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How to read your summary of benefits and coverage
How many times have you looked at a health insurance policy, seen the first few pages, and not really known what you’re looking at or how to understand what you were seeing?
The summary of benefits and coverage (SBC) is the first page of an insurance policy outlining the coverage provided, and excluded, by that specific plan. It helps to clarify the cost-sharing structure of the plan without needing the digest all of the fine print. The SBC also make it easier to compare plans during open enrollment.
Under the ACA, all insurance providers are required to have a SBC for all of their plans. While the documents all read the same and have the same layout, the details about what they cover and at what cost to you differ depending on the policy.
**Note: The following images depict a sample plan, and are not representative of any specific coverage.
Header: At the top of each SBC is a header that gives the insurer’s name, the official plan name, the coverage period, the election tier, and the plan type.
- The Coverage Period is the set of dates that the plan is valid between. A lot of times coverage periods are the same as the January 1-December 31 calendar, but not always. Check the dates on your SBC to make sure you know how long these plan details last.
- The plan type will be an acronym such as PPO, EPO, HMO, or other network type, which indicates the network type for this plan. To read more about networks, click here.
- Make sure that the ‘Coverage for” is correct. This indicates if you are looking at a plan for just one person or a family. Plans that cover families will usually have the important information for individuals included and not require a second SBC.
Important Questions: In this section we begin to see a little bit about our cost associate with the plan. When comparing details between two or more plans, this in one of the most important sections to look at unless you have specific medical needs.
- What is the overall deductible?- This is how much money you need to pay before the insurance company will start to pay their share. Once you reach the deductible, you will not need to do so again for the remainder of the Coverage Period shown in the section above. Deductibles are different for individuals and families. While you, the policy holder may have a $500 deductible, everyone else in your family has a separate $1,000 deductible that they contribute to together. The deductible is sometimes split between in-network and out-of-network. If your SBC shows only one, that means the deductible amount shown applies to both
- Are there services covered before you meet your deductible? This shows any services that will be covered even if your deductible has not been met met. Normally, a plan will not pay if you have not met your deductible; exceptions to this are always listed here. On the right, you can select the link for your SBC to see a full list of services that will be covered before the deductible is met. As per the ACA, all preventative care MUST be covered by MEC plans prior to the deductible being met. A list of preventative services can be found here.
- Are there other deductibles for specific services? Often times there are different deductibles for different types of services. Prescription medication is almost always a separate deductible.
- What is the out-of-pocket limit for this plan? This shows the maximum amount of money you will pay over the course of the Coverage Period. Your deductible, copayments, and coinsurance amounts all count towards your max-out-of-pocket. Like the deductible, this is shown for the individual who purchased the plan, and again for anyone else on the plan. There is also difference in the out-of-pocket limits for service that are covered in-network and out-of-network. Once you reach your out-of-pocket limit, you will not pay anymore money for covered services until the Coverage Period starts over again. To learn more about cost-sharing in general and how those terms apply to health insurance, click here.
This is a continuation of ‘Important Questions.’
- What is not included in the out-of-pocket limit? Premiums are never included in the out-of-pocket limit. Balance-billing applies to out-of-network charges and is also usually excluded.
- Will you pay less if you use a network provider? This will explain if you pay a different amount depending if you use a provider in-network or out-of-network. You are also able to select the link to see a list of network providers. A broker or agent who helped enroll you in this plan should have already ensured that your preferred providers are in network.
- Do you need a referral to see a specialist? Some plans require that you seek a referral from a specialist before the plan will agree to pay for certain services, others do not require this.
This is called the Common Medical Events Chart and it is always included with a SBC. Note at the top there is the specification that, if applicable, you need to have met your deductible BEFORE the listed copayments and coinsurance cost apply.
- If you visit a health care provider. This shows the cost associated with going to see a doctor. Doctor visits are broken into a few categories, such as primary, specialist, and preventative care in this SBC; other SBCs may show visits differently. Notice the difference in what you will pay between in-network and out-of-network, as well as the disclaimer on needing preauthorization (referral) for specialist visits.
- Diagnostic Test have their own cost. These are usually paid per test, not per visit. So if you have both a x-ray and MRI in one visit, you’ll pay for each.
- Prescription Drug are broken into tiers, and each tier has it’s own cost. They also often have their own deductible that is separate from the plan’s deductible. The difference between in-network and out-of-network here is where you pick the medication up from. On the far right, you will see how many days worth of medication you will receive for your copayment or coinsurance.
- Emergency Medical Attention will always be covered per ACA requirement. However, the insurance company is allowed to scrutinize your visit and not pay the bill IF it is determined that you should have reasonably known that you did not need emergency medical help. This becomes really important when you are out of network (say on vacation) and you get sick. If you choose to visit the ER for emergency medical care (20% coinsurance) but your insurance company decides it was not an emergency, they may bump it to urgent care (40% coinsurance). While there is not cut and dry line on what is classified as Emergency vs Urgent, this article from the Mayo Clinic does a great job breaking the two down.
Excluded Service
NOTE- Pay extra attention here and make sure that you thoroughly go through ALL of the excluded services which can be viewed using the link in this section. You want to make 100% sure of what is and is not included.
Where is it says dental care, note how it specifies Adult. This is because under the ACA, dental care and vision care must be provided for minors up to age 19 as it is considered an Essential Health Benefit.
Consumer Protections
This section reads a bit more like a lawyer wrote it, but, it does have some pretty important information. Specifically, it talk about how to appeal a claims decision, if your plan is considered an MEC plan, and how to continue your coverage once the Coverage Date ends.
What is NOT included in my SBC?
Information about specific networks, premiums, balance-billing charges, penalties for failure to obtain preauthorization for certain services, and a complete list of excluded services.
All of this information can be found either directly through the insurance company offering the plan, or through links shown on the SBC itself.
How do SBCs work with my Marketplace CSR?
When you purchase a Marketplace plan, if you qualify and if you chose a Silver Tier plan, you will be eligible for Cost Share Reductions, or CSR. This subsidy directly lowers your deductibles, copayments, and coinsurance. There are 3 different CSR levels (CSR 73, 87, and 94), plus two more for American Indians and Alaskan Natives, in addition to the plan’s base cost share.
The cost sharing amounts change depending on what group you are in, which directly effects the SBC pages for your plan.
Marketplace plans can include (but not always-sometimes this part is done for you) up to 7 different SBCs, one for each CSR, AI/AN, and the base plan. These are then repeated in Spanish.
Make sure you understand your CSR level when you are comparing plans.
Takeaways
The ACA did a pretty good job requiring insurance companies to include the Summary of Benefits and Coverage in all health insurance plan; it definitely makes it easier to understand what you are signing up for when you are able to reference this document. It isn’t all inclusive though. Make sure you are paying attention to networks, drug formularies, and excluded services as these aer really easy to miss or are just not on the SBC without digging.
If you have any questions about this, need some help going through your SBC, or have questions about anything else, feel to give us a call so we can talk.
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