Summary of Benefits and Coverage Clause Samples

Summary of Benefits and Coverage. Contractor shall develop and maintain a Summary of Benefits and Coverage as required by Federal and State laws, rules, and regulations. The Summary of Benefits and Coverage must be available online and the hard copy sent to Enrollees on request shall be available to Enrollees in English, Spanish, and other languages as required by Federal and State laws, rules, and regulations. Contractor shall update the Summary of Benefits and Coverage annually and Contractor shall make the Summary of Benefits and Coverage available to Enrollees pursuant to Federal and State laws, rules, and regulations.

Summary of Benefits and Coverage. Contractor shall develop and maintain an SBC as required by Federal and State laws, rules and regulations. The SBC will be available online and the hard copy sent to Enrollees on request shall be available to Enrollees in English, Spanish, and other languages as required by Federal and State laws, rules and regulations. Contractor shall update the SBC annually and Contractor shall make the SBC available to Enrollees pursuant to Federal and State laws, rules and regulations.

Summary of Benefits and Coverage. Description The DEPARTMENT reserves the right to require the CONTRACTOR to assist with drafting and mailing the federally required Summary of Benefits and Coverage (SBC) to PARTICIPANTS in a manner similar to the annual OPEN ENROLLMENT materials mailing process. (See Section III.A.1. Eligibility.) Frequency As needed

Summary of Benefits and Coverage. “SBC”). Unless otherwise provided in the applicable ASO BPA, Employer acknowledges and agrees that Employer will be responsible for the creation and distribution of the SBC as required by Section 2715 of the Public Health Service Act (42 USC 300gg-15) and SBC regulations (45 CFR 147.200), as supplemented and amended from time to time, and that in no event will Claim Administrator have any responsibility or obligation with respect to the SBC and Claim Administrator will not be obligated to respond to or forward misrouted calls, but may, at its option, provide participants and beneficiaries with Employer’s contact information.

Summary of Benefits and Coverage. A Summary of Benefits and Coverage (SBC) gives an overview of the benefit options of your insurance plan. All insurance companies are required to provide you with an SBC, which is in a format required by the government. You can find your SBC by going to My Health Toolkit. You may also contact a Customer Service Advocate and ask us to send you a copy of the SBC. We can send it to you electronically or mail a paper copy (free of charge). Please note: the format and content of an SBC is controlled by federal agencies. In the event of an inconsistency between the SBC and these Policy documents, these Policy documents are controlling. Preauthorization is also called prior authorization, prior approval or precertification. It is important to understand what Preauthorization means. It means the service has been determined to be medically appropriate for the patient’s condition. A Preauthorization does not guarantee that we will pay benefits. Preauthorization must be obtained for certain categories of benefits; a failure to get preauthorization may result in benefits being denied. We will make our final benefit determination when we process your claims. Even when a service is preauthorized, we review each claim to make sure: ● The patient is a Member under the Policy at the time service is provided; and ● The service is a Covered Service (Policy limitations or exclusions may apply); and ● The service provided was Medically Necessary as defined by your Policy, including appropriateness, health care setting, level of care, and effectiveness. A Preauthorization may only be for a specific period of time or number of visits/treatments. If you have any questions about this, please contact Marketplace Operations. If your request for Preauthorization of services is denied, you can request further review; see the Appeal Procedures Section of this Policy. Preauthorization denials are considered denied claims for purposes of appeals and grievances. Network Providers in South Carolina will be familiar with the requirement to obtain Preauthorization and will get the necessary approvals. If a Network Provider in South Carolina does not get Preauthorization, it cannot Balance-Bill you. If you use an Out-of-Network Provider, it is your responsibility to contact us before receiving services and/or supplies. An Out-of-Network Provider can Balance-Bill you for the difference unless prohibited by law. This is also true for Network Providers through the BlueCard® program. If you are o...

Summary of Benefits and Coverage. The Corporation will have complied with federal law by providing applicable Summary of Benefits and Coverage (SBCs) to the Employer. It will be the Employer’s responsibility, and not the Corporation’s, to distribute the SBCs to its Employees (and Dependents who live at a different address when it is known) in accordance with federal law. VI.07 Group Replacement Standards a. If the Employee and/or Dependents had continuous coverage with the Employer’s prior Group Health Plan and are now insured by this plan, credit will be given for Deductibles and Coinsurance to the extent that they were fully or partially met under similar provisions of the prior plan. The credit will apply for the same or overlapping Benefit Periods and for expenses actually incurred and applied against the Deductible and Coinsurance provisions of the prior plan during the 90 days before the Effective Date of this plan. This applies only if this Contract covers these expenses and these expenses are subject to similar Deductible and Coinsurance provisions. b. Each person not eligible for coverage under this Contract because of the Actively-at-Work provision (unless due to a Health Status Related Factor) is nevertheless covered under this Contract, based on the following rules if the person had valid coverage (including Extension of Benefits) under the Employer’s prior Group Health Plan on the date it ended. Each person must also be eligible for coverage under this Contract. Any reference in the following rules to a person who was or was not totally disabled is a reference to the person’s status immediately before the date this Contract became effective.

Summary of Benefits and Coverage. Company will timely provide Group with a Summary of Benefits and Coverage as required under the ACA. Group agrees to timely deliver to its members the Summary of Benefits and Coverage as required under the ACA.

Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this

Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: other sections of the Agreement or Summary of Benefits and necessary. The Section being referenced will be bolded. ake action within a certain timeframe to comply with your Plan. An 