Insurance Plan Sample

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013 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 plan document at www.[insert] or by calling 1-800-[insert]. Important Questions Answers Why this Matters: $500 person / You must pay all the costs up to the deductible amount before this plan begins to pay for What is the overall $1,000 family covered services you use. Check your policy or plan document to see when the deductible deductible? Doesn’t apply to preventive care 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 Yes. $300 for prescription drug You must pay all of the costs for these services up to the specific deductible amount deductibles for specific coverage. There are no other before this plan begins to pay for these services. services? specific deductibles. Yes. For participating providers Is there an out–of– $2,500 person / $5,000 The out-of-pocket limit is the most you could pay during a coverage period (usually one pocket limit on my family year) for your share of the cost of covered services. This limit helps you plan for health expenses? For non-participating providers care expenses. $4,000 person / $8,000 family What is not included in Premiums, balance-billed the out–of–pocket charges, and health care this Even though you pay these expenses, they don’t count toward the out-of-pocket limit. limit? plan doesn’t cover. Is there an overall The chart starting on page 2 describes any limits on what the plan will pay for specific annual limit on what No. covered services, such as office visits. the plan pays? If you use an in-network doctor or other health care provider, this plan will pay some or all Does this plan use a Yes. See www.[insert].com or of the costs of covered services. Be aware, your in-network doctor or hospital may use an network of providers? call 1-800-[insert] for a list of out-of-network provider for some services. Plans use the term in-network, preferred, or participating providers. 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 No. You don’t need a referral to You can see the specialist you choose without permission from this plan. see a specialist? see a specialist. Are there services this Yes. Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan plan doesn’t cover? document for additional information about excluded services. Questions: Call 1-800-[insert] or visit us at www.[insert]. OMB Control Numbers 1545-2229, If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1210-0147, and 0938-1146 1 of 8 at www.[insert] or call 1-800-[insert] to request a copy. Corrected on May 11, 2012

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013 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 participating providers by charging you lower deductibles, copayments and coinsurance amounts. Your Cost If Your Cost If Common You Use a You Use a Medical Event Services You May Need Participating Non- Limitations & Exceptions Provider Participating Provider Primary care visit to treat an injury or illness $35 copay/visit 40% coinsurance –––––––––––none––––––––––– If you visit a health Specialist visit $50 copay/visit 40% coinsurance –––––––––––none––––––––––– care provider’s office 20% coinsurance 40% coinsurance or clinic Other practitioner office visit for chiropractor for chiropractor –––––––––––none––––––––––– and acupuncture and acupuncture Preventive care/screening/immunization No charge 40% coinsurance If you have a test Diagnostic test (x-ray, blood work) $10 copay/test 40% coinsurance –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) $50 copay/test 40% coinsurance –––––––––––none––––––––––– Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 2 of 8 at www.[insert] or call 1-800-[insert] to request a copy.

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO Your Cost If Your Cost If Common You Use a You Use a Medical Event Services You May Need Participating Non- Limitations & Exceptions Provider Participating Provider $10 copay/ Covers up to a 30-day supply (retail If you need drugs to Generic drugs prescription (retail 40% coinsurance prescription); 31-90 day supply (mail treat your illness or and mail order) order prescription) condition 20% coinsurance Preferred brand drugs (retail and mail 40% coinsurance –––––––––––none––––––––––– More information order) about prescription 40% coinsurance drug coverage is Non-preferred brand drugs (retail and mail 60% coinsurance –––––––––––none––––––––––– available at www. order) [insert]. Specialty drugs 50% coinsurance 70% coinsurance –––––––––––none––––––––––– If you have Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance –––––––––––none––––––––––– outpatient surgery Physician/surgeon fees 20% coinsurance 40% coinsurance –––––––––––none––––––––––– If you need Emergency room services 20% coinsurance 20% coinsurance –––––––––––none––––––––––– immediate medical Emergency medical transportation 20% coinsurance 20% coinsurance –––––––––––none––––––––––– attention Urgent care 20% coinsurance 40% coinsurance –––––––––––none––––––––––– If you have a Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance –––––––––––none––––––––––– hospital stay Physician/surgeon fee 20% coinsurance 40% coinsurance –––––––––––none––––––––––– Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 3 of 8 at www.[insert] or call 1-800-[insert] to request a copy.

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO Your Cost If Your Cost If Common You Use a You Use a Medical Event Services You May Need Participating Non- Limitations & Exceptions Provider Participating Provider $35 copay/office Mental/Behavioral health outpatient services visit and 20% 40% coinsurance –––––––––––none––––––––––– coinsurance other If you have mental outpatient services health, behavioral Mental/Behavioral health inpatient services 20% coinsurance 40% coinsurance –––––––––––none––––––––––– health, or substance $35 copay/office abuse needs Substance use disorder outpatient services visit and 20% 40% coinsurance –––––––––––none––––––––––– coinsurance other outpatient services Substance use disorder inpatient services 20% coinsurance 40% coinsurance –––––––––––none––––––––––– If you are pregnant Prenatal and postnatal care 20% coinsurance 40% coinsurance –––––––––––none––––––––––– Delivery and all inpatient services 20% coinsurance 40% coinsurance –––––––––––none––––––––––– Home health care 20% coinsurance 40% coinsurance –––––––––––none––––––––––– If you need help Rehabilitation services 20% coinsurance 40% coinsurance –––––––––––none––––––––––– recovering or have Habilitation services 20% coinsurance 40% coinsurance –––––––––––none––––––––––– other special health Skilled nursing care 20% coinsurance 40% coinsurance –––––––––––none––––––––––– needs Durable medical equipment 20% coinsurance 40% coinsurance –––––––––––none––––––––––– Hospice service 20% coinsurance 40% coinsurance –––––––––––none––––––––––– If your child needs Eye exam $35 copay/ visit Not Covered Limited to one exam per year dental or eye care Glasses 20% coinsurance Not Covered Limited to one pair of glasses per year Dental check-up No Charge Not Covered Covers up to $50 per year Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 4 of 8 at www.[insert] or call 1-800-[insert] to request a copy.

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO 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.) Cosmetic surgery Long-term care Routine eye care (Adult) Dental care (Adult) Non-emergency care when traveling outside Routine foot care Infertility treatment the U.S. Private-duty nursing 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.) Acupuncture (if prescribed for rehabilitation Chiropractic care Most coverage provided outside the United purposes) Hearing aids States. See www.[insert] Bariatric surgery Weight loss programs Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 5 of 8 at www.[insert] or call 1-800-[insert] to request a copy.

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO Your Rights to Continue Coverage: ** Individual health insurance sample – ** Group health coverage sample – Federal and State laws may provide protections that allow you If you lose coverage under the plan, then, depending upon the to keep this health insurance coverage as long as you pay your circumstances, Federal and State laws may provide protections premium. There are exceptions, however, such as if: OR that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, You commit fraud which may be significantly higher than the premium you pay The insurer stops offering services in the State while covered under the plan. Other limitations on your rights to continue coverage may also apply. You move outside the coverage area For more information on your rights to continue coverage, For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your contact the insurer at [contact number]. You may also contact state insurance department, the U.S. Department of Labor, your state insurance department at [insert applicable State Employee Benefits Security Administration at 1-866-444-3272 Department of Insurance contact information]. or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. 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 contact information from instructions]. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 6 of 8 at www.[insert] or call 1-800-[insert] to request a copy.

Insurance Company 1: Plan Option 1 Coverage Period: 1/1/2011 – 12/31/2011 Coverage Examples Coverage for: Individual + Spouse | Plan Type: PPO About these Coverage Having a baby Managing type 2 diabetes Examples: (normal delivery) (routine maintenance of a well-controlled condition) These examples show how this plan might cover  Amount owed to providers: $7,540  Amount owed to providers: $5,400 medical care in given situations. Use these  Plan pays $5,490  Plan pays $3,520 examples to see, in general, how much financial  Patient pays $2,050  Patient pays $1,880 protection a sample patient might get if they are covered under different plans. Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 This is Hospital charges (baby) $900 Office Visits and Procedures $700 not a cost Anesthesia $900 Education $300 Laboratory tests $500 Laboratory tests $100 estimator. Prescriptions $200 Vaccines, other preventive $100 Radiology $200 Total $5,400 Don’t use these examples to Vaccines, other preventive $40 estimate your actual costs Patient pays: under this plan. The actual Total $7,540 Deductibles $800 care you receive will be different from these Patient pays: Copays $500 examples, and the cost of Deductibles $700 Coinsurance $500 that care will also be Copays $30 Limits or exclusions $80 different. Coinsurance $1320 Total $1,880 See the next page for Limits or exclusions $0 important information about Total $2,050 Note: These numbers assume the patient is these examples. participating in our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may be higher. For more information about the diabetes wellness program, please contact: [insert]. Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 7 of 8 at www.[insert] or call 1-800-[insert] to request a copy.

Insurance Company 1: Plan Option 1 Coverage Period: 1/1/2011 – 12/31/2011 Coverage Examples Coverage for: Individual + Spouse | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the What does a Coverage Example Can I use Coverage Examples assumptions behind the show? to compare plans? Coverage Examples? For each treatment situation, the Coverage Yes. When you look at the Summary of Costs don’t include premiums. Example helps you see how deductibles, Benefits and Coverage for other plans, Sample care costs are based on national copayments, and coinsurance can add up. It you’ll find the same Coverage Examples. also helps you see what expenses might be left When you compare plans, check the averages supplied by the U.S. up to you to pay because the service or “Patient Pays” box in each example. The Department of Health and Human treatment isn’t covered or payment is limited. smaller that number, the more coverage Services, and aren’t specific to a the plan provides. particular geographic area or health plan. Does the Coverage Example The patient’s condition was not an excluded or preexisting condition. predict my own care needs? Are there other costs I should All services and treatments started and  No. Treatments shown are just examples. consider when comparing ended in the same coverage period. The care you would receive for this plans? There are no other medical expenses for condition could be different based on your any member covered under this plan. doctor’s advice, your age, how serious your Yes. An important cost is the premium Out-of-pocket expenses are based only condition is, and many other factors. you pay. Generally, the lower your on treating the condition in the example. premium, the more you’ll pay in out-of- The patient received all care from in- Does the Coverage Example pocket costs, such as copayments, network providers. If the patient had deductibles, and coinsurance. You received care from out-of-network predict my future expenses? should also consider contributions to providers, costs would have been higher.  No. Coverage Examples are not cost accounts such as health savings accounts (HSAs), flexible spending arrangements estimators. You can’t use the examples to (FSAs) or health reimbursement accounts estimate costs for an actual condition. They (HRAs) that help you pay out-of-pocket are for comparative purposes only. Your expenses. own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8 at www.[insert] or call 1-800-[insert] to request a copy.