Discussion Draft Question 1 – What is the Overall Deductible?
Discussion Draft Question 2 – Are there services covered before you meet your deductible?
Consumer Information (B) Subgroup
Conference call 6-2-15
FOR DISCUSSION –– STREAMLINING QUESTION 1 AND ADDING A NEW QUESTION 2.
Includes sample language based on last conference call and 2 suggestions from Lynn Quincy, who cannot be on the call on 6-2-15. Instructions for
Questions 1 and 2 together have been drafted with the “Sample Language.” Additional instructions would have to be created for Lynn Quincy’s options.
Clean Question 1
Important Questions
What is the overall
deductible?
Answers
Why This Matters:
$
Sample language
Important Questions
Answers
Why This Matters:
For most covered services, you must pay all the costs up to the deductible amount before
this plan begins to pay. However, this plan pays all costs for covered preventative care
and generic drugs.
What is the overall
deductible?
$500/person or
$1,000/family
The plan begins to pay for a family member’s covered services once their individual
deductible has been met. Once the family deductible is also met, the plan pays for any
family member’s covered services. This plan has an embedded deductible.
The Common Medical Events chart below shows how much you pay for covered services
after you meet the deductible
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Lynn Quincy - Question 1- Sample language - Option A
Important Questions
What is the overall
Deductible?
Answers
$500/individual
$1,000/family
Why This Matters:
Generally, you must pay all the costs from in-network doctors, hospitals, labs up to the
deductible amount before this plan begins to pay.
If you have other family members on the policy, they have to meet their own
deductible until the overall family deductible amount has been met.*
Lynn Quincy - Question 1- Sample language - Option B
Important Questions
Answers
Why This Matters:
Deductible: How much
will I pay before the plan
begins to pay for services?
$500/individual
$1,000/family
Generally, you must pay all the costs from in-network doctors, hospitals, labs up to the
deductible amount before this plan begins to pay.
If you have other family members on the policy, they have to meet their own deductible until
the overall family deductible amount has been met. *
* For instructions - Alternative Language for aggregate deductibles: If you have other family members on the policy, the overall family deductible must be met
before the plan begins to pay. (Note from Lynn: Can we say the individual deductible does not apply in this case?)
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New Question 2. Are there services covered before you meet your deductible?
Clean
Important Questions Answers
Are there services
covered before you
meet your deductible?
Why This Matters:
Sample language
Important Questions
Answers
Are
there
services
Yes, preventative care and
covered before you meet
generic drugs.
your deductible?
Why This Matters:
This plan covers some items and services even if you haven’t yet met the annual
deductible amount. But a copayment or coinsurance may apply.
Lynn Quincy – Question 2 – Sample Language Option A
Important Questions
Are there services that
the plan pays for before
you meet the
deductible?
Answers
Yes
Why This Matters:
These services include: specific preventive care, generic drugs (after a copay) and 2
primary care visits (after copay)
Lynn Quincy – Question 2 - Sample language - Option B
Important Questions
Are there services that
the plan pays for before
you meet the
deductible?
Answers
Yes
Why This Matters:
These services include: specific preventive care, generic drugs (after a copay) and 2
primary care visits (after copay). See Common Medical Events table for details.
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Group Instructions
General Instructions for the Important Questions chart:
•
This chart must always begin on page 1, and the rows must always appear in the same order. Plans and issuers must complete the Answers
column for each question on this chart, using the instructions below.
•
Plans and issuers must show the appropriate language in the Why This Matters box as instructed in the instructions below. Plans and issuers
must replicate the language given for the Why This Matters box exactly, and may not alter the language.
•
If there is a different amount for in-network and out-of-network expenses (such as annual deductible, additional deductibles, or out-of-pocket
limits), list both amounts and indicate as such, using the terms to describe provider networks used by the plan or issuer. For example, if the
plan uses the terms "preferred provider” and "non-preferred provider” and the annual deductible is $2,000 for a preferred provider and $5,000
for a non-preferred provider, then the Answers column should show "$2,000 preferred provider, $5,000 non-preferred provider”.
1. What Is The Overall Deductible?:
Answers column:
•
•
If there is no overall deductible, answer "$0.”
If there is an overall deductible, answer with the dollar amount and, if the deductible is not annual, indicate the period of time that the deductible
applies.
•
If there is an overall deductible, underneath the dollar amount, plans and issuers must include language specifying major categories of covered
services that are NOT subject to this deductible. For example, "Does not apply to preventive care and generic drugs.”
•
If there is an overall deductible, underneath the dollar amount plans and issuers must include language listing major exceptions, such as out-ofnetwork coinsurance, deductibles for specific services and copayments, which do not count toward the deductible. For example, “Out-ofnetwork coinsurance and copayments don’t count toward the deductible.”
•
If portraying family coverage for which there is a separate deductible amount for each individual and the family, show both the individual
deductible and the family deductible (for example, “$2,000 /person or $3,000 /family”).]
Why This Matters column:
•
If there is no overall deductible, show the following language: “See the Common Medical Events chart below for your costs for services this plan
covers.”
•
If there is an overall deductible, show the following language: “For most covered services, you must pay all the costs up to the deductible
amount before this plan begins to pay.”
If there is an overall deductible, plans and issuers must include the following language: “The Common Medical Events chart below shows how
much you pay for covered services after you meet the deductible.”
•
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2. Are 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, preventative care and generic drugs.
Why This Matters column:
•
If there are no services covered before the deductible, show the following language: “See the Common Medical Events chart below for your
costs for services this plan covers.”
•
If there are services covered before the deductible is met, show the following language: “The health insurance policy or plan covers some items
and services even if you haven’t yet met the annual deductible amount. But a copayment or coinsurance may apply.”
Individual Instructions
General Instructions for the Important Questions chart:
•
•
•
This chart must always begin on page 1, and the rows must always appear in the same order. Issuers must complete the Answers column for each
question on this chart, using the instructions below.
Issuers must show the appropriate language in the Why This Matters box as instructed in the instructions below. Issuers must replicate the
language given for the Why This Matters box exactly, and may not alter the language.
If there is a different amount for in-network and out-of-network expenses (such as annual deductible, additional deductibles, or out-of-pocket limits),
list both amounts and indicate as such, using the terms to describe provider networks used by the issuer. For example, if the policy uses the terms
"preferred provider” and "non-preferred provider” and the annual deductible is $2,000 for a preferred provider and $5,000 for a non-preferred
provider, then the Answers column should show "$2,000 preferred provider, $5,000 non-preferred provider”.
1. What Is The Overall Deductible?:
Answers column:
•
•
If there is no overall deductible, answer "$0.”
If there is an overall deductible, answer with the dollar amount and, if the deductible is not annual, indicate the period of time that the deductible
applies.
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•
If there is an overall deductible, underneath the dollar amount, issuers must include language specifying major categories of covered services that
are NOT subject to this deductible. For example, "Does not apply to preventive care and generic drugs”
•
If there is an overall deductible, underneath the dollar amount issuers must include language listing major exceptions, such as out-of-network
coinsurance, deductibles for specific services and copayments, which do not count toward the deductible. For example, "Out-of-network
coinsurance and copayments don’t count toward the deductible.”
•
If portraying family coverage for which there is a separate deductible amount for each individual and the family, show both the individual deductible
and the family deductible (for example, "$2,000 /person or $3,000 /family”).
Why This Matters column:
•
If there is no overall deductible, show the following language: “See the Common Medical Events chart below for your costs for services this plan
covers.”
•
If there is an overall deductible, show the following language: “For most covered services, you must pay all the costs up to the deductible
amount before this plan begins to pay.
If there is an overall deductible, plans and issuers must include the following language: “The Common Medical Events chart below shows how
much you pay for covered services after you meet the deductible.”
•
2. Are 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 and answer “Yes” and list major categories of covered
services that are NOT subject to the deductible, for example, preventative care and generic drugs.
Why This Matters column:
•
If there are no services covered before the deductible, show the following language: “See the Common Medical Events chart below for your
costs for services this plan covers.”
•
If there are services covered before the deductible is met, show the following language: “This health insurance policy or plan covers some items
and services, even if you haven’t yet met the annual deductible amount. But a copayment or coinsurance may apply.”
Additionally
1) Concept removed from SBC: “Check your policy or plan document to see when the deductible starts over (usually, but not always, January
6
1st).” Recommend moving to the Glossary. While important information, this is not “front page” necessary for comparison shopping.
2) Move up information in the Medical Events section so that preventive services receive greater prominence.
3) Definitions for “embedded deductible” and “aggregate deductible” should be added to the Glossary.
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FOR DISCUSSION – OPTION 2a AND 2b – LYNN QUINCY OPTION 2a
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