If you’re shopping for a health plan through a web broker like ihealthagents.com or HealthCare.gov, the site will provide you with access to documentation for each potential plan before you make your choice. If you are looking at plans through your employer, it should be presented to you when you enroll.
You can always contact your insurance company directly to request your SBC. Typically, you can also find these documents by exploring through a search engine, especially if you know the specific insurance company or plan you’re looking for.
The purpose of a summary of benefits and coverage
SBCs can help you determine which plan is best for you when shopping for health coverage. Many people don’t review these documents carefully until after they’re enrolled in a plan. When you don’t know the details of your coverage, you could end up surprised by a bill or the cost of an unexpected service. Understanding the specifics of your coverage helps you know what to expect, especially in the event of an emergency or if you have specific treatment needs.
If you’re on one plan now and exploring different plans, use SBCs to help you spot differences in coverage and understand what best suits your personal health needs. For example, if you’re trying to get pregnant in the next year, pay special attention to the “If you are pregnant” section of the SBC. This outlines prenatal and postnatal care, as well as delivery. It will also tell you plan specifics like what it will cost to visit an in-network versus out-of-network provider, limits for certain services (such as the annual number of covered visits), and a general overview of what your plan does not cover.
SBCs are required to be provided in specific situations, such as the following:
- When you enroll in a new health insurance plan
- If changes are made to your plan between when you enroll and when your coverage starts
- When changes are made to your plan when you are renewing your coverage or during your coverage period
- If you request them from your insurance company (you should receive it within a week of asking)
A sample summary of benefits and coverage
Let’s take a look at this SBC from Anthem Blue Cross of California. You’ll know it’s the plan for the current year based on the date in the upper right corner. Calendar year plans will always roll over in January, and policy year plans restart on the anniversary of when your coverage originally began.
Every SBC includes the name of the plan, service cost information for both in- and out-of-network providers, as well as frequently asked questions and answers.
Your deductible is the amount you are expected to pay out of pocket before your insurance provider will start paying for certain benefits. For example, if you have a $500 deductible, and your office visit copay is listed as $40, you would be expected to spend a total of $500 out of pocket for any doctor appointments. After you’ve reached that amount, you would just pay the $40 copay.
Keep in mind: If you have additional family members on your plan, the deductible will be higher. This means you will have to meet a higher out-of-pocket amount before certain services are covered for anyone on your family’s policy.
Exceptions include services that list copay as not being subject to the deductible. In this case, you would only pay the copay amount, regardless of your deductible. Common examples of this include prescription drugs and primary care appointments.
Your plan may also have separate deductibles for specific coverage. Prescription deductibles are a common example of this. If this applies to your plan, you can expect to pay a given amount out of pocket for drugs before your insurance starts paying.
The out-of-pocket limit listed is the maximum amount you can expect to pay in a year for your portion of provider services. If you think of your deductible as the lowest amount you’ll be expected to pay out of pocket, then the limit is the highest amount.
For example, if your out-of-pocket limit is $7,000, and you have surgery, any expenses over the $7,000 would be covered at 100% by your provider. Once you’ve paid a certain amount in a given year, your insurance will pay for everything else and you won’t incur any additional costs.
Keep in mind: Much like with your deductible, if you have additional family members on your plan, your limit will be higher.
Preventive care is any type of medical service intended to defend against medical emergencies. This includes care like your annual physical or well-woman appointments. Preventive care is fully covered by insurance under every ACA-compliant plan.
However, you may be responsible for the cost of any additional care at a given appointment. If you go in for your annual physical and also get lab testing, you may be responsible for the cost of tests, just not the appointment itself.
If you have a specific condition requiring prescription medication, pay special attention to the drug section. This section will help determine your prescription costs. Many plans have medications categorized by tier. It may take a bit more investigating to figure out if an insurance plan covers your medication.
Each insurance provider will typically have a formulary or other documentation to supplement the SBC. This documentation will help you determine what drugs are covered and how much they will cost. On the example SBC below, a link is provided on the left to learn more about the specific medication coverage.
Copay vs. coinsurance
Most health services will either have a fixed service fee (copay) or a fixed percentage amount you will pay (coinsurance). Many people prefer plans with copays because they know exactly a visit to their provider will cost. With coinsurance, the fee differs by service type and the “allowed amount” for the service, or the total agreed-upon fee. So if the allowed amount for a procedure is $1,000 and your plan lists 20% coinsurance, you would pay $200 out of pocket.
In network vs. out of network
Another feature of the SBC is pricing information for visiting providers both “in network” and “out of network.” What this means for you is how much you’ll pay based on the provider you see.
In-network providers are contracted with any given insurance company. They agree to accept a specific service payment amount from both covered patients and the insurance company.
Out-of-network providers are not held to the same service pricing standard since they are not contracted with a given insurance provider. You will be charged any amount the medical office chooses based on their own service rates, and your insurance contributes far less, if at all. Additionally, out-of-network care might not count towards your deductible. This is why it’s best to always stay in network when possible.
Seeing in-network providers is especially important if you have an HMO plan. With HMOs, out-of-network services are only covered in life-threatening situations. For example, if you’re traveling and need to see an out-of-network provider for a minor medical issue, you will pay the full price for any care you receive.
Hypothetical health and insurance scenarios
Another helpful section of the document is the hypothetical scenarios. They are meant to give you an idea of your coverage for specific conditions, such as pregnancy or diabetes, and the potential cost of care. This is important since it gives you an idea of how the plan functions and what the cost sharing looks like.
An easy way to find what services may not be covered under a prospective plan is to check the end of the document. This typically includes coverage details of specific services like acupuncture, chiropractic, cosmetic procedures, and beyond. This section may also outline other covered services not already listed on the document.
A summary of benefits and coverage is meant to guide you and break down the coverage provided under your health insurance plan. While they can be confusing at face-value, knowing how to interpret the information can help you make informed choices for your year in health coverage.