This is a list of medical services and supplies a health insurance plan covers and the associated costs. These summaries are useful when comparing different plans. The Affordable Care Act requires health plans to provide a summary of benefits written in plain English that includes certain information.
The summary includes:
Covered services: Any care and treatment a health plan pays for in part or in full is considered a covered service.
Deductible amounts: The deductible is how much you must spend before insurance starts to pay its part. Some services may be covered before the deductible, such as preventive care. Plans may also have separate deductibles for different types of benefits, such as prescription drugs.
Copay: A copay is a fixed amount you pay at the time of care. For instance, you might have a $20 copay for a doctor's appointment and a $30 copay to see a specialist.
Coinsurance is a percentage of the cost of services that you must pay. For instance, if your coinsurance for an MRI is 20%, you pay 20% of the charge. So if the bill was $100, you would owe $20 (usually after your deductible is met).
Cost for prescription medicines: This section will outline what you will pay for both generic and brand-name drugs.
Coverage exclusions: These are things that the plan does not cover under any circumstances. Common coverage exclusions include acupuncture, certain fertility treatments, cosmetic surgery, and weight loss surgery.
Limits to coverage: Health plans must limit how much you pay toward services covered by your health plan. This is called an out-of-pocket limit. Once you reach that limit, the plan pays 100% for your care.
The Affordable Care Act does not allow plans to impose annual or lifetime limits on essential health benefits. A plan can impose caps on specific benefits, for example, only covering 20 physical therapy treatments. Plans also can put an annual dollar limit and a lifetime dollar limit on spending for health care services that are not considered essential health benefits.
Common medical events: The Summary of Benefits includes a list of common medical events, the services you might need, and how much they will cost. The common medical events include things like hospitalization, pregnancy, and visiting your doctor.
The Summary describes the plan rules including whether you pay more for using out-of-network providers and whether you need a referral in order to see a specialist, as well as your rights to file a grievance or appeal.