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How to Read a Summary of Benefits and Coverage

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The Summary of Benefits and Coverage (SBC) was created under the Affordable Care Act. It was designed as a standardized tool to help you better understand what is covered by your health plan or to directly compare different health insurance plans. The following is a guide on how to read a Summary of Benefits and Coverage.

General Plan Information

At the top of the SBC is a section with general information about the health plan. It will include the name of the insurance company, the name of the plan, the dates of coverage, the individuals covered (yourself, you and your spouse, you and your family), and the plan type (HMO or PPO).

Important Questions

Below the general plan information, is the important questions section. It answers questions about your financial responsibility under the plan. This section tells you:

  • How much the deductible is for an individual or a family
  • Whether there are deductibles for specific services, such as prescription drug coverage
  • What is the out-of-pocket limit for participating and non-participating providers
  • Whether there is an overall annual coverage limit
  • Where to find a list of providers participating in the plan
  • Whether you need a referral to see a specialist

Definitions

The SBC provides a list of definitions of common health insurance terms. For example, “co-payments” are defined as fixed dollar amounts you pay for covered health care, usually at the time you receive the service. “Coinsurance” is your share of the costs of a covered service, calculated as a percentage of the allowed amount for the service.

Covered Benefits and Costs

This section tells you how much your costs will be for certain medical services. It states how much your copay will be when you visit your primary care doctor, when you see a specialist, when you have x-rays or blood work, or when you have an MRI or CT scan. It will also provide information about your out-of-pocket costs for generic, preferred brand, non-preferred brand, and specialty prescription medications, and when you use a non-participating provider.

Coverage Examples

The Summary of Benefits and Coverage will provide examples of coverage for managing Type 2 diabetes and having a baby. It will give you an estimate of the total amount owed to providers, the amount the plan will pay, and the amount you will pay for each of these two medical events. It will also break down the details of the annual costs of each service associated with these events, such as prescription medications, office visits and procedures, and laboratory tests.

Excluded Services and Other Covered Services

The SBC will specifically list services excluded from the plan. It will also list other covered services, such as acupuncture, bariatric surgery, weight loss programs, hearing aids, and chiropractic care.

The Summary of Benefits and Coverage makes health insurance plans usually easier to understand, although they can still be confusing. See our friendly agents if you need help choosing a health insurance plan or understanding your coverage under an existing plan.

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