Comment:

Coverage needs to include the following benefits/coverage information:

Benefit information needs to be provided including the following

Plan Begin Date

Member Original Effective Date

Plan Level Deductible Amount - Individual (needed for both In- and Out-of-Network)

Plan Level Deductible Remaining Amount - Individual (needed for both In- and Out-of-Network)

Plan Level Deductible Amount - Family (needed for both In- and Out-of-Network)

Plan Level Deductible Remaining Amount - Family (needed for both In- and Out-of-Network)

Plan Level Deductible Start Date

Copay Amount for Service

Coinsurance Percentage for Service (needed for both In- and Out-of-Network)

Plan Level Member Out of Pocket Limit Amount - Individual (needed for both In- and Out-of-Network)

Plan Level Member Out of Pocket Limit Amount Remaining - Individual (needed for both In- and Out-of-Network)

Plan Level Member Out of Pocket Limit Amount - Family (needed for both In- and Out-of-Network)

Plan Level Member Out of Pocket Limit Amount Remaining - Family (needed for both In- and Out-of-Network)

Benefit or Service Level Deductible Amount (needed for both In- and Out-of-Network)

Benefit or Service Level Deductible Amount Remaining (needed for both In- and Out-of-Network)

Benefit or Service Level Out of Pocket Limit Amount (needed for both In- and Out-of-Network)

Benefit or Service Level Out of Pocket Remaining Amount (needed for both In- and Out-of-Network)

Benefit or Service Level Number of services allowed (needed for both In- and Out-of-Network)

Benefit or Service Level Number of services remaining (needed for both In- and Out-of-Network)

Pattern of usage details (i.e., One visit allowed per 24 months)

Expiration date