific information about the penalty. If there are no items that meet the significance threshold described above, then the plan or issuer should show “Noner each Common Medical Event in the chart. The plan or issuer should merge the boxes in the Limitations, Exceptions, and Other Important Informationcolumn and display one response across multiple rows if such a merger would lessen the need to replicate comments and would save space.Refer to the specific instructions below for details on completing the Limitations, Exceptions, and Other Important Information column. SpecificAdditional InstructionsforSometheCommonMedicalEvents:If youvisit healthcare provider’s officeclinic: The issuer should always include, in a separate paragraph at the end of the LimitationsExceptions, & Other Important Informationcolumn, the following language: “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 fo

12 r.” If the plan or issuer does not
r.” If the plan or issuer does not combine the services (the rows) for the Common Medical Event into one box, this statement should always appear in line with “Preventive care/screening/immunization.If spaceallows(i.e., thefour double sided pagelimitwouldnot be exceeded),issuersmayinclude informationon additionaltypes of practitioners, suchnursepractitioners or physicianassistants.If youneeddrugstreatyourillnesscondition: Under the Common MedicalEventscolumn, provide a direct linkor URL address to the formulary drug list where the participant or beneficiaryfindmoreinformationaboutprescription drug coverageforthis plan. there no website, provide a contactphonenumber where the participant or beneficiaryreceivemoreinformationaboutprescription drug coverageforthisplan.Under the ServicesYouMayNeedcolumn,theplan or issuershouldlistandcompletethecategories of prescription drug coverage under the plan(forexample, the issuermightfillout 4 rowswith the terms,“Generic drugs”, “Preferred branddrugs”, “Nonpreferredbranddrugs”, and“Specialtydrugs”).Plans and issuers may describe tiered formularies using the terminology used by the plan. However, to the extent that a plan is using plan terminology ��Individual – April 2017 - 12 - to describe its tiered formulary, the plan or issuer should also include the corresponding terms (such as generic, preferred, nonpreferred, or specialty) used in the SBC to describe formularies in parenthesis, as applicable. For example, in the “Services You MayNeed” column, a plan or issuer might add “Tier 1” next to “(Generic drugs)”, if Tier 1 is the term used to label generic drugs in the plan or policy’s formulary. Under the What You Will Paycolumn, plans andissuers should include thecost sharing forboth retail andmailorder,as applicable.If youhave outpatientsurgery: thereare significantexpensesassociatedwitha typical outpatient surgery that have higher cost sharing thanthefacilityfee or physician/surgeon fee, or are covered, thenthey must be shown undertheLimitations,Exceptions,& Other Important Information column. Significancesuchexpensesdetermined the planissuer based on twofactors: probability of use andfinancialimpact on the participant or beneficiary. Forexample,a plan or issuermightshowthat the cost sharing for the physician/surgeon feerow“20% coinsurance”, but the Limitations,

13 Exceptions& Other Important Informationm
Exceptions& Other Important Informationmight show “50% coinsurance for anesthesia.” If youhave a hospital stay: thereare significantexpensesassociatedwitha typicalhospitalstaythat has higher cost sharing thanthefacilityfeeor physician/surgeonfee, or arenot covered,thenthatmust be shown under theLimitations,Exceptions, & Other Important Informationcolumn. Significance of suchexpensesdetermined the plan or issuer basedtwofactors: probability of use andfinancialimpact on the participant or beneficiary. Forexample,plan or issuermightshowthat the cost sharing for the facilityfeerow “20% coinsurance”, buttheLimitations,Exceptions& Other Important Informationmightshow “50% coinsurance for anesthesia.” If youneed mentalhealth, behavioral health,substanceabuseservices: the cost sharing differsfor inpatient or outpatientservicesfor mental health, behavioralhealth, orsubstanceabuse servicesshow the cost sharing foreach. Forexample,planissuermightshowthatthecost sharing for mental health, ehavioralhealth, or substance abuse outpatient services as“$35copay/officevisit and 20% coinsurance for other outpatient services.”If you are pregnantIf applicable, plans and issuers should include an explanation in the Limitations and Exceptions column that describes that the cost sharing amounts listed may not apply to some services. The plan or issuer should determine which, if any, of the following sentences to include: “Cost sharing does not apply for preventive services.” “Depending on the type of services, a [copayment, coinsurance, or deductible] may ��Individual – April 2017 - 13 - apply.” “Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)” If you need help recovering or have other special health needsIf applicable, exclusions for physical Therapy, Occupational Therapy and Speech Therapy services must be listed in the LimitationsExceptions, & Other Important Informationcolumn for the Rehabilitation services and Habilitation services rows.If there is aquantitative limit (for examplenumber of days, hours, or visits covered) applicable to that service, those limits must be specified.IV.DISCLOSURESTheExcludedServicesandOtherCoveredServicesYourRights to Continue Coverage,YourGrievanceand Appeals Rights, Minimum Essential Coverage/Minimum Value StandardLanguage Access(if applicable),andCoverage Examplesse

14 ctionsmustalwaysappearthe order shown.Th
ctionsmustalwaysappearthe order shown.TheExcludedServicesandOtherCoveredBenefitsmustalwaysfollowimmediatelyafter the chartthat startspage 2. ExcludedServicesandOther CoveredServices:Eachissuermust placeallserviceslistedbeloweithertheServices Your PlanGenerallyDoesNotCover or theOtherCoveredServicesbox accordingto the policy provisions. Therequiredlist of services includes: Acupuncture, Nonemergencycarewhen traveling Bariatricsurgery, outside theU.S.,Chiropracticcare, Privateduty nursing, Cosmeticsurgery,Routine eye care (Adult), Dentalcare(Adult),Routine footcare, andHearingaids,Weightlossprograms.Infertilitytreatment,Long-term care,The issuermay notaddany other benefitsthe OtherCoveredServicesbox otherthan the ones listedabove. However,other benefits must be added to the Services Your Plan Generally Does Not CoverBoxif the plan or issuer requires the participant or beneficiary to pay 100% of the service innetwork. Forexample,coveragethatexcludesservicesnetwork, suchhabilitationservices,prescription drugs, or mentalhealthservices,must showtheseexclusions the Services Your Plan Generally Does Not Coverbox. Listplacementmust be alphabeticalorderforeachbox. Thelistsmustusebullets next to item.FORQUALIFIEDHEALTHPLANS:ForSBC preparedforqualified healthplan ��Individual – April 2017 - 14 - (QHP)offered througha Marketplace, the issuermustreflect whether abortion servicesarecovered. Plansthat cover exceptedandnonexceptedabortionservicesmust list“abortion”thecoveredservicesbox.Plansthat exclude all abortions shouldlist “abortion” the excludedservices box. Plansthatcover onlyexceptedabortionsshouldlist the excludedservices “abortion (exceptcases of rape,incest, or whenthelife of the motherendangered)”andmayalso include crossreferenceanotherplandocumentthatmore fullydescribestheexceptions.While it is not required, nonQHP issuers may choose to indicatewhether abortion services are covered. If a plan or issuer voluntarily chooses to include information regarding coverage of abortion services, the plan or issuer may do so in the same manner proscribed for Qualified Health Plans above.WithrespectMultiStatePlans,the Office of Personnel Managementmayissueadditional instructions.MultiState Planissuersaredirectedcomplywithsuchinstructionswithrespectdisclosureregardingcoverageor exclusion of abortionservices.In lieu of summarizingcoverageforitemsandservices provided outside theUni

15 tedStates,the plan or issuer may provide
tedStates,the plan or issuer may provide internetaddress (orsimilarcontact information) for obtaining information about benefitsandcoverage provided outsidetheUnitedStates. ThisstatementshouldappeartheOtherCoveredServicesbox.Forexample:“Coverageprovided outsidetheUnitedStates.Seewww.[insert].com.” For those services shown in the Other Covered Servicesbox, plans and issuers must describe any limitations that may apply. For example, the following statement might be shown in the OtherCoveredServicesbox, follows:“Acupunctureprescribeda physicianforrehabilitation purposes.” Forexample,issuerexcludesall of theservices on the list above exceptChiropracticservices, andalso showed exclusion of HabilitationServices on page 2, the Other CoveredServicesbox would show “Chiropractic Care”and the ServicesYourPlanGenerally DoesNotCoverbox wouldshow“Acupuncture,BariatricSurgery,Cosmeticsurgery,Dentalcare(Adult),HabilitationServices,HearingAids,Infertilitytreatment, Long-termcare, Nonemergencycarewhen traveling outside the U.S., Privatedutynursing, Routine eyecare(Adult), Routine footcare,Weightloss programs." YourRightsto Continue Coverage: Thissectionmustappearshown on the template. Insertcontactinformationfortheissuerthesecondsentence. In the second sentence: State insurance department contact information [Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or https://www.dol.gov/ebsa/contactEBSA/consumerassistance.html]. State consumer assistance program, if other than state insurance department [provide statespecific contact information available from ��Individual – April7 - 15 - http://www.cms.gov/CCIIO/Resources/Consumer-AssistanceGrants/]. Office of Personnel Management Multi State Plan Program:https://www.opm.gov/healthcare-insurance/multistateplanprogram/externalreview/Healthcare.gov http://ww.HealthCare.gov or call 1-800-318-2596 OR state healthinsurance marketplace or SHOPC.YourGrievanceandAppealsRights:Thissectionmustappear shown on the template. Contactinformation should be insertedfollows (morethan one these instructions may be applicable): InsertapplicableStateDepartment of Insurance contact information.If applicable your stateinsert: “Additionally,consumer assistance program help you file your appeal. Contact[insertcontact information].”Note:list of stateswithConsumerAssistanceProgramsavailablehttp://ww.

16 dol.gov/ebsa/healthreform andhttp://www.
dol.gov/ebsa/healthreform andhttp://www.cms.gov/CCIIO/Resources/Consumer-AssistanceGrantsForMultiStatePlans,theOffice of PersonnelManagementmayissueadditionalinstructions.MultiStatePlansaredirectedfollow such instructionswithrespectthe disclosure for Grievance and Appeals Rights.Minimum Essential Coverage/Minimum Value StandardThe following questions and statements must appear, immediately following, Your Grievance and Appeals Rights and the issuer must provide the appropriate answer: Does this plan provide Minimum Essential Coverage? [Yes/No] If you don’t have Minimum Essential Coverage for a month, you’ll have to pay make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? [Yes/No]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 MarketplaceLanguageAccessServices,taglines,culturallyandlinguistically appropriaterequirements(ifapplicable):In order satisfy the requirement to provide theSBCculturallyandlinguisticallyappropriate manner, plan or issuer follows therulestheclaimsandappealsregulationsunder PHSActsection2719. Plansandissuerscanfindwrittentranslations of the SBCtemplateanduniformglossary non-Englishlanguageshttp://cciio.cms.gov/programs/consumer/summaryandglossary/index.html ��Individual – April7 -16 - FOR QUALIFIED HEALTH PLANS:For an SBC prepared for a qualifiedhealth plan (QHP) offered through a Marketplace, the issuer must include an addendum with 15 language taglines as required 45 C.F.R. §155.205(c)(2)(iii) . If any additional taglines are required under PHS Act 2719 they must also be included in this addendum. For example, if Navajo meets the requirements under PHS Act action 2719 but is not included in the 15 language tag line requirement under 45 C.F.R. § 155.205(c)(2)(iii), a plan must include the Navajo tag line in addition to the 15 required languagetag lines in the addendum. The addendum, which must only include tagline information required by language access standards for critical documents, will not count towards the page limit. COVERAGE EXAMPLESTheU.S.Department of HealthandHumanServices(HHS)willprovideall plans andissuerswithstandardizeddata be inserted the Total Example Costsectionfor thecoverageexamples.willalso provide underlying detailt

17 hatwillallow plans andissuerscalculateIn
hatwillallow plans andissuerscalculateIn this example [Patient] would payamounts,including: Date of Service,medicalcoding information, Provider Type,Category,descriptiveNotesidentifying the specificservice provided, andAllowedAmounts.Allplansandissuerswill be allowedcontinued use of the CoverageExamplesCalculator. For the calculator,instructions,andlogic,see http://www.cms.gov/cciio/Resources/Forms-ReportsandOther- Resources/index.html#SummaryofBenefitsandCoverageandUniformGlossary. Issuers should specify cost sharing category for each line of the templateto accurately reflect the plan. For example, a plan that applies a copayment to a specialistvisit must replace [cost sharing]” with “copayment”, i.e.Specialist copayment”. Eachplan or issuermustcalculatecost sharing, using thedetaileddataprovidedHHS,andpopulatethePatient pays fields.Dollarvaluesaregenerally to be rounded off to the nearesthundreddollars(forsamplecarecoststhat are equal to or greaterthan $100) or the nearesttendollars(for samplecarecosts thatareless than $100), order reinforceconsumersthat numbers the examples are estimatesand do notreflecttheir actualmedicalcosts.Forexample,thecoinsurance amount estimated $57, the issuerwouldlist$60 the appropriate In this example, [Patient] would paysection of the CoverageExamples.If applying the rounding rulescauses the deductible amountdisplayedexceed the actual overall deductible (forselfonlycoverage),thenthe deductibleamountmust be cappedandshownthe amount of theactual deductible. Forexample, the overall deductible $1,750 andwill be satisfied,then theplan or issuermust show “$1,750” andnot “$1,800.” Services on the template provided are listedindividuallyforclassificationand ��Individual – April7 - 17 - pricing purposes facilitate the population of the appropriate In this example [Patient] would paysection. specifiesthe Categoryused to rolldetailcosts into the Total Example Costcategorysection.Someplansmayclassifythatservice under anothercategoryand should reflect that difference accordingly.Theplan or issuer should applytheircost sharing andbenefitfeaturesforplan order to complete the In this example Patient] would paysection, butmust leave the Total Example Cost section as is. Examplesof categoriesthat mightdiffer betweentheIn this example [Patient] would payand Total Example Cost sectionscould include, butarenotlimitedto:Payment of services

18 basedthelocationwheretheyare provided (i
basedthelocationwheretheyare provided (inpatient,outpatient, office,etc.)Payment of itemsprescription drugs vs. medical equipment Eachplan or issuermustcalculateandpopulatetheIn this example [Patient] would paytotalandsub- totalsbased upon thecost sharing andbenefitfeatures of theplanforwhichthe document being created.For plans and issuers that combine information for different coverage tiers in one SBC, the coverage examples should be completed using the cost sharing (for example, deductible, and outpocket limits) for the selfonly coverage tier (also sometimes referred to as the individual coverage tier). In addition, the coverage examples should note this assumption. Thesecalculationsshouldbe made using the order which the serviceswere provided (Date of ServiceDeductible– includes everything the participant beneficiarypays up thedeductible amount. Anycopaymentsthataccumulatetowardthedeductibleareaccountedforin thiscost sharing category,rather than under copayments. Copayment those copayments that don’t apply to the deductible.Coinsurance– anything the participant or beneficiarypays above the deductible that’snot a copayment or non-coveredservice.This should be the samefiguretheTotallesstheDeductible, Copayments and Limits or exclusions.Limits or exclusions– anything the participant or beneficiarypaysfor non-coveredservices or services thatexceedplanlimits. the planhaswellnessprogramthat variesthe deductibles, copayments, coinsurance, or coverageforanyof theserviceslistedin a treatmentscenario,theplanor issuer must complete the calculations for that treatment scenario assuming that the patient is NOT participating in the wellness program. Additionally, if applicable, the plan or issuer must include a box below the coverage examples with the following language (and appropriate contact information): “Note: These numbers assume the patient does not participate in the plan’swellness program. If you participate in the plan’swellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: [insert].”If the plan has deductibles for specific services included in the coverage example, that cause the deductible amount in the In this example [Patient] would paydeductiblesection to exceed ��Individual – April7 - 18 - the overall deductible amount listed, add a * next to the deductible in the In this exampl

19 e Patient] would paytable. Additionally
e Patient] would paytable. Additionally, plans must include a box below the coverage examples with the following language: This planhas other deductibles for specific services included in this coverage example. See re there other deductibles for specific services?” row ove.” If allof the costsassociatedwith the CoverageExamplesare excluded under the plan, thenthe phrase “(Thisconditionnot covered, patientpays 100%is addedafter the In this example [Patient] would payamount.Otherwise no narrative should appearaftertheIn this example [Patient] would payamount.FOR QUALIFIED HEALTH PLANS: For an SBC prepared for a qualified health plan (QHP) offered through a Marketplace, that is an AI/AN limited cost sharing plan, plans must include a box below the coverage examples with the following with language: “Note: These numbers assume the patient received care from an IHCP provideror with IHCP referral at a nonIHCP. If you receive care from a nonIHCP provider without a referral from an IHCP your costs may be higher.”PaperworkReductionActStatementAccording to the Paperwork Reduction Actof 1995(Pub.L. 10413)(PRA),no personsarerequired to respondto a collection of informationunlesssuchcollectiondisplays a validOffice of Managementand Budget (OMB)control number. TheDepartmentnotesthata Federalagencycannot conduct or sponsor collection of informationunlessapprovedby OMB under thePRA,anddisplaysa currentlyvalidOMB control number, andthepublic not required to respond to a collection of information unlessit displayscurrently validOMB control number. See 44U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subjectto penalty forfailing to comply with a collectionof information the collectioninformationdoesnot displaya currentlyvalidOMB control number. SeeU.S.C.3512.The public reporting burden forthiscollection of informationestimated to averageapproximately one minuteper respondent. Interestedpartiesareencouraged to sendcomments regarding the burden estimateor anyother aspectthiscollection of information, including suggestionsfor reducingthis burden, to the U.S.Department of Labor, Office of PolicyandResearch,Attention:PRAClearanceOfficer,200Constitution Avenue, N.W., Room N-5718, Washington,20210email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0123. OMB Control Number 1545-2229, 12100147,and0938-1146 [expiresApril 5, 2019 ��Individual – April7 - 1