How to Read a Summary of Benefits and Coverage

How to Read a Summary of Benefits and Coverage

A Summary of Benefits and Coverage is an easy-to-read summary that lets you compare costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You’ll get the “Summary of Benefits and Coverage” (SBC) when you shop for coverage on your own, through your job, or your health insurance broker.

Although the summary is designed to be easy to read, it can still be challenging to understand – especially if you are unfamiliar with specific insurance terms or concepts. Below, we look at how to read a summary of benefits and coverage on your health insurance plan. If you need further help, feel free to contact Insurance Enterprise. 

Summary of Benefits and Coverage (SBC) Explained

A summary of benefits and coverage (SBC) is a document that all insurance companies must provide. It details the coverage and costs for any Affordable Care Act-compliant health plan. No matter the insurance provider, all SBCs outline the same basic information. 

This is meant to help you compare your options and understand your coverage. They may vary slightly in format and wording, but they all present the same information. 

If you’re shopping for a health plan, your provider or health insurance broker 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, you should present it when you enroll. You can always contact your insurance company directly to request your SBC. You can also find these documents by performing a Google search online.

Why is an SBC Important?

When you do not 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 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 section of the SBC that addresses maternity coverage. This outlines prenatal and postnatal care, as well as delivery. It will also tell you plan details 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 essential in situations such as:

  • 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)

What Information Do SBCs Cover?


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 amount 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.

Out-of-pocket limit

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, the limit is the highest.

Preventive care

Preventive care is any type of medical service that’s intended to defend against medical emergencies. This includes care like your annual physical or well-woman appointments. 

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 medicine.

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 precisely what a visit to their provider will cost.

Contact Insurance Enterprise for Group Health Insurance

If you have questions about group health insurance and need health insurance quotes, contact Insurance Enterprise at 888-350-6605. Speak to a licensed agent and find out more about how you can get an affordable health insurance plan.