Even though health insurance is for everyone, policies often contain language only a medical professional could understand. With so much jargon to sift through, health plans can be confusing and overwhelming for the average person. That’s why the Affordable Care Act requires that every health insurance company provides a Summary of Benefits and Coverage (SBC) for every plan they offer.
SBCs break down important information about health insurance plans in plain and concise terms — so you can understand your health plan options, without getting bogged down by tons of fine print. In this blog, we’ll explain how to read the summary of benefits and coverage, so you can make informed decisions about your health insurance — even if you don’t have a medical degree.
Think of your summary of benefits like your cheat sheet to your health insurance plan. You’ll find essential information like how cost-sharing is structured, what services are covered (and aren’t), benefits, and exclusions, all in your SBC. Health insurance companies must provide these guides because they make it easy to understand your options, estimate healthcare costs, and compare plans.
A summary of benefits gives an overview of what you might pay for certain services. You can look at a summary of benefits, even before enrolling in a plan. An explanation of benefits (EOB), on the other hand, is something you only see once you’ve received treatment. After you’ve seen a doctor, your insurance company will send you an EOB, detailing how they processed your claim. The EOB will show the services you received, how much the health insurance company paid, and what you might owe. If you owe a balance, you might still receive a bill after you get your EOB. Don’t agree with your bill? Learn how to fight a medical bill.
While every health insurance company might organize and word their SBC differently, here’s a basic look at what you should see in your summary: benefits, coverage, cost-sharing structure, and exclusions.
Here’s a more detailed list of the sections you can expect in a summary of benefits:
If you can’t find the answers you’re looking for in your SBC, it should also contain a phone number you can call to be connected to a member of the carrier’s customer support team.
Where you’ll find your SBC will depend on how you’re receiving health insurance. If your employer provides health coverage as a benefit, review a summary of coverage when choosing your plan. Someone from the Human Resources department should provide this to you. If you’re shopping for a plan on the ACA health insurance marketplace, you can view a SBC for each plan on the platform before enrolling.
Already have health insurance? Simply log into your carrier’s online portal, where you should be able to access a digital copy of your SBC. Our helpful AI assistant can also quickly pull this up for you, and you can keep it in your digital wallet for easy retrieval.
It’s a good idea to review the full summary of benefits for any plan you’re interested in enrolling in. However, for times when you're looking for quick answers to specific answers, it can be helpful to know how to navigate your SBC at a glance. Below we’ll provide summary of benefits and coverage example sections, to help you better understand this important document.
The top of every SBC should contain a header with the following information:
It’s important to remember that the coverage period doesn’t always align with the calendar year, especially if you enroll during a Special Enrollment Period.
Individuals just like you have been reaching out to insurance companies for decades with questions about coverage. That’s why most insurers have compiled a list of the most commonly asked questions — and their answers — in their SBCs. Here are some of the questions you’ll likely find answers to in this section:
If you do not find the answer to your question in this section, call the provided customer support number and a representative should be able to assist you. Alternatively, you can ask our AI tool, which can scan an entire policy in seconds to provide you with instant answers.
From “co-insurance” to “Health Savings Account” and “allowed amount,” you’ll come across more than a few confusing terms in your SBC. A summary of benefits and coverage will contain a Glossary of terms, where you can find the definitions for important medical words and phrases. It’s a good idea to skim this before reading the rest of your SBC because it will make it easier to understand the other sections.
Want a general overview of what you might pay for common services? Review the Common Medical Events section, where you’ll find a breakdown of coverage for things like specialty visits, labwork, or routine screenings. The insurance company will likely provide this in the form of a table, with the following columns:
This is a broad overview of your potential out-of-pocket costs. However, for an in-depth look at what a bill could be, you’ll review the “coverage examples” section (read on).
So far, we’ve covered sections offering information on typical healthcare situations. But, what if your health status isn’t exactly typical? Look to the Exclusions and Additional Benefits section, where you can find exceptions to the rules, and benefits that fall outside of routine/common services. Every plan is unique, but common exclusions include:
Meanwhile, you might be surprised that some plans offer these additional benefits:
If you have healthcare needs or goals that fall outside what’s considered “common,” be sure to check this section.
As a consumer, you’re entitled to certain rights. If you believe your health insurance company has failed to provide you with coverage to which you’re entitled or violated ACA compliance standards, reference this section. Here you’ll find information on topics like:
Hopefully, you never need this section. But if you feel your insurance company has treated you unfairly, it’s good to know that this information is here.
At times, your medical treatment might involve multiple aspects of your plan, such as a specialist visit, lab work, and prescription medications. That’s when estimating your total cost can get tricky, which is why in every summary of benefits, examples of complex bills are usually provided.
One example could include a visit to an OBGYN, along with bloodwork, and an antibiotic. The example will list each type of service provided (so in this case, a specialist, a lab, and a prescription). Then, for each service, it will show you:
These give you an idea of how various elements of your plan come together and help you better predict your financial liability.
Now that you understand how to read a Summary of Benefits and Coverage, you can use your SBC to guide you in selecting the right plan for your needs. Here are some things to consider when choosing coverage:
Once you’re comfortable reviewing SBCs, you can easily access these helpful documents for multiple plans and complete side-by-side comparisons.
Insurance ‘N You is here to empower you with tools and insights to help you navigate your plan options. In an insurance market that can feel complicated and crowded, having an informed ally makes a difference. We’re that ally.
We think that finding coverage that revolves around you should be easy. Instantly compare health insurance quotes that meet your wellness and wallet goals. Once you’re all set up with a plan, you can store your important documents — including your SBC — in our helpful digital wallet.
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