How to Read Your Summary of Benefits img

How to Read Your Health Insurance Summary of Benefits

Do you know how to read your Summary of Benefits and Coverage document (or SBC)? It is a consumer-facing document outlining the coverage provided by a health insurance plan. Devoid of legalese, this summary helps to clarify the cost-sharing structure of a plan without the need to digest lengthy fine print from an insurer.

The SBC also makes it easier to compare plans during open enrollment. All insurance providers are required to provide SBCs for all their plans. The easiest way to obtain your SBC is by contacting the HR department of your employer, but they should always be available to you no matter who provides your insurance.

Tips on how to read your Summary of Benefits and Coverage:

While they help consumers out, these plan documents can still be confusing. 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.

  • Check your header to make sure you have the right SBC.
  • Check the coverage dates, as these are often not the calendar year.
  • Note the election tier (who the plan covers). Although the SBC often describes coverage for individuals and families, you should know who you are insuring as you read through the cost-sharing structure.
  • The plan type acronym will indicate the provider network you will have under the policy. See our explanation of these abbreviations here.

Important Questions

This section is where you look to get a sense of:

  • the plan’s structure
  • deductibles
  • How much you can expect to be covered before you meet your deductible.
  • what types of providers are covered

Unless you have specific medical needs, this is the most important section of the SBC to examine when comparing plans.

Common Medical Events

This table shows the cost of specific visits and procedures under the plan. These expenses meet common medical needs, such as office visits and tests. What you will pay is provided for most (but not all) forms of care. If your plan has a provider network, this table will also tell you how much it costs to see a provider outside the network. 

Pay attention to the limitations column, as these exceptions are often substantial. For example, many patients forget that while a provider may be in their network, the clinical labs used by that provider might not be.

Excluded Services and Other Covered Services

This section shows two things:

  1. Excluded services: services that your plan generally does not cover
  2. Other covered services: services that don’t fit into the “Common Medical Events” section but are still relatively common. It is not an exhaustive list, though.

Be careful if this section crosses a page break in the SBC. When this happens, it can be easy to mistake the excluded services for covered services and vice versa!

Consumer Protection

These paragraphs are for your protection. They detail your rights and describe how to file a complaint. You might not need to read these while selecting a plan, but it is good to know where this information is should you run into problems with your insurance. Topics include:

  • Your rights to continue coverage
  • Your grievance and appeals rights
  • Minimum essential coverage and value standards: Your plan should meet federal standards for essential coverage and value. You are eligible for a tax credit if it does not!
  • Language access services
  • Nondiscrimination and accessibility requirements

Plan Year vs. Calendar Year

A plan year (your coverage period) often differs from a calendar year. A plan year does not always start on Jan 1.

Plan year tells you when your deductible renews, so you know when you will have to start paying your medical expenses again (assuming you hit the deductible for the previous plan year). Additionally, it is important to distinguish between plan year and calendar year because HSA and FSA contributions are regulated by calendar year, even if your plan year is different.

If you need further guidance, your insurer should provide a glossary of terms specific to your SBC. Always refer to your insurance provider’s documents for the most specific and up-to-date information.

Contact Insurance Enterprise for Premier Health Insurance

If you have questions about the group or individual health insurance and need health insurance quotes, contact Insurance Enterprise at 888-350-6605. Speak to a licensed agent and learn more about getting an affordable health insurance plan.