Summary of Benefits and Coverage (SBC) - Bronze 60 HDHP HMO - 60 HDHP HMO

Sep 22, 2026

The Summary of Benefits and Coverage (SBC) explains how costs are shared for covered health care services under the plan, including key deductible and out-of-pocket amounts. It states that premium information is provided separately and that the SBC is only a summary. The document addresses whether services are covered before meeting the deductible, whether other deductibles apply, referral and specialist access rules, network-provider pricing, and what expenses do not count toward the out-of-pocket limit.

LanguageEnglish

CategoryForms

FormatPDF

Pages6

Reading Time2 min

AccessFree to download

Important Questions

Overall deductible

Services covered before the deductible

Other deductibles for specific services

Out-of-pocket limit

What is not included in the out-of-pocket limit

Network provider vs out-of-network

Common Medical Events

Office or clinic visits

Specialist visits

Preventive care/screening/immunization

Diagnostic tests and imaging

Prescription drugs

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The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage,
[www.communitycarehealth.org](www.communitycarehealth.org) or by calling 1-559-724-4995 . For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can [view the Glossary at](view the Glossary at www.healthcare.gov/sbc-glossary/ or call)[ ](view the Glossary at www.healthcare.gov/sbc-glossary/ or call)[www.healthcare.gov/sbc-glossary/](view the Glossary at www.healthcare.gov/sbc-glossary/ or call)[ ](view the Glossary at www.healthcare.gov/sbc-glossary/ or call)[or call](view the Glossary at www.healthcare.gov/sbc-glossary/ or call) 1-559-724- 4995 to request a copy. | | | | --- | --- | --- | | | | | | Important Questions | Answers | Why This Matters: | | What is the overall deductible? | $6,650 Individual / $13,300 Family | Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. | | Are there services covered before you meet your deductible? | Yes. Preventive care and the other services listed in the“What you will pay” column of the chart starting on page 2, indicates services covered before you meet your deductible. | This plan covers some items and services even if you haven’t yet met the deductible amount, but a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at [https://www.healthcare.gov/coverage/preventive-care-benefits/](https://www.healthcare.gov/coverage/preventive-care-benefits/) . | | Are there other deductibles for specific services? | No. | You don’t have to meet deductibles for a specific service. | | What is the out-of-pocket limit for this plan? | $6,650 Individual / $13,300 Family | The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. | | What is not included in the out-of-pocket limit? | Copayment for certain services, premiums, balancing-billing charges, and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out–of–pocket limit. | | Will you pay less if you use a network provider? | Yes. See [www.communitycarehealth.org](www.communitycarehealth.org) or call 1-559-724-4995 for a list of network providers. | This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing) . Be aware, your network provider might use an out-of-network provider for some services (such as lab work) . Check with your provider before you get services. | | Important Questions | Answers | Why This Matters: | | --- | --- | --- | | Do you need a referral to see a specialist? | Yes. | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. | All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductibl

FAQs

What is the overall deductible under this plan?

$6,650 for Individual coverage or $13,300 for Family coverage. Generally, you pay costs from providers up to the deductible before the plan begins to pay.

Are any services covered before you meet your deductible?

Yes. Preventive care and other listed services may be covered before meeting the deductible, though copayment or coinsurance can still apply depending on the service.

Do you need a referral to see a specialist?

Yes. The plan pays some or all specialist costs for covered services only if you have a referral before you see the specialist.

Sep 22, 2026

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