Use a Summary of Benefits and Coverage to stay informed about your health plan

Do you know what your health plan covers and what your costs may be when using your health plan?

The Affordable Care Act requires insurance companies and job-based health plans to provide covered members with a short, plan-language Summary of Benefits and Coverage (SBC) that summarizes health plan information and provides estimated costs of commonly used services, or basically illustrate how your health plan will pay for what’s covered in your health plan.

Most people rely upon what their medical provider says they owe.  Being an active consumer of health care requires we take a proactive, and not a reactive, approach. Wouldn’t it be a good feeling to know in advance what you should expect to pay for a medical service? A great place to start is by reading your health plan’s SBC.  You don’t need to be a rocket scientist to read and understand a SBC.

Reading the SBC will tell you a number of important and valuable facts like:

  • How much is your deductible and out-of-pocket maximum?
  • Does your plan use a network providers, and also cover non-network providers?
  • Are there services not covered or excluded?
  • How to I file a complaint or grievance?

Another valuable reason to use a SBC is to compare health plan options. If you have more than one health plan option to choose from, the SBC enables an easy apples-to-apples comparison of the services and financial components of a health plan.

What does a SBC look like? 

The Centers for Medicare Services maintains a sample copy on their website.  All SBCs are created using the same templated format with same identical sections, titles and common language.   Here’s a link to the sample. https://www.cms.gov/CCIIO/Resources/Files/Downloads/sbc-sample.pdf

Where can I get a copy of my SBC?

You can ask for a copy from your insurance company or group health plan any time. All health plans must provide the SBC at important points in the enrollment process, like when you apply for or renew your policy. Employer-based plans typically provide the SBC online within the company’s intranet or benefits system, or by distributing in electronic or paper form during the enrollment period.  You can always request a copy from your employer.

SBCs are updated each year as benefits and coverage details may change, so make sure you get an updated version each year if you remain in the same health plan year after year.

To learn more about SBC’s, go to the Healthcare.gov website.

https://www.healthcare.gov/health-care-law-protections/summary-of-benefits-and-coverage/

William J. Pokluda is certified benefits professional with over 25 years experience helping people every day understand and maximize their health insurance. His latest book Maximize Your Health Insurance helps people become proactive consumers of their health insurance.

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