Summary of Benefits

A Basic Explanation

Reading the fine print on a health insurance policy is no one’s idea of fun, but it’s definitely worth the effort. Choosing a policy based on the monthly premium alone might not get you the best coverage for your money, or the best deal. It’s important to also weigh your medical needs against things like copays, coinsurance, and deductibles – examples of how an insurance company shares the cost of coverage with you – as well as provider network.

A plan’s Summary of Benefits and Coverage (SBC) describes how copays, coinsurance, and deductibles apply to each type of covered service.

Expert Advice About Summary of Benefits

The Affordable Care Act (ACA) requires all policies sold on the exchange -- as well as many employer plans -- to explain plan benefits in detail in a Summary of Benefits brochure that meets certain federal guidelines. (A few types of policies, including stand-alone dental and vision, are exempt from this requirement.) Reading the descriptions of what’s covered and how it’s covered makes it easier to comparison-shop policies before you enroll. And it gives you something to refer to if you have questions.

For example, let’s say you’ve got a pre-existing condition like diabetes, so you know you’ll be visiting the doctor often and taking prescription drugs every day. If one of the plans you’re considering has a slightly higher premium but covers your regular medication and requires just a small copay – and includes your family doctor in its network -- you’ll actually save a ton of money in the long run.

Or, if there’s a particular service you think you’ll need, you can look at the Summary of Benefits for different plans and compare. For instance, if you’re trying to have a baby and considering infertility treatment, or you usually get regular chiropractic care to keep your back feeling good, you’ll want to check the Summary of Benefits of the plans you’re looking into to see if those services are covered. (You’ll also want to check the list of approved providers to make sure the infertility doctor you’ve heard good things about, or your favorite chiropractor, is in-network.)

The ACA requires the Summary of Benefits information to be available during any enrollment period. Carriers must notify policyholders of any changes in writing, at least 60 days in advance. Anytime you renew a plan, you should receive a new summary.